The future of treating pelvic organ prolapse
Dr Ninivaggio is a fellow in the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
Dr Dunivan is an Associate Professor and Fellowship Program Director in the Division of Female Pelvic Medicine & Reconstructive Surgery, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.
Approximately one quarter of women in the United States have at least one pelvic floor disorder such as urinary incontinence (UI), fecal incontinence, or pelvic organ prolapse (POP).1 POP—vaginal descent of the bladder, uterus, or bowel—results in symptomatic pelvic pressure, or a bulge that women can feel and/or see. Depending on the definition used, the prevalence of bothersome POP ranges from 3% to 8%.1,2 By age 80, approximately 20% of women will undergo surgery for treatment of urinary incontinence or POP.3
The demand for POP surgery is expected to increase by nearly 50% over the next 40 years.2 As our understanding of POP has evolved, surgical techniques and outcomes have evolved as well, with a diverse number of treatment options. These range from expectant management and nonsurgical approaches (such as physical therapy and removable devices) to surgery. Surgical approaches vary widely from vaginal reconstruction with or without graft materials to abdominal or vaginal approaches.
Here we review treatment options for POP and discuss the importance of a patient-centered approach to decision making.
A discussion of prolapse treatment options must begin with patient education, articulation of patient goals, and shared decision-making to reach the best individualized option for a patient. Traditionally, surgeons have focused on anatomic success or correction of the prolapse into a high pelvic position. But anatomic correction does not always result in a satisfied patient. For example, a woman who no longer has bulge symptoms following prolapse repair, but continues to have urinary incontinence, may be dissatisfied with her surgical repair despite surgical “anatomic” success. Indeed, goal achievement for prolapse repair is highly influenced by resolution of incontinence symptoms.4 Thus, the definition of successful prolapse repair has evolved to include composite outcomes that also incorporate patient perception of an array of pelvic floor symptoms, function, and satisfaction.
Given the elective nature of POP repair, an upfront discussion is needed regarding the patient’s goals and expectations, and adequate time should be allowed for patient education about what prolapse treatment and repair can and cannot achieve. POP treatment discussion lends itself well to shared decision-making, which is defined as “a collaborative process that allows patients and their providers to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences.”5
A paternalistic physician-patient model of counseling no longer aligns with the changing medical field in which patient choice is crucial, particularly for elective procedures. Patient autonomy and increased access to information has led to adoption of an interpretive model of medical counseling. The role of the physician is to help the patient clarify and integrate priorities, preferences, and values into the decision-making process while acting as an information source.6