Exciting Research Sheds Light on the High Failure Rate of Conventional Prolapse Repair Surgery

Professor Hans Peter Dietz, an Australian researcher revolutionising our understanding of pelvic floor imagery.

Professor Dietz, a researcher at The University of Sydney, has spent years trying to improve the way that imaging technology (such as ultrasounds) is used for diagnosis and treatment of pelvic floor disorders.

As part of this research, he and his team have discovered that pelvic organ prolapse (POP) generally occurs when the puborectalis (pelvic floor) muscle tears or becomes detached from the bone during childbirth. If this damage is serious, it can cause any surgical prolapse repair attempts to fail.

Though he has identified this problem, there is currently no way to prevent or repair this muscle damage. Professor Dietz currently has two studies going - one focused on a possible prevention and the other on a possible repair.

However, this improvement in our understanding of POP is already a great achievement.

Professor Dietz also shows a good understanding of the situation faced by many women with POP when he acknowledges that we often deal with medical professionals who are not aware of this new research. If you find yourself in that situation, you could direct your healthcare provider to Dr Dietz's website, or take along a printout of the section that is relevant to you.

There is so much information freely available on Professor Dietz's website that it is well worth visiting to explore in more detail. Begin with his 'General Info' page which summarises his knowledge of the field an explains some of the medical terms he uses in the rest of his website.

There is also extensive information available on this website for medical professionals, including a page of teaching resources.

Warning: This webpage includes a number of clinical images and videos of pelvic floor damage. Images from the labour room may be particularly upsetting to women suffering from birth trauma. If you would like to read the information without viewing the images, ask a friend or family member to copy the text into a document for you, without the pictures.

Learn About Managing Prolapse Through Lifestyle Changes on MD Conversation

 

MD Conversation provides online presentations that can be used instead of information pamphlets by doctors and specialists. While this is a subscription service, the introductory presentation on Pelvic Organ Prolapse (POP) is available free online here: An Introduction to Pelvic Organ Prolapse.

 

This presentation is very detailed, and includes moving diagrams that may help you to understand pelvic anatomy and POP.

 

The best feature of this presentation is that it clearly states what the goals of POP treatment are, and then compares the available treatments against this list of goals. It also goes into much more detail about lifestyle changes (such as quitting smoking) than most other resources.

 

The presentation can be paused, and you can review individual sections as many times as you want.

 

Please note that the Prolapse Information Project is not affiliated with MD Conversation, nor am I necessarily suggesting that you subscribe to this service. I am only directing you towards the free portion of this service.

A Resource to Help You Get Informed Post-Surgery and Have the Best Chance of Recovery

Prolapse Repair Surgery is a big step to take. It is major surgery, usually with a fairly long recovery period. Added to that is the relatively high rate of failure, which makes it all the more important for you and your surgeon to work as a team for the greatest possible chance of success.

 

However, it can be difficult to be a team if you do not have a clear method of communication. Often, information about how a procedure went, and what you need to do to look after yourself post-surgery, is given to you in the recovery room or in the days following the surgery while you may still be disoriented or overwhelmed.

 

The National Patient Safety Foundation in America has recognised this, and has created a tool to help you and your surgeon clearly record your discharge information. It is a PDF, and can be downloaded here: Post-Discharge Tool.

 

This excellent resource includes spaces for you and your surgeon to record:

• Follow up appointments, including a plan for what you need to bring and ask at each appointment
• A clear diagnosis
• A checklist of important steps during your recovery
• A medication list, including detailed information about doses, and the reason you need to take each medication

If your medical practice includes post-surgical care, distributing this resource to your patients may improve your surgical outcomes, and field fewer phone calls asking for clarification of your instructions.

 

Everyone involved in managing prolapse, both patients and health professionals, benefits from improved communication.  

 

 

What the National Guideline Clearninghouse Says About POP May Surprise You

Ever wondered just what your doctor or specialist was thinking when they recommended a particular treatment for Pelvic Organ Prolapse (POP)? The US National Guidelines on POP may help shed some light on their thought process.

 

The National Guideline Clearinghouse is part of the US Department of Health and Human Services. Their recommendations about Pelvic Organ Prolapse summarise all of the research on the topic until 2011 in a single page of dot points. You can read these guidelines here: Pelvic Organ Prolapse: Recommendations.

 

The most interesting part of these guidelines is the difference between the guidelines from good-quality research (Level A evidence) and the guidelines based on 'professional knowledge' from health care providers who treat POP (Level C evidence).

