Curriculum Vitae
Name: Dr. Budi Iman Santoso, SpOG(K)Education:
FKUI tahun 1980Pasca Sarjana Spesialis Obstetri Ginekologi FKUI tahun 1987Konsultan Uroginekologi tahun 2003
Working Experience:1989 – sekarang Staf Pengajar Dept. Obsgyn
FKUI/ RSCM2004 – sekarang Kepala Divisi Uroginekologi,
Dept. Obsgyn, FKUI/ RSCM
Organization:Anggota IDIAnggota POGIPresident Elect PKMISekretaris Pengurus Besar PERKINAAnggota International Uro-Gynecological Association (IUGA)Anggota International Continence Society (ICS)Direktur P2KS
NONSURGICAL MANAGEMENT OF GENITAL
PROLAPSE
Dr. Budi Iman Santoso,SpOG(K)
Division of UrogynecologyDepartment of Obstetrics and Gynecology
School of Medicine, University of Indonesia/Dr. Cipto Mangunkusumo Hospital
Jakarta, Indonesia
INTRODUCTION Approximately 25 million women world
widereach menopause every year. In 1990 there were 567 million
postmenopausal women with an average age of 60.
By 2030, it is estimated that 47 million women will reach menopause every year, and the total number of post menopausal women will reach 1.2 billion.
The prevalence of genital prolapse increases with age
More women are living longer, genital prolapse will become even more common in our daily practices.
Currently this complication is treated surgically, and there is minimal information about nonsurgical treatment
The prevalence of genital prolapse increases with the age of the women
There were 590.000 hysterectomies in 1990 in this country, and > 90% were done for benign indications in women of reproductive age.
In 1993, 58,1% of hysterectomies were in women younger that 45.
Recently, the number of hysterectomies has begun to decrease. As compared to 1990, hysterectomy decreased 7.8%, from
590,000 to 544,000 in 1993, whereas the vaginal rate (proportion of vaginal from the total number of hysterectomies) increased from 26.1 to 34,9
in 1993. As compared to younger women, women > 65 years have a higher vaginal rate (40.3 in 1990 and 41.9 in 1993)
Surgical procedures for prolapse without adequate identification of the support system defect or an enterocele, for instance, cannot correct the problem.
surgery has almost become the only widely available treatment for genital prolapse.
Figure 1. Number of women with genital prolapse, by age group
78,00080,00082,00085,00086,00088,00090,00092,00094,00096,000
85,000
94,00096,000
15 – 44 years > 65 years45 - 64
Figure 2. Number of women (x1,000) with vaginal and uterine prolapse, by age group
353025201510
50
15-44 YEARS > 65 YEARS45-64
□ Vaginal ■ Uterine
Thou
sand
s 21 23
31
9
29
6
PELVIC SUPPORT SYSTEM
The levator ani muscles the endopelvic fascia three pair of muscles form the levator ani: the pubocoocygeus, puborectalis and iliococygeus. These muscles contain two types of fibers: 70% slow twitch fibers (fatigue resistance fibers) and 30% fast twitch fibers (responding to increases in intra abdominal pressure ). The levator ani and sphincter muscles of the pelvic floor are innervated by the anterior sacral roots S2-S4, The external anal.sphincter and the striate urethral sphincter are innervated by branches of the pudendal nerveThe uterus, upper vaginal and rectum lie parallel to and directly on the levator plate.
