Hypothesis / aims of study
The aim of current study was the examination of the influence of level I defect on building of cystocele.
The proposed approach of urogynecological examination which combines the use of the basic form of POP-Q scale and the modified clinical classification by DeLancey, taking into account the impact of level I defects on pelvic organ prolapse in level II in anterior compartment. The inclusion of the apical defect has a significant impact on the decision making process, as it alters the surgical management of pelvic organ prolapse and promotes methods that focus on repairing the anatomical cause of the defect rather than just its clinical presentation.
Study design, materials and methods
This study includes 302 women, who reported complains connected to pelvic organ prolapse. The patients were examined using a new, simple and standardized method of urogynecological examination which assumes the simultaneous application of the basic form POP-Q System and the modified classification of lower pelvic organ prolapse by DeLancey expanded by the impact of level I defect (apical defect) on level II prolapse in anterior compartment.
In presennted study the patient was placed in the lithotomy position on a gynecological chair with an averagely-filled bladder (about 200-250 ml assessed by ultrasound measurement). The examination started with the assessment of the vulva, perineum and vagina at rest and at maximum Valsalva. Then, using two Kristeller specula, the following were evaluated:
using anterior and posterior specula - level I
using the posterior speculum - anterior compartment, level II - cystocele and level III - urethrocele. The influence of the reposition of level I defect on the cystocele.
using the anterior speculum - posterior compartment, level II - recto- or enterocele, not taking into account in current study
If the cystocele was present, the type of defect was assessed as lateral or central. For a cystocele with a lateral defect the vesical fascia is unilaterally or bilaterally detached from the arcus tendineus, vaginal rugae are preserved, whereas in the case of a cystocele with a central defect the vaginal mucosa appears smooth.
Then, after inserting both specula, the patient was asked to perform the Valsalva maneuver during which the specula were slowly pulled out of the vagina and the position of the reference point for level I was assessed. As the reference point, the authors agreed on the vaginal cuff for patients after a hysterectomy or the point where the anterior and posterior fornix merge with the vaginal portion of the cervix. This method allows to assess a defect at level I.
By detection level I defect with concomitant cystocele presence it is necessary to insert the posterior speculum which restores the leading part of the prolapse at level I. Once the level I defect has been compensated, the possible changes in the presentation of the cystocele was evaluated. It is possible that the cystocele completely disappears, if the exclusive cause for its presence at level I defect is reasoned. In case of cystocele caused of mixed defect at level I and II reposition of level I using posterior specula the cystocele get smaller but it doesn’t disappear. In this situation the examiner should quote the extension of the cystocele before reposition of level I and quote the extension of the cystocele after reposition together with determination of the type of level II defect. The cystocele caused exclusive by lateral or central defect requires lack of level I defect.
Results
The 302 patients aged 27-88 years, among the study group 188 (62%) were postmenopausal women, and 114 (38%) premenopausal. In terms of their BMI, 51% of patients had a normal weight, 3% were underweight, 32% were overweight, and 14% were obese. Regarding the family history of POP, approximately one third of women (28%) had positive family history. The demographic and clinical characteristics as well as life-habits are presented in table.
The apical defect was present in 218 patients (72.2%), where the frequency of cystocele caused by apical defect, mixed central or lateral cystocele coexists with apical defect were 30.8%, 9.6% and 31.8% of all cystocele, respectively.
Thus, a lateral cystocele with concomitant defect at level I was 3-times more frequent than central cystocele coexists with defect at level I. Cystocele caused exclusive by a defect of the vesicovaginal fascia was found in 84 patients (27.8%) - central defect cystoicele was founded only in 13 patients (4.3%) and in 71 patients (23.5%) a cystocele with a lateral defect was identified. Therefore, isolated lateral defects were 5.5-times more often recognized than isolated central defects in studied population.
Interpretation of results
Analysis of differences between particular parameters and types of defects has shown that the number of pregnancies, parity, weight of the biggest newborn and age by first delivery were not statistically significant. However, for two of the parameters (age and BMI) significant differences were observed. The mean age in the mixed apical/central defect was significantly higher compared to lateral (p<0.001), apical (p = 0.012) and mixed apical/lateral (p = 0.031) defects. Similarly, mean values of BMI were significantly higher in the mixed apical/central cystocele than in lateral (p = 0.002), apical (p = 0.003) and mixed apical/lateral (p = 0.005) defects.
Besides, cystocele caused by isolated central or mixed apical/central defect were observed more often in women over 50 years of age with overweight and obesity.
In terms of the family history, the detailed examination revealed its relationship to age of onset of pelvic organ prolapse. The mean age of women with family history was significantly lower (p = 0.035) in relation to those without family history. Interestingly, the frequencies of women with family history in the eleven established groups were higher in younger women (up to 45 years of age).
Our approach to POP-Q system, especially regarding cystocele assessment, may be a useful tool for planning causal operative treatment of pelvic organ prolapse. However, prospective analysis of recurrence following corrective surgery according to proposed system of urogynecological examination is needed. Additionally, larger epidemiological studies should be carried out to determine the incidence of the defects specified in the modified DeLancey scale and to develop imaging methods for the apical defect, particularly in ultrasonography and magnetic resonance imaging (MRI). Currently, sonography has only limited significance in assessing the apical defect, it doesn’t recognize consequently over 70 % of POP defects. MRI seems to be more promising, although MRI is not the standard procedure urogynaecological examination in planning of surgical treatment.
We postulated that the proposed system of urogynecological examination and then appropriate surgical treatment for defect repair can improve the effectiveness of surgical therapy of cystocele and significantly reduce the rate of recurrence.