 

The agreement between healthcare providers is that women with POP who were asymptomatic (had no symptoms) or who had mild symptoms required no treatment. Many women with 'mild' POP, who perhaps experience discomfort or mild pain and incontinence, may be familiar with this view; having been told by health professionals that they do not require treatment.

 

However, there is no evidence from good-quality research that mild POP should go untreated. In fact, the National Guidelines state that a pessary would be appropriate for most women regardless of the degree of their prolapse.

 

We often assume that health professionals are acting based on the most up-to-date scientific evidence, but it is worth remembering that they are also using information that they received during their training, or impressions they have formed during their career.

 

If you have mild prolapse, have seen a health professional who believes you do not require treatment, and can not change health professionals, then it may be worth printing out this section of the guideline while trying to demonstrate to them that you need treatment.

 

Remember that at the Prolapse Information Network I recommend that you continue to seek medical help until you receive it. You are entitled to receive evidence-based, appropriate treatment for your prolapse.

Free Multilingual Patient Information Leaflets about Prolapse and Many Other Bowel and Bladder Issues

 

As a GP, it can be difficult to find accurate, easy-to-understand information for your patients about prolapse and continence. You may also feel that you do not have the time or resources to find and print off a pamphlet for each female patient who has bladder, bowel or prolapse symptoms.

The International Urogynecological Association has created an extensive library of patient information leaflets that can be found here: Patient Leaflets.

There are leaflets on many conditions and treatment options, including:

• Pelvic Organ Prolapse (POP)
• Types of POP repair surgery
• Constipation
• Urinary Tract Infection
• Pelvic Floor Exercises

These leaflets are available in a number of languages, including English, Mandarin, Italian, Spanish and Arabic. They are in question and answer format, and include clear detailed diagrams. These leaflets download as PDFs, so you could save them to your hard drive if you do not have consistent internet access in your clinic.  

It is well worth your time to print off the relevant resource for your patients who are suffering from any of these conditions. When your patients are more informed about their health problems:

• They are less likely to suffer undue anxiety due to misunderstanding their condition and treatment
• They are less likely to get unscientific information from non-reputable sources, such as websites with commercial interests in the condition; and therefore less likely to undertake unproven treatments that could make their condition worse
• They are more likely to follow your instructions for care if they truly understand them and understand how they will help
• It will build better communication and more trust between your and your patients
• This will in turn make your patients more likely to return to you for help, rather than turning to unproven alternative therapies

If you are a woman with a prolapse, you can also access these resources directly by using the link above.

The Best Evidence for Prolapse Repair Surgery

In previous posts, I explained how you can use Cochrane Reviews (a summary of recent medical research) to get the latest scientific evidence about each treatment option for prolapse. You can read the reviews here: pessary, oestrogen and conservative management.

 

The Cochrane Review for prolapse repair surgery can be found here: Surgical management of pelvic organ prolapse in women.

 

Because of the vast number of surgeries available, and the controversy surrounding many methods, this review cannot be quickly summarised, and needs to be read in its entirety.

 

I strongly recommend that you at least look at the section about the type of surgery that you are considering, or that your surgeon has recommended. This is not necessarily because you should not go through with the surgery, but it will help you to be informed about the risks and ask the right questions at your specialist appointment.

Pelvic Floor Disorders Network: Working Together to Research Prolapse

 

 

The Pelvic Floor Disorders Network (PFDN) is an American group trying to improve the quality and speed of research about conditions such as prolapse.

 

It is made up of eight American research hospitals working together. This enables the PFDN to research more quickly, and to include more participants in their studies. This is very important, as the more people there are in a study, the more likely it is to produce results that will apply to a wide variety of women.

 

Currently, their research projects relating to prolapse include:

• A comparative study of uterine prolapse procedures
• Examining the durability of prolapse repair surgery
• The position of the bladder, bowel and vagina in the years following prolapse repair surgery

 

You can read more about these research projects on their website: Pelvic Floor Disorders Network.

 

Much of the research about prolapse in the last 10 years has been produced by the PFDN - to date their members have published 79 papers. They should be acknowledged for their contribution to our understanding of prolapse, and improvements in treatment.

Mesh Surgery in the News

Elevate prolapse repair mesh

A common type of prolapse surgery currently being used involves using a synthetic mesh to support the pelvic organs. It is the alternative to the more traditional type of surgery known as 'native tissue' surgery, which uses the woman's own muscle and ligaments to do this.

