• About Us
    • Contact Us
    • Login
    • ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • #GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
About Us Contact Us Login ObGFirst
  • COVID-19
  • Alerts
  • OB
  • 2T US Atlas
  • The Genome
  • GYN
    • 0 CME Hours
    • GYN
    • Sexual Health
  • Primary Care
  • Your Practice
  • #GrandRounds
  • My Bookshelf
  • Now@ObG
  • Media
Alerts
CMECNE

ACOG/AUGS Guidance Update: Diagnosis and Management of Pelvic Organ Prolapse Including Role of Mesh

image_pdfFavoriteLoadingFavorite

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the definition of pelvic organ prolapse
2. Describe the role of synthetic mesh in the treatment of pelvic organ prolapse

Estimated time to complete activity: 0.5 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 1/15/2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.5 contact hours.

Read Disclaimer & Fine Print

Table of Contents  

  • POP Definition and Staging
  • History
  • Physical
  • Risk Factors
  • Treatment
  • Synthetic Mesh and Biologic Graft Materials in Vaginal POP Surgery

SUMMARY:

ACOG and AUGS have updated the Pelvic Organ Prolapse (POP) recommendations. Guidelines now address the FDA order for manufacturers to discontinue sale and distribution of mesh for treatment of POP in the US. The FDA order applies only to mesh placed vaginally for POP and does not apply to (1) transvaginal mesh for SUI or (2) sacrocolpopexy (abdominal placement). POP is considered ‘benign’, but symptoms can seriously impact quality of life, affecting defecatory, voiding and sexual function.

CLINICAL ACTIONS:

POP Definition and Staging

Definition

  • Descent of uterus or vagina which may result in organ prolapse
    • Anterior wall
      • Cystocele (bladder) | Urethrocele | Cystourthrocele
    • Posterior wall
      • Rectocele (rectum) | Enterocele (small bowel)
    • Apical
      • Uterine | Vaginal vault (post hysterectomy)
  • ACOG/AUGS state

Pelvic organ prolapse only should be considered a problem if it is causing prolapse symptoms (ie, pressure with or without a bulge) or sexual dysfunction or if it is disrupting normal lower urinary tract or bowel function

POP-Q Staging

See below in ‘Learn More – Primary Sources’ for link to AUGS POP-Q tool

  • Stage 0
    • No prolapse
  • Stage 1
    • Criteria for stage 0 are not met
    • Most distal prolapse is more than 1 cm above the level of the hymen
  • Stage 2
    • Most distal prolapse is between 1 cm above and 1 cm below the hymen
  • Stage 3
    • Most distal prolapse is >1 cm below the hymen but no further than 2 cm less than the total vaginal length
  • Stage 4
    • Complete procidentia or vault eversion

History

  • Women presenting with POP should undergo a careful history and physical examination with attention to the degree of bother caused by the prolapse
    • Assess urinary incontinence and bladder emptying
      • Gravitational effect (increased organ displacement): Is voiding more difficult after standing?
      • Does manually reducing the bulge (‘splinting’) improve urinary flow?
    • Assess bowel function
      • Straining | Laxative use | Splinting to reduce rectocele and improve rectal emptying
    • Impact on sexual function
      • Dyspareunia | Coital continence

Physical

  • Comprehensive abdominal and physical exam
  • For some patients, extent of descent can be evaluated in the supine position but if unclear, having patient stand may uncover extent of prolapse
  • Pelvic floor tone
    • Ask patient to contract and relax musculature and grade on following scale
      • Absent | Weak | Normal | Strong
  • Use single blade to hold away opposite vaginal wall during visual exam of the vault and apex
  • Urinary symptoms
    • Voiding symptoms or prolapse is evident beyond hymenal ring
      • Perform postvoid residual volume (catheter or ultrasound)
      • Note: Consider urodynamics in the presence of incontinence and ≥stage II prolapse or voiding dysfunction
    • Urgency or other UTI symptoms
      • Perform urinalysis: Culture and microscopy
  • Assess the pelvic organs and perform a pelvic organ prolapse quantification (POP-Q)
    • The POP-Q system is recommended before treatment of POP to quantify the degree of prolapse
  • Note: If findings do not match symptoms, referral to urogynecologist “may be needed”

