Management of Genital Prolapse: Experience of One African Surgery Department

Introduction

Genital prolapse is a common condition in elderly women with multifactorial causes. It is particularly favored by multiparity, pregnancies, dystocic deliveries, and senescence of pelvic musculofascia and perineal structures related to age and menopause. Genetic factors, obesity, smoking, obstructive disorders, and history of pelvic surgery can also predispose a patient to a pelvic floor disorder.

The dominant mechanical causes for the genesis of prolapses are strongly encountered in areas with insufficient health care, such as in Sénégal, where parity is high and the conditions of delivery are still difficult. Advanced forms of prolapse are frequent and require adequate management and care to promote less morbidity and fewer recurrences.

Several procedures are proposed and all aim at suspension or support of the pelvic viscera with judgment criteria based on anatomical or better functional results. The oldest procedures use the patient's own tissue or self-plasty, with a major inconvenience being lack of strength, with a relatively high recurrence rate of 30%.^1,2 The use of prosthetic material to strengthen fragile tissues is logical and is done to reduce recurrences. The anatomical results are better but involve significant risks of complications related to the prostheses (vaginal erosion, fistula, painful sequelae, dyspareunia, etc.). Significant postoperative complications confirm the nontrivial nature of this functional surgery for which the indications are posed with discernment, depending on the discomfort and the age of the patient.

The objective of the current study was to report the experience of managing genital prolapse in patients in tropical Africa. Epidemiologic, clinical, and therapeutic aspects were analyzed.

Materials and Methods

This was a retrospective descriptive study from January 2010 to June 2016, on patients who were followed-up for procedures done in cases of complete genital prolapse. The study was conducted in the Department of Surgery of Ouakam Military Hospital in Dakar, Sénégal. Only prolapses involving at least two compartments, that were operated either vaginal or abdominal routes, were included in the analysis. Cases of cystocele or isolated rectocele, asymptomatic cases, inoperable cases, and cases with incomplete records were excluded.

Data collected included:

Preoperative period: Age, associated comorbidities, surgical history, symptoms, type and degree of prolapse, and associated urinary or gastrointestinal disorders

The preoperative evaluation was completed in collaboration with the anesthetist. The classification used was that described by Baden and Walker. ³ Classifications of Baden and Walker are as follows:

Stage 1: Intravaginal

Anesthesia was either local–regional or general. Antibiotic prophylaxis was administered at induction with a third-generation cephalosporin (2 g) followed by postoperative 2 g/day of amoxicillin clavulanic acid for 7–10 days.

The laparotomy approach was reserved for genital prolapse in young patients desiring to retain the ability to achieve pregnancy. The procedure included the placement of two synthetic prostheses, anterior and posterior, attached on the anterior vertebral ligament to the promontory, associated with a douglassectomy.

The vaginal approach was reserved for older patients (Fig. 1A and B). This procedure comprised a simple hysterectomy, or with an adnexectomy, an anterior inverted T colpotomy, dissection, and overlap repair of Halban's vesical fascia (Figs. 2 and 3). The key technical points are the high crossing of the uterosacral ligaments, extensive lateral dissection to identify the more-solid nondilated part of Halban's fascia, suture on the upper layer of the identified fascia after sufficient bladder retraction, and high suture of the pouch of Douglas by leaning on the uterosacral ligaments.

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FIG. 1.

(A,B) Complete vaginal prolapse (grade 4).

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FIG. 2.

Vaginal hysterectomy followed by fascial autoplasty.

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FIG. 3.

Vaginal dissection with bladder and pouch of Douglas.

Medium- and long-term results were judged by the degree of patient satisfaction, complaints (bulging of the vagina, dyspareunia, functional impairment, etc.), and on the clinical aspects noted on examinations.

Postoperative follow-up was performed every 3 months (clinical examinations without imaging). The median follow-up duration was 36 months (extremes: 12 months and 78 months).

Results

Thirty-two patients met the inclusion criteria. The average age was 59, with extremes of age being 24 and 81. There were 3 young patients of childbearing age (9.3%). In this group, there was a primipara, age 24, who had no other abnormalities. Other patients were multiparas (average was 4 paras).

Twenty-two patients (68%) were >60 years old and were postmenopausal. Multiparity was noted in 31 patients with a mean of 6 paras (extremes: 3 and 11 paras). Comorbidity was observed in 17 cases. These results are summarized in Table 1.

The patients were all black. Geographical origin was not analyzed. The duration of evolution of these cases was not evaluable (it was imprecise for the most part). One patient had already undergone vaginal prolapse treatment (thus, she was having a recurrence).

The symptoms were dominated by a vaginal bulge with a bearing-down effort or permanent spontaneous exteriorization (Fig. 3). Urinary incontinence was found in 3 cases, of which 1 was associated with incontinence of flatulence and a fibroid uterus. Clinical manifestations are summarized in Table 2.