 

Mesh surgery is controversial because although it has worked well for many women, it has a relatively high rate of complications. These include incontinence, pain during sex, and complications from the mesh eroding the vaginal walls. You can read more about this in the Cochrane Review of Prolapse Surgery.

 

The controversy about mesh surgery has been in the news recently.

 

You can read about the halt to all use of mesh surgery for prolapse in Scotland here: "Cheers and tears for brave mesh victims as controversial operations are suspended."

 

This article from the Wall Street Journal details the large-scale Embrace study currently underway in America, testing the safety and effectiveness of one the most common mesh products, following a recent FDA advisory on the topic: "American Medical Systems Enrolls First Patient in Embrace."

 

Links to news articles are provided only to keep you up to date with what is happening around the world with the issue of prolapse. These articles are from mainstream newspapers, not scientific sources, and are not intended to provide information about how to manage your prolapse.

 

Bethesda Hospital Prolapse Information Video

You may have already had a look at the information sheets and diagrams that can be found by clicking the Information Sheets tab. But you may have found the language confusing, or the diagrams unclear. You may find this information easier to understand presented in the following video.

Bethesda Naval Hospital in America has created a great detailed video to explain prolapse to its patients.

This video can be accessed on YouTube, or viewed here:

The video covers the following points:

• What is prolapse?
• Different types of prolapse (explained using animated diagrams)
• Types of treatment that are available
• An overview of some types of surgery
• A detailed explanation of Sacrocolpopexy surgery
• A discussion of the risks and benefits of different types of treatments

These points are explained clearly in everyday language, making this video a great starting point to understanding prolapse.

Warning: This video includes footage of a Sacrocolpopexy surgery. This footage begins at 6 minutes. Please stop watching the video at this point, or do not watch the video at all, if this will be distressing to you or if it will stop you from seeking appropriate treatment.

National Association for Continence "Tools for Patients"

The National Association for Continence is an American organisation that aims to help women and men with continence and pelvic floor problems.

 

They have put together a page of excellent resources for women with prolapse, both in America and around the world: Tools for Patients.

 

General resources that can be used by all women, and their advocates, include:

• Information on patients' rights and informed consent, including a clear list of the information you should be given as a patient
• A summary of the latest findings and FDA statements about the use of mesh in prolapse repair surgery
• The questions that your surgeon should ask you before recommending a particular type of surgery, and the information you should be given about your condition and the suggested treatment

One of the most important parts of managing your prolapse is knowing the right questions to ask when you are talking to a health professional. This resource will help you to go into important conversations well-informed. It is also useful to read this if you will be advocating for a woman with prolapse at medical appointments.

 

For women in America, there is information on the 'Centres of Excellence' program, which identifies clinics that are specialists in dealing with prolapse. This is very important, as it can be extremely difficult to find a surgeon or practitioner who is experienced in dealing with prolapse and in whom you are confident. This program aims to take the guess-work out of the process by identifying health professionals who meet certain standards in training and results. 

Once You Have Chosen Surgery, What are Your Options?

Making decisions about which treatment path to take can be difficult when you have a prolapse. Each path (conservative management, pessary, or surgery) has benefits and drawbacks. There is a lot of conflicting evidence, and often not much objective research.

 

So it can be very disheartening if you make the decision to proceed with surgery to then find out that there are so many types available, and that there is a lot of controversy about many prolapse repair techniques.

 

The Royal Women's Hospital in Melbourne, Australia is a well-respected research hospital. They have put together the following information to outline the main types of prolapse repair surgery available, and the dangers and benefits of each: More about surgery.

 

Reading this resource can really help you to be informed about procedures that have been suggested to you. It can also help you to determine if your surgeon is right for you. If they are suggesting a type of surgery that seems less appropriate than another, considering your lifestyle and health, then it might be a good idea to seek a second opinion.

 

Surgery, like all forms of prolapse treatment, is a big decision that can have a huge impact on your quality of life. Make sure you are informed and confident before you proceed.

Wound Care - How to Look After Yourself Post-Operation or After Childbirth

 

There is a lot of conflicting information on the internet about how to care for wounds. Much of it is unfortunately not based on clear evidence.

Your first source of information should of course be the health professional who performed your surgery or delivered your baby. However, it can be difficult to know where to turn if the information you have received is insufficient, contradictory, or if you received no information at all.

