PERSONALIZED TREAMENT ALGORITHM OF UROGENIATAL PROLAPSE IN PERIMENOPAUSAL WOMEN USING PELVIC FLOOR ULTRASOUND

Goncharenko V.M.¹, Bubnov R.V.¹, Benyuk V.O.², Dovgaliov R.V.², Strokan A.M.¹

¹Clinical Hospital ”Pheophania“, Kyiv, Ukraine

²Third Department of Obstetrics and Gynecology, Bogomolets National Medical University, Kyiv, Ukraine

Background.

Urogeniatal prolapse is a widespread problem, requires about 200,000 operations annually in USA [1]. Many surgical  methods for treatment are utilized to such patients [1,2]. Myofascial pelvic pain is detected in 10% to 15% of all gynecological patients. Ultrasound has strong potential for diagnosis of pelvic floor disorders and treatment of pelvic muscles dysfunction [3,4], however many issues of personalized diagnosis and treatment of bladder neck mobility still were not studied and consolidated.

The aim was to develop and evaluate protocol for personalized diagnosis and treatment of bladder neck mobility.

Materials and methods.

We included consecutive 52 premenopausal and postmenopausal patients, females (45–82 years, 69±7 years old), suffering from pelvic floor dysfunction, pelvic pain with different location, urinary incontinence, and also from different gynecological pathology. According to the aim all patients underwent general gynecological examination, 0-21 scoring ICIQ (Incontinence Questionnaire), translabial and tranabdominal ultrasound for evaluation bladder neck mobility. Measurements were taken at rest and on maximal Valsalva, and the difference yields a numerical value for bladder neck descent. Additionally the transabdominal ultrasound guided testing motility by cervical tracking in gynaecological chair (down test’) was performed. Bladder neck descent over 45 mm on translabial ultrasound and over 60 mm on transabdominal ultrasound and on ‘down test’ we considered as hypermobility. Additionally all patients were assessed for myofascial trigger points in pelvic and low back muscles physically and on US. According to the results of tests patients were assessed for personalized treatment. For assessment of efficacy we consider as: the primary endpoint was symptoms (assessed with ICIQ tests); and the secondary endpoint was the bladder neck hypermobility - the data, evaluated by US.

Results.

In 18 patients we revealed  posterior vaginal wall compartment prolapse (“rectocele”, RC); In 22 patients we revealed  anterior vaginal wall compartment prolapse (“cystocele”, CC); and in in 14 patients we revealed  combination of CC+RC. We diagnosed uterine fibroids in 32 patients, uterine adenomyosis - in 16 patients, endometrial hyperplasia and polyps - in 10 patients, and the combination of two or more gynaecologic pathologies – in 23 patients. We diagnosed the myofascial trigger points in pelvic muscles in 18 patients and inactivated by dry needling under ultrasound guidance.

Patients were considered for personalized treatment as follows:

1)       Myofacial pain treatment [4,5];

2)       Surgery: transabomianl hysterectomy; transvaginal hysterectomy; laparoscopic hysterectomy; utero-vaginal meshsacropexy (LUV-MESH); colporrhaphia with perineo-levatoro-plastics.

Uterus enlargement over 12 weeks (length over 100 mm on US) were considered for hysterectomy. Bladder neck descent hypermobility was diagnosed in 36 patients (69 %) before and 16 (31%) after treatment (p <0.05). The mean ICIQ score was 15.3 ± 3.2 before, and 4.2 ± 0.5 after treatment respectively. Fourty six patients (88 %) reported subjective improvement. The moderate correlation (r=0.35) was revealed between subjective and US measurements of hypermobility in patients with complex gynaecologic pathology. Tranabdominal ultrasound guided testing motility by cervical tracking in gynaecological chair (‘down test’) had correlation with transabdominal ultrasound data (r=0.43). After laparotomy hysterectomy we registered subjective improvement in 12/20 patients; in 3/20 patients - impairment; and in 5/20 patients no changes were registered. After transvaginal hysterectomy we registered subjective improvement in 7/10 patients; in 3/10 - no changes were registered.

Conclusion.

Personalized treatment was effective in 88 % of patients. For providing personalized therapy of urogeniatal prolapse we should consider  the interaction of internal genitalia with pelvic floor muscle (as trigger points, spasticity and weakness of pelvic muscles), resulting bladder neck hypermobility and evoking urogenital symptoms with specific gynaecologic background (pathology of myometrium and endometrium).

For assessment bladder neck mobility the of combination of translabial and transabdominal ultrasound with the transabdominal ultrasound guided testing motility by tracking in gynaecological chair (‘down test’).

References

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3. Dietz HP: Pelvic floor ultrasound: a review. Am J Obstet Gynecol. 2010 Apr;202(4):321-34. doi: 10.1016/j.ajog.2009.08.018.
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