What are the management options for genito-urinary prolapse in a patient?

Management of Genito-Urinary Prolapse

Initial Conservative Management Should Be First-Line

Conservative therapy should be attempted first in all patients with pelvic organ prolapse, as approximately 25% will achieve adequate symptom control without surgery. 1

Conservative Treatment Options

• Pelvic floor physiotherapy is the cornerstone of initial management, reducing symptoms and improving quality of life 2
• Pessary devices provide effective non-surgical management for patients not desiring surgery or those medically unfit for operative intervention 3, 2
• Local estrogen therapy can alleviate symptoms of urogenital prolapse, particularly in postmenopausal women 2
• Dietary modifications, fluid management, and bowel training programs should be implemented to address associated bowel dysfunction 1

When Conservative Management Fails

Surgery should only be considered after failure of conservative therapy and in patients with symptomatic grade 3-4 prolapse causing significant quality of life impairment 1

Comprehensive Pre-Operative Assessment

Essential Clinical Evaluation

Before any surgical intervention, you must systematically evaluate:

• Anatomical structures involved and prolapse grade through clinical examination, supplemented by imaging if clinical data are insufficient or if there is discrepancy between symptoms and clinical findings 4
• Recurrence risk factors, particularly high-grade prolapse which predicts higher failure rates 4
• Urinary symptoms: Perform flowmetry with post-void residual measurement, urinalysis, and renal-bladder ultrasound to assess for urinary incontinence, overactive bladder, dysuria, or upper tract involvement 4, 5
• Anorectal symptoms: Screen for irritable bowel syndrome, obstructed defecation, and fecal incontinence 4
• Occult stress incontinence: Up to 60% of women with pelvic organ prolapse have coexisting urinary incontinence that may be masked by the prolapse itself 5

Critical Imaging Considerations

In cases of long-standing prolapse, obtain imaging (radiographs, ultrasonography, or CT scan) to assess the entire urinary tract for stones, obstruction, and dilatation, as multiple vesicle calculi can cause irreducible prolapse requiring emergency intervention 6

Surgical Management Algorithm

Approach Selection Based on Compartment and Severity

For symptomatic prolapse requiring surgery, the surgical approach depends on compartments involved, extent of prolapse, and patient factors:

Anterior/Apical Prolapse

• Laparoscopic/robotic sacrocolpopexy is preferred for apical prolapse, offering shorter hospital stays and fewer postoperative complications compared to open approaches 1
• Fascial reconstruction techniques are indicated for primary pelvic organ prolapse 2
• Mesh-based procedures should be reserved for recurrences and severe prolapse 2

Posterior Compartment (Rectocele)

• Transanal approach (STARR) effectively reduces rectocele size from average 3.8 cm to 1.9 cm, with 82% of patients reporting >50% reduction in obstructed defecation scores at one year 1
• Ventral rectopexy is recommended for high rectoceles or those associated with other pelvic floor disorders, performed open or laparoscopically 1
• Perineal procedures have lower perioperative morbidity but higher recurrence rates (5-21%) compared to transabdominal rectopexy (0-8%) 1

Concomitant Stress Urinary Incontinence Management

When pelvic organ prolapse surgery is planned in patients with stress urinary incontinence, consider concomitant anti-incontinence procedures:

• Synthetic midurethral slings achieve 85-87% cure/dry rates at 12-47 months when performed with concurrent prolapse treatment 7
• Autologous fascial slings demonstrate 85-92% cure/dry rates at 24-47 months with concurrent prolapse repair 7
• Patients undergoing combined surgery have lower rates of postoperative stress incontinence but higher rates of voiding symptoms and complications (bladder perforation, urethral injuries, tape exposure occurring in 14% vs 8%) 7

The mean complete continence rate with combined POP and MUS surgery is 80% at 22-month follow-up 7

Critical Pitfalls to Avoid

Surgical Complications Counseling

• After posterior rectopexy, 50% of patients develop severe constipation - this must be discussed preoperatively 1
• Bowel resection should be avoided in patients with preexisting diarrhea and/or incontinence as these symptoms may worsen 1
• The correlation between symptom improvement and anatomical correction is often weak - anatomical abnormalities may be caused by underlying functional disorders not corrected by surgery 1
• Rare but serious complications after STARR include fistula, peritonitis, and bowel perforation, with higher risk of infection, pain, incontinence, and bleeding 1

Emergency Situations

In cases of incarcerated prolapse without signs of ischemia or perforation, attempt conservative measures and gentle manual reduction under mild sedation or anesthesia 7

In hemodynamically unstable patients with complicated prolapse, do not delay surgical management to attempt conservative reduction 7

Multidisciplinary Coordination

A collaborative approach between gynecologists and colorectal surgeons is ideal, particularly for complex cases with multiple pelvic floor disorders 1

Surgery is necessary in less than 5% of patients with defecatory disorders - the vast majority should be managed conservatively with biofeedback therapy 1