The following page from Mater Hospital in Queensland provides up-to-date information on how to care for a third or fourth degree tear following childbirth: Recovering from 3rd or 4th degree perineal tears.

 

Though this page naturally includes specific information on third a fourth degree tears, it also has good general guidelines on caring for genital wounds. It also warns you against some of the incorrect advice circulating on forums (such as drying yourself with a hairdryer, which can put you at risk of burns if you have reduced sensation in the area). Remember, online forums are best used as a source of support, or as the start of your research into your treatment.

 

The most important thing to remember is that your wound requires regular cleaning and monitoring. Though you may not want to look at or touch the area, particularly if you have just had a traumatic birth, it is vital that it receives proper attention. If you can not bring yourself to care for your wound, ask a trusted family member or friend to help you. If you do not feel comfortable doing this, then you need to urgently seek help from your doctor or hospital. You are at risk of infection or other complications if you do not keep your wound clean. If you cannot get help anywhere else, go to your local hospital emergency department, and explain that you need mental health support in dealing with your wound.

 

As always, I encourage you to ask for the help you need, and to continue asking until someone helps you.  

At the Prolapse Information Project, I always recommend you seek professional medical advice, even if it means that you need to seek a second opinion in order to feel confident about what you have been told. The information in this article is provided only to help you become informed about your care.

Women's Health Queensland Prolapse Information Sheet

This series covers information sheets about POP from professional health organisations. These pages, though they don't necessarily go into a great deal of detail, are a good place to start. They help you gain a clear understanding of POP.

The Women's Health website from the Queensland Government has detailed fact sheets on many common health conditions. Their fact sheet on Prolapse can be found here: Genital Prolapse Fact Sheet.

The strengths of this fact sheet include:

• The level of detail it provides
• It includes information about less common forms of prolapse, such as Enterocele and Urethrocele
• Clear diagrams of different types of prolapse, and a diagram showing how a Pessary sits when inserted properly

The main feature of this fact sheet is that it includes a good outline of what examinations your health professional should do when diagnosing your prolapse. This means that you can go to your appointment mentally prepared for the physical examination. It also empowers you to make sure your health professional is doing a thorough job, particularly if you are seeing someone like a GP without specialist training.

RANZCOG Prolapse Information Sheet

This series covers information sheets about Pelvic Organ Prolapse (POP) from professional health organisations. These pages, though they don't necessarily go into a great deal of detail, are a good place to start. They help you gain a clear understanding of POP.

 

 

 

The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) has put out a short information sheet about prolapse: Prolapse of the Pelvic Organs. 

 

Though it has some information on what is referred to as 'conservative treatment' (which may include monitoring, physiotherapy or insertion of a Pessary), its main focus is on surgery.

 

The main strength of this fact sheet is that it includes a video that explains laparoscopy (a common form of prolapse repair surgery), and shows what happens during a laparoscopy.

 

While I encourage women to be as informed as possible about their prolapse and any treatment they undertake, you know yourself best. If watching a video like this will make you more anxious about surgery, then it may be better to read about what happens during the surgery rather than watching it.

 

Warning: The end of the video shows how laparoscopy can be used to treat Ectopic pregnancy. Stop it before the end, or do not watch it at all, if this will be distressing to you.

Prolapse on "The Conversation"

The Conversation is an Australian news website on which specialists (usually academics) write articles about their field of expertise.

 

Caroline Gargett, one of the researchers in the Monash/CSIRO team currently working on improved prolapse repair surgery, has written an article about prolapse on The Conversation: What is Pelvic Organ Prolapse?

 

This article includes a good general introduction to prolapse, some thoughts about the impact it can have on a woman's life, and some of the developments in treatment.

 

She uses the following example to show just how common prolapse is:

 

"Considering these statistics, three generations of women in a family may potentially be affected at any given time – the new mum, her mum and her grandmother."

 

She also acknowledges the devastating and ongoing effect that prolapse, particularly if it causes incontinence, can have on a woman's life:

 

"...the impact of incontinence on the quality of life and daily functioning can be severe. Indeed, it’s comparable to the effects of having a stroke or dementia."

 

Gargett also speculates about why research in this area is just gathering momentum now, and why so many women still do not seek treatment:

 

"The reason so little is known about pelvic organ prolapse in the community is that these symptoms are incredibly embarrassing for women."