Level 1Level IILevel III
Genital prolapse can be caused by factors that chronically increase intraabdominal pressure, by weakened pelvic supports and by inappropriate corrective surgery.The pelvic support system may be weakened by congenital or acquired myopathy or neuropathy, familial predisposition, traumatic deliveries, multiparity, large newborns, inadequate perineal repairs, failed postpartum exercises, poor nutrition, and hormonal deficiency
Figure 3. Number of women (x1,000) with vaginal prolapse after hysterectomy and enterocele, by age group
141210
86420
45-64 YEARS > 65 YEARS
□ Vaginal prolapse after hysterectomy ■ Enterocele
Thou
sand
s14
7
1416 14
GENITAL PROLAPSE STANDARD NOMENCLATURE
Catatan nilai setiap titik yang diperoleh dan menentukan stadium prolapscm cm cm
Dinding anterior(-3 sampai + 3 cm)
Aa Dinding anterior(-3 sampai + TVL)
Ba Cervix cuff(+ TVL)
C
Hiatus genitalis GH Perineal Body PB Panjang total vagina
TVL
Dinding posterior (-3 sampai + 3 cm
ap Dinding posterior(-3 sampai + TVL)
Bp Forniks posterior(+ TVL)
D
Stadium 0 Tidak ada prolaps Tanda – diatas hymen
Stadium 1 Tepi prolaps < - 1 sampai – 2 cm Tanda + dibawah hymen
Stadium 2 Tepi prolaps -1,0, atau + 1 cm
Stadium 3 Tepi prolaps + 2 sampai + (TVL-3) Catatan : Hymen sebagai titik referensi
Stadium 4 Tepi prolaps +(TVL -2) sampai + TVL
SKEMA TANPA PROLAPS
Aa-3
Ap-3
C-8
D-10
Aa-3, Ap-3, C-8, D-10
Before the vaginal examination, unless the prolapse is evident, gh and pb are measured
Stage 0Stage IStage IIStage IIIStage IV
COMMON SYMPTOMS OF GENITAL PROLAPSE
♫ Traditionally genital prolapse has been associated with lower urinary tract, bowel-rectum, sexual and other symptoms.
♫ Genital prolapse is common : it is estimated that at least half of multiparous women have some degree of genital prolapse but that only 10-20% complain ot symptoms
♫ Common urinary symptoms include frequency, urgency, stress and urge incontinence, hesitancy, weak or prolonged urine stream, feelings of incomplete emptying, need for manual reduction of the prolapse or position changes to begin or complete voidin. and urinary retention.
♫ Moreover, for every 3 cm of cervical descent, the ureter descends 1 cm. the surgeon must therefore be aware of the location of the ureters at all times during the procedure.
COMMON SYMPTOMS OF GENITAL PROLAPSE
♫ Common bowel symptoms♫ Some of these symptoms commonly occur during the postpartum
period, as compression and stretching of muscles and nerves cause partial denervation of the pelvic floor muscles.
♫ Although most women recover by two months postpartum, electrophysiologic evidence of denervation injury can be demonstrated even five years later.
♫ Prolonged second stage, without pushing, is not associated with denervation injury
♫ Common sexual symptoms, inability to have vaginal intercourse (37%)
♫ However, genital prolapse with or without urinary incontinence does not affect most women who continue to be sexuallv active (56%)
TREATMENT CONSIDERATION FOR GENITAL PROLAPSE
Women with genital prolapse have several treatment options: observation, nonsurgical management, corrective surgery and colpocleisis
Kegel exercise Kegel recommended five contractions per minute for 20
minutes, three times a day
PessaryThere have been more than 120 types of pressaries
A. Smith (silicone, folding)B. Hodge without support (silicone. folding)C. Hodge with support (silicone, folding)A. Gehrung with support (silicone, folding)A. Risser (silicone, folding)A. Ring with support (slllcone, folding)B. Ring without support (slllcone, folding)A. Cube (silicone, flexible)B. Tandem-Cube (silicone, flexible)C. Rigid Gellhom (acrylic, multiple drain)D. 95% Rigid Gellhom (silicone, multiple drain)A. Flexible Gellhom (silicone, multiple drain)A. Ring incontinence (silicone)B. Shaatz (silicone. folding)C. Incontinence dish (silicone, folding)D. Inflate Ball (latex)A. Donut (silicone)
Currently most pessaries are made of silicone as it is considered nonallergenic, does not absorb odors or secretions, is resistant to repeat cleansing and autoclaving, and is soft and pliable.
Latex pessaries have fallen out of favor because the general population has allergic reactions that can range from mild skin irritation to asthma and anaphylaxis.