KEY POINTS:

Risk Factors

Increasing parity | Vaginal delivery | Age | Menopausal status | Obesity | Connective tissue disorders | Chronic constipation

Treatment

Nonsurgical

  • Consider nonsurgical treatment options when appropriate
    • Modifiable risk factors include obesity and constipation
    • Pelvic muscle exercises
    • Pessary – generally considered low-risk option and a good alternative for women who wish to maintain fertility
      • Follow up 3 to 4 months if patient can not replace own pessary; Otherwise annual visit sufficient
      • In case of erosion, remove pessary for 2 to 4 weeks and apply local estrogen therapy (may resolve without estrogen therapy) | Consider more frequent pessary removal and cleaning

Surgical Therapy for Failed/Declined Nonsurgical Treatment

  • Upper vaginal prolapse
    • Abdominal sacrocolpopexy
    • Uterosacral ligament suspension
    • Sacrospinous fixation
  • Anterior wall prolapse
    • Anterior colporrhaphy
  • Posterior wall prolapse
    • Posterior colporrhaphy

Additional Notes on Surgical Treatment

  • Vaginal apex suspension (uterosacral or sacrospinous ligament suspension) should be performed at the time of hysterectomy for uterine prolapse
  • Anterior wall prolapse is commonly associated with apical prolapse
    • Both should be surgically corrected if present to reduce risk of recurrent POP
  • Posterior wall prolapse repair is more effectively done vaginally rather than transanally
  • Candidates for abdominal sacrocolpopexy (mesh or biologic graft from vaginal apex to anterior longitudinal ligament of sacrum) include those at high risk for recurrence
    • Age <60 years
    • POP-Q stage 3 or 4
    • BMI >26
    • Authors of the Cochrane Review (2016) of sacrocolpopexy for apical repair concluded that mesh was not superior to native tissue repair

Sacral colpopexy is associated with lower risk of awareness of prolapse, recurrent prolapse on examination, repeat surgery for prolapse, postoperative SUI and dyspareunia than a variety of vaginal interventions

Synthetic Mesh and Biologic Graft Materials in Vaginal POP Surgery

  • FDA (April 2019) ordered manufacturers of synthetic mesh for POP to discontinue sale and distribution in the US
  • This order applies to transvaginal mesh only and not transabdominal POP or SUI

Vaginal Prolapse Repair

  • Both mesh or biologic grafts are associated with greater likelihood of repeat surgery for combined outcomes of prolapse, stress incontinence or mesh exposure
  • Data on biologic grafts (e.g. cadaver) are limited and of low quality (most no longer available for use)

Posterior Wall Prolapse

  • Use of synthetic mesh or biologic grafts is associated with increased complications (mesh exposure) and no improvement in outcome
  • Mesh or grafts should not be used routinely in the primary repair of posterior wall prolapse

Anterior Wall Prolapse

  • Biologic grafts show minimal/ no difference in recurrence risk vs native tissue repair
  • Synthetic mesh improves anatomic outcome, but is associated with
    • Increased risk of repeat surgery for prolapse, urinary incontinence and mesh exposure
    • Longer operating times and greater blood loss
    • 11% risk of mesh erosion following anterior vaginal repair
    • 7% of cases that will require surgical correction
    • Dyspareunia rate of approximately 9%

Notes:

  • Use of mesh or biologic grafts should only be undertaken by surgeons who have training specific for these procedures
    • Training should include patient selection, anatomy, intraoperative and postoperative techniques, treatment of any adverse outcomes
  • Routine intraoperative cystoscopy should be performed during POP surgery when there is risk to the bladder or ureter
  • AUGS 2013 position statement on credentialing includes the following

It is imperative that local hospitals and health systems establish and strictly enforce robust processes to both/credential and audit surgeons with specific expertise, experience, training and skill to perform these procedures. AUGS has developed, and published credentialing guidelines for transvaginal mesh surgery for pelvic organ prolapse and sacrocolpopexy for the treatment of pelvic organ prolapse.