 

At the end of the article, Gargett mentions that she and her team are in the early stages of testing their new mesh and stem-cell combination surgery. As the article is from September 2012, this research has since been completed, and the results look very promising. The abstract (a short summary of the study) can be found here: Human endometrial mesenchymal stem cells modulate the tissue response and mechanical behavior of polyamide mesh implants for pelvic organ prolapse repair.

 

Jean Hailes Foundation Information Sheet

This series covers information sheets about POP from professional health organisations. These pages, though they don't necessarily go into a great deal of detail, are a good place to start. They help you gain a clear understanding of POP.

The Jean Hailes Foundation is an Australian charity that promotes research and awareness of women's health issues.

Their prolapse information sheet can be found here: Prolapse and Bladder Weakness.

Their information sheet on prolapse is quite detailed, and has a really clear focus on giving women accurate information on which to base their decisions.

The key strengths of this information sheet include:

• A clear diagram showing types of prolapse
• A table showing the degrees of prolapse
• A table showing the different types of tests that you may have to undergo, and what they involve
• A table showing treatment and management options
• It was updated recently (January 2014), to bring it in line with current research

The Jean Hailes Foundation may also be able to help you with other women's health issues. They can be contacted within business hours on 1800 JEAN HAILES (532 642).

Voices for PFD Information Sheet

This series covers information sheets about POP from professional health organisations. These pages, though they don't necessarily go into a great deal of detail, are a good place to start. They help you gain a clear understanding of POP.

'Take the Floor' is a website about Pelvic Floor Dysfunction (including prolapse), produced by the American Urogynecologic Society.

Here is the page of frequently asked questions: Take the Floor.

The strengths of this information sheet include:

• The fact that it is produced by a reputable professional organisation
• It presents both the pros and cons of different treatment options
• It includes some information on conditions that other information sheets may not, and which some GPs and even Gynaecologists may not be aware of (such as underlying incontinence that can be revealed by a cystocele repair)

One weakness is the lack of diagrams, which may make it difficult for readers to get a clear understanding of what is actually going on inside a person with a prolapse.

Which Health Professional Should You be Seeing?

 

 

Being diagnosed with a prolapse can plunge you into a world filled with unfamiliar medical terminology.

 

One of the most confusing things can be navigating which type of professional you should seek help from. A continence nurse? A women's health physio? A urogynaecologist? What the heck even is a urogynaecologist?

 

The Continence Foundation of Australia has put together a really informative page that tells you what the qualifications of each of these professionals are, and in what situation they can help you. This is particularly important when finding a properly qualified physiotherapist, or when choosing which type of professional should perform your surgery (if you choose to have surgery).

 

This great resource is available here: Which Health Professional?
 

Remember, the Continence Foundation of Australia can also help you to find an appropriate practitioner close to where you live. Call their help line 1800 33 00 66 Monday to Friday 8AM to 8PM.

New Surgical Technique with an Improved Success Rate

When you are first diagnosed with a prolapse, and do the inevitable internet search, it can seem like there is little good news to be found - particularly when it comes to surgery. Posts in this series (with the tag "Breakthroughs") will help you keep up to date about exciting innovations in the treatment of prolapse.

Dr Carey, head of Urogynaecology at the Royal Women's Hospital in Melbourne

Dr Marcus Carey, head of Urogynaecology at the Royal Women's Hospital in Melbourne, has developed a new technique for prolapse repair surgery that compliments the existing use of mesh.

Dr Carey comments: "I saw a huge, unmet need for women needing this surgery, which currently has a high fail rate...Traditional surgical techniques for this operation had been around for about 100 years." His innovation involves the use of a silicone support during surgical recovery, which improves outcomes by almost 15%.

If you'd like to read about the outcomes in more detail, the abstract for a 12 month study of this new technique is available on Pub Med here: Vaginal surgery for pelvic organ prolapse using mesh and a vaginal support device.

A Better Mesh for POP Surgical Repairs



When you are first diagnosed with a prolapse, and do the inevitable internet search, it can seem like there is little good news to be found - particularly when it comes to surgery. Posts in this series (with the tag "Breakthroughs") will help you keep up to date about exciting innovations in the treatment of prolapse.

Dr Edwards, one of the researchers

One of the elements that causes the most complications in many current types of prolapse repair surgery is the mesh used to support the vaginal walls.

Monash University and the CSIRO are currently researching this problem, with two promising lines of inquiry. They are looking at creating a mesh that has better properties, and also considering using stem cells to help the body accept the mesh when it is implanted.

Good luck to the research team - hopefully we will all be benefiting from their success before long!