Therapeutically, the abdominal approach and promontal-fixation was performed in 3 patients (9%). Colpohysteropexy was performed in 2 patients, and colpopexy was performed after hysterectomy for uterine myomatosis in 1 patient. This procedure was associated with colposuspension according to Burch in the same patient (she had associated urinary incontinence).

The vaginal approach was used in 29 patients (90%). A hysterectomy was associated with adnexectomy in 7 patients. Intraoperative difficulties encountered were related to lateral dissection with venous bleeding, which was sometimes heavy, thus, needing compression. The urinary catheters were removed on the first or second postoperative days. The average length of the hospital stay was 2.7 days (extremes: 2 and 5 days).

Short- and long-term morbidity and mortality are summarized in Table 3. Three patients had recurrences (9%) with intravaginal loops. No other treatment was offered outside of regular monitoring (of an elderly patient). The satisfaction rate was 96%, and these patients had no disabling complaints. One patient presented with back pain after promontal fixation with a prosthesis. Symptomatic treatment was administered.

Discussion

Genital prolapse of various stages affect >50% of women who have given birth. ⁴ Nevertheless, only 10% to 20% become symptomatic. ⁵ Studies from western countries show a predominance of grades 1 and 2 types of prolapse. Swift, in his series of 497 cases, reported 43% with grade 1 prolapse, 48% with grade 2 prolapse, while grades 3 and 4 prolapses were 3% and 0%, respectively. ⁶ This problem presents differently in Africa, especially the clinical presentation, evolution, and surgical management.

In fact, voluminous prolapses are common in Africa, mainly among rural populations, where patients do not seek medical help early, letting the condition evolve for many years. Oraekwe et al., in Nigeria, reported 60.7% of rural women, with an average age of 56.7 years, had prolapses; and the majority of patients were menopausal and multiparous. ⁷ Akmel and Segni, in Ethiopia, reported 80.6% of rural women with prolapses and described the impact of the activities of these women on their pelvic floor stability. ⁸

High parity rates, together with difficulties during childbirth in African countries, lead to, at older ages, weakness of the support structures and the pelvic floor.^7–10 In addition, repeated traumata, and several other mechanisms are involved, such as denervation of pelvic tissues, collagen degradation, synthesis of anodal adhesions, and defects or distension of fasciae.^11,12

Symptomatically, vaginal bulge was the main manifestation in the current series, which reflects an advanced form of prolapse. Urinary disorders were, however, less frequent (9%). They were 1.5% (1/64 cases) in Oraekwe et al.'s series, ⁷ and appeared to be more frequent in the western counties at 45% in the series of Bouchet et al., ¹³ and at 63% (39/62 cases) for Gabriel et al. ¹⁴

Prolapses were rarely isolated in the current study. They affected the anterior and middle layers in 100% of the cases. Rectocele was often minimal and no major symptomatic forms were found in this current series.

Autoplasty remains an old procedure that has undergone several modifications. More recently, the sacrospinous fixation technique by Richter has improved fixing of the vaginal vault and has become the reference technique using the vaginal route. It was not performed in the current patients. An encoring suture of the fascia to the uterosacral ligaments that were already crisscrossed was the alternative technique chosen. The complication rate in the intraoperative period is low in autoplasty. Complications were limited to hemorrhages during the dissection in the current series. Manual dissection, using gauze to separate the vesicovaginal space, carries less risk of bladder injury and risk of bleeding; this risk is always high, but it is possible to stop the bleeding by compression and coagulation.

Overlap repair or burial allows support of pelvic organs with various results. A recurrence rate of 30% has been reported and attributed to the poor quality of the fascia used.^1,2 The recurrent rate was 10% in the Salvatore et al. series, with the criterion of recurrence attributed to ≥ grade 2. ¹⁵ Dia et al., in the same region reported 2 cases (2/36) of recurrence in the form of elytroceles. ¹⁶ However, that evaluation was mainly based on anatomical results and less on functional results. In the current series, the functional result in 96% of patients was satisfactory, and no debilitating complaints were noted. The satisfactory result was 100% after cure by the vaginal route, whereas the anatomical correction was satisfactory in 81%.

Several recurrence factors have been identified and should be integrated into the decision-making processes. These factors are the severity of the clinical grade, a chronic cough, chronic constipation, obesity, and a history of fetal macrosomia etc. ¹⁵

Management is changing with the appearance and validation of the cure by using prosthetic materials. These materials reinforce the solidity of the bladder support or the uterovaginal suspension with anatomically satisfactory results. Several mesh-related complications have been reported in the literature with varying incidence.^4,17 They include vaginal erosion, exposure of the prosthesis, retraction, dyspareunia, painful sequela, fistula, etc.

Conclusions

Various procedures for correcting genital prolapse have advantages and disadvantages. The indications must take into account the age of the patient and factors that could contribute to recurrences. Autoplasty by palatal suture of the Halban's fascia is an old procedure that still retains its indication, particularly in elderly women, in whom the evaluation criteria should include the concept of patient satisfaction as well as anatomical results. The risk of complications, might be underestimated, and, in the future, will be an essential factor of choice of the surgical method.