Want to be notified when new guidelines are released? Get ObGFirst! Tap Here »

Learn More – Primary Sources:

ACOG Practice Bulletin 214: Pelvic organ prolapse

ACOG Committee Opinion 694: Management of Mesh and Graft Complications in Gynecologic Surgery

AUGS: Update on FDA Announcement on Transvaginal Mesh for Prolapse

FDA takes action to protect women’s health, orders manufacturers of surgical mesh intended for transvaginal repair of pelvic organ prolapse to stop selling all devices

Cochrane Review: Surgery for women with anterior compartment prolapse. Cochrane Database of Systematic Reviews

Incidence and Management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systemic review. Systematic Review Group of the Society of Gynecologic Surgeons.

AUGS Position Statement on Restriction of Surgical Options for Pelvic Floor Disorders, March 26, 2013

AUGS POP-Q Tool

FIGO review of statements on use of synthetic mesh

Take a post-test and get CME credits

TAKE THE POST TEST

image_pdfFavoriteLoadingFavorite
< Previous
All Alerts Posts
Next >

Related ObG Topics:

Comparing the Use of Mesh Against Standard Repair for Prolapse
Practical info for your gynecology practice
Surgery for Urinary Incontinence – When the Sling’s the Thing
Practical info for your gynecology practice
Cystourethroscopy – Did I Cut, Twist, Suture, Burn, or Make a Hole in It?

Sections

  • COVID-19
  • Alerts
  • OB
  • GYN
    • GYN
    • Sexual Health
  • 2T US Atlas
  • The Genome
  • Primary Care
  • Your Practice
  • #Grand Rounds
  • My Bookshelf
  • Now@ObG
  • Media

ObG Library

  • Hysteroscopy
  • Fertility
  • Site Map/
  • © ObG Project/
  • Terms and Conditions/
  • Privacy/
  • Contact Us/
© ObG Project
SSL Certificate


  • Already an ObGFirst Member?
    Welcome back

    Log In

    Want to sign up?
    Get guideline notifications
    CME Included

    Sign Up

Get Guideline Alerts Direct to Your Phone
Try ObGFirst Free!

Sign In

Lost your password?

Sign Up for ObGFirst and Stay Ahead

  • - Professional guideline notifications
  • - Daily summary of a clinically relevant
    research paper
  • - Includes 1 hour of CME every month

ObGFirst Free Trial

Already a Member of ObGFirst®?

Please log in to ObGFirst to access the 2T US Atlas

Password Trouble?

Not an ObGFirst® Member Yet?

  • - Access 2T US Atlas
  • - Guideline notifications
  • - Daily research paper summaries
  • - And lots more!
ObGFirst Free Trial

Media - Internet

Computer System Requirements

OBG Project CME requires a modern web browser (Internet Explorer 10+, Mozilla Firefox, Apple Safari, Google Chrome, Microsoft Edge). Certain educational activities may require additional software to view multimedia, presentation, or printable versions of their content. These activities will be marked as such and will provide links to the required software. That software may be: Adobe Flash, Apple QuickTime, Adobe Acrobat, Microsoft PowerPoint, Windows Media Player, or Real Networks Real One Player.

Disclosure of Unlabeled Use

This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.

The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Jointly provided by

NOT ENOUGH CME HOURS

It appears you don't have enough CME Hours to take this Post-Test. Feel free to buy additional CME hours or upgrade your current CME subscription plan

Subscribe

JOIN OBGFIRST AND GET CME/CE CREDITS

One of the benefits of an ObGFirst subscription is the ability to earn CME/CE credits from the ObG entries you read. Tap the button to learn more about ObGFirst

Learn More
Leaving ObG Website

You are now leaving the ObG website and on your way to PRIORITY at UCSF, an independent website. Therefore, we are not responsible for the content or availability of this site