By Howard Goldman, MD
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Women older than 80 are a rapidly growing segment of the population, and because of the general prevalence of pelvic organ prolapse (POP), management of the condition in this group is becoming increasingly important.
Treatment of POP in elderly patients is not necessarily substantially different than in the general population, but there can be special considerations, lifestyle concerns and comorbidities that factor in the treatment decision. Physicians should not base treatment decisions solely on chronological age.
Degree of bother by symptoms is a key factor
In older patients, whether and how to treat POP depends on their functional status, the degree to which they are bothered or inconvenienced by the condition, and their personal preference.
If an elderly woman has anatomic POP but lacks bothersome symptoms, the condition rarely requires treatment. Conversely, POP symptoms may cause depression and poor self-image and impair participation in social activities. Associated bladder, bowel or sexual symptoms can also take their toll. And quality of life may be impacted regardless of the stage of prolapse. Vaginal bulge causing discomfort and/or bleeding, difficulty voiding and/or defecating, recurrent urinary tract infections and POP-associated low back pain are all symptoms that may warrant treatment.
Natural progression of POP is unclear
What happens without treatment? Unfortunately, we know little about the natural course of POP in this age group due to scarce data and contradictory findings. An inverse relationship between POP and stress urinary incontinence (SUI) has been described. SUI may improve as POP worsens because of kinking of the urethrovesical junction. Occasionally, significant POP can lead to renal dysfunction caused by ureteral kinking.
Possible POP progression is a consideration when weighing treatment. As reported by Pizarro-Berdichevsky and colleagues in the International Urogynecology Journal, a 47.5 percent progression rate was seen in symptomatic patients awaiting surgical treatment and the chance of progression increased bothersome prolapse that extends beyond the hymen (stage ≥II) is a clinically relevant finding that often indicates the need for treatment.
Observation (which may include physical therapy), pessaries and surgery are the three main POP treatment options. In my estimation, 30 to 40 percent of patients who choose non-observational treatment opt for a pessary, and the remainder elect surgery.
Pelvic floor physical therapy (PFPT) is among the least invasive treatment options, and when administered by a qualified physical therapist, can lead to mild anatomic improvements in POP and associated symptoms. However, PFPT is considered most useful for women with mild to moderate POP — not severe POP.
Pessaries are the oldest known treatment for POP, dating back 2,500 years. They act as space fillers in the vaginal canal to support the vagina and block the intrusion of prolapsing tissue. They can be an excellent form of noninvasive treatment, improving POP and its associated urinary symptoms. Well-designed studies comparing pessaries’ efficacy to surgery are scant, however. In addition to first-line treatment, pessaries can also be an excellent bridge to surgery.
Surgical intervention provides the best chance for definitive resolution of POP and associated symptoms. Surgical treatment is feasible and generally safe in elderly POP patients, and postoperative complication rates are less than 5 percent. Research does not indicate a higher failure rate of POP surgery in elderly patients compared with younger patients, regardless of the surgical technique used.
In selecting a specific surgical procedure, all existing pelvic floor defects and prior intra-abdominal surgeries should be evaluated. Surgical options vary in their complexity and success rates, and some may be more appropriate for elderly individuals than others.
Colpocleisis — the narrowing or closure of the vagina and introitus — is a straightforward procedure that may be offered to elderly patients who are not sexually active and do not plan to resume vaginal intercourse. Patients must be explicitly counseled that intercourse will be impossible after surgery. Colpocleisis may require shorter operative time and result in fewer perioperative complications than reconstructive repair, and prolapse recurrence is rare.
Reconstructive surgeries involve either a transvaginal or an abdominal approach. There are no systematic reviews or meta-analyses that provide insight on which type of reconstructive surgery is most effective in elderly patients. In general, transvaginal POP surgery is less invasive than abdominal surgery and is preferred in older patients, especially those with comorbidities, because of its shorter recovery time and reduced pain and surgical risk. Overall, transvaginal surgery has a five-year success rate of approximately 70 percent if success is defined as no subsequent significant prolapse. With a broader definition of success to include outcomes with some subsequent prolapse but no need for further intervention, five-year success rates rise to approximately 85 percent.
Transvaginal procedures are characterized as either native tissue repairs (correcting apical or anterior/posterior compartment defects) or mesh-augmented surgeries. Mesh-augmented transvaginal procedures have higher anatomic success rates than do native tissue repairs, but also unique complications related to the use of transvaginal mesh – recent litigation involving transvaginal mesh has led to a decline in its use.
Abdominal POP reconstructive surgery – sacrocolpopexy – involves attaching the vaginal apex to the sacral anterior longitudinal ligament using a graft, typically synthetic nonabsorbable mesh.
Sacrocolpopexy often is performed laparoscopically or robotically, although there is no clear advantage to either over an open abdominal approach. Ten-year sacrocolpopexy success rates are approximately 85 to 90 percent, but the abdominal approach’s increased surgical and postoperative complication risks and lengthened recovery time mean that physicians evaluating elderly POP patients are likely to pursue nonsurgical treatment or a transvaginal surgery rather than sacrocolpopexy.
Dr. Goldman is a staff member of Cleveland Clinic Glickman Urological & Kidney Institute’s Department of Urology. He is also the Urological & Kidney Institute’s Vice Chair for Quality and Patient Safety, and a Professor of Medicine at Cleveland Clinic Lerner College of Medicine.