The patient must feel comfortable when sitting, standing, squatting, bearing down and walking. When the pessary is properly fitted, the patient cannot feel it, and the pessary does not descend into the introitus during the Valsalva maneuver.
PESSARY BENEFITS
The Smith-Hodge vaginal pessary (size 2 and 3) increased urethral-functional length and urethral closure pressure in 12 womens.
COMPLICATIONS ASSOCIATED WITH THE PESSARY
Pessaries should be removed periodically for cleaning and evaluation or the genital mucosa.Estrogen vaginal cream is usually applied daily at the beginning. these applications are reduced to once or twice a weekSome older women may be distracted and forget about the presence of the pesari (embedded) pessariesAny foreign body in the vagina for a long time can cause metaplasia and even dysplasia of the mucosa. Vaginal cancer represents only 1-2% of all gynecologic cancer
COMPLICATIONS ASSOCIATED WITH THE PESSARY
The mean interval from insertion to the diagnosis of cancer was 18 vears(1-41 years), with vaginal cancer occurring more frequently than cervical cancer (30% versus 2.6%)Only 10.1% were associated with a pessary 36 women with a pessary need periodic examination because of the possibility of serious consequencesCommonly used pessaries include the ring, donut and Gellhorn) Physicians need only stock two or three sizes of one or two pessary models.
FOLLOW-UP CARE101 women, 50 used a pessary, 66% of those who used the pessary for a month continued to use it for more than 12 months, and 53% continued to use it for more than 36 months.
0nly 21 women discontinued the pessary, and no major complications were associated with its use
Figure 4. long-term pessary use and surgical readiness: proportion of women who continue pessary use or discontinue use for surgical and surgical therapy
70
6050
40
302010
0
Until for surgeryn=19,4 died
Postponed surgeryn=24
Declined surgeryn=58
□ Continue use ■ No, surgical ■ No, nonsurgicalPe
rcen
t
60.0
6.7
33.320.8
62.2
16.7
62.1
17.220.7
Clinicians teach and encourage patients and their partners to remove the pessary regularly (i.e., weekly or monthly). Most women in a study that evaluated this issue chose not to remove the pessary themselves
RECOMENDATIONS FOR FOLLOW UP
After the initial fitting, the woman should return for reexamination in two weeks. If she is satisfied she can return at three-month intervals during the first year of follow-up.Women should be caunseled that appropriate pessary fitting often requires trial and error.At each visit the pessary is removed, rinsed with tap water and dried. The clinician inspects the vagina (and cervix) for abrasions or erosion. and then the lubricated pessary is reinserted. A pessary should be replacedAfter one year. If, after the first year of visit, follow-up has been satisfactory, visits can be schedulecd for every six months
Figure 5. Reason (%) given by 47 women for discontinuing pessary use
60
50
40
3020
10
0Fall-outwanted
surgery
53 (Inconvenient, Inadequate reliaf, uncomportable)
1323
Did not work
Difficultremoving
Unable to void
6 5
N=47 women who discontinue pessary use, 26 of them have surgery
EXAMINATION, EVALUATION OF PROLAPSE AND RELATED CONDITIONS, KEGEL EXCERCISES
Treatment
• Hysterectomy, repair• Colpocleisis
• Observe• Pessary
Non-surgical Surgical
Properly fixed
Danger signs
NoYes
Return in 2 weeksReevaluate
YesTreat
Return q 3 m x 4 ← No↓
Return q 6m
Danger signs: pessary falls out, bleeding, leakorrhea, pain, urinary retention
Figure 6. Genital prolaps management
CONCLUSIONGenital prolapse will increase in frequency as more women are living longer.By avoiding interventions known to cause injury, such as routine episiotomy and elective operative vaginal deliveries, later occurrence of genital prolapse may be avoided. Many recommend attaching the sacrouterine, cardinal and round ligaments to each side of the vaginal apex during hysterectomy and obliterating the space between the sacrouterine ligaments to prevent the development of prolapse.Clinicians must encourage women to perform Kegel exercises routinelyWomen satisfactorily fitted with pessaries need evaluation every three to six months.
