Urogenitale prolaps (POP) Opereren: IN…….of….. .UIT? Sterkte, kans of dreiging… Dr. Marijke C.Ph. Slieker-ten Hove Bekkenfysiotherapeut en wetenschappelijk onderzoeker Profundum Instituut Erasmus MC
• • • • • • • •
Introductie Urogenitale prolaps en de etiologie Prevalentie Risicofactoren Conservatieve behandeling Implementatie in EBP Conclusies Take home message
Voor het doel
intern
schadelijk
Sterkte
Zwakte
extern
Voor de organisaie
hulpvol
Kans
Dreiging
Voor het doel
intern
schadelijk
Sterkte
Zwakte
extern
Voor de organisaie
hulpvol
Kans
Dreiging
Voor het doel
intern
schadelijk
Sterkte
Zwakte
extern
Voor de organisaie
hulpvol
Kans
Dreiging
hulpvol
schadelijk
intern
Sterkte
Zwakte
extern
Voor de organisaie
Voor het doel
Kans
Dreiging
Rationale etiologie POP in vrouwen Instrumentele partus? Spontane partus? Genetische risicofactor? Obstipatie? COPD?
Zwakke BB
Spreiding Hiatus Genitalis
Rek op bindweefsel
POP
Chen et al., 2006
Prevalentie POP signs (POPQ) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 %
Svihra et al, abstract ICS 2011, n=785 (mean age 47)
51,3 Slieker-ten Hove et al. 2009 n = 649
25,7 17,7 4,2
S.E. Swift et al., 2000 n = 497
Stage 0
1
2
3
1,0 4
Prevalentie POP signs (POPQ) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 %
Svihra et al, abstract ICS 2011, n=785 (mean age 47)
51,3 Slieker-ten Hove et al. 2009 n = 649
25,7 17,7 4,2
S.E. Swift et al., 2000 n = 497
Stage 0
1
2
3
1,0 4
Kans 1
Prevalentie POP signs (POPQ) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 %
Svihra et al, abstract ICS 2011, n=785 (mean age 47)
51,3 Slieker-ten Hove et al. 2009 n = 649
25,7 17,7 4,2
S.E. Swift et al., 2000 n = 497
Stage 0
1
2
3
1,0 4
Kans 1
• Pelvic Organ Prolapse (POP) common in women 75% • 19% chance for at least 1 surgery • Medical cost increase (due to global aging) • Need for preventive strategies (DeLancey JO, 2005)
• 1:10 POP, asymptomatic • 2:10 POP, symptomatic • 3:10 no POP, symptomatic
Svihra et al., abstract 618 ICS Glasgow
100 90 80 70 60 50 symptomatic
40
asymptomatic
30 20 10 0 stage 0 18.2
Slieker et al., 2009
stage 1 21.2
stage 2A 15.4
stage 2B stage 2C 19.2 6.4
asymptomatic symptomatic stage 3 4.2
stage 4 15.1
• 1:10 POP, asymptomatic • 2:10 POP, symptomatic • 3:10 no POP, symptomatic
Svihra et al., abstract 618 Mean age 47
100 90 80 70 60 50 symptomatic
40
asymptomatic
30 20 10 0 stage 0 18.2
Slieker et al., 2009 Mean age 57
stage 1 21.2
stage 2A 15.4
stage 2B stage 2C 19.2 6.4
asymptomatic symptomatic stage 3 4.2
stage 4 15.1
Risk factors in women Parity Pelvic surgery Menopause
Mother POP/inc Conncective tissue weakness
HRT
POP
Joint hypermobility
Hysterectomy Inc surgery Constipation Heavy phys work
Age
Constipation (vs obstretric injury) a potential cause of PF damage PF damage ≥ 2 alterations ≥ 3 alterations
≥ 4 alterations
Constipation
Obstetric injury
Yes (105) vs No (491)
Yes (102) vs No (494)
35 % vs 19 %
32 % vs 20 %
2.38 (1.47-3.85) P=0.0001
1.18 (0.71-1.98) P=0.51
18 % vs 9 %
19 % vs 9 %
2.43 (1.32-4.47) P=0.004
1.51 (0.80-2.86) P=0.20
11 % vs 9 %
9 % vs 5 %
3.16 (1.45-6.87) P=0.004
1.07 (0.45-2.53) P=0.87
Amselem et al., 2009
Conclusion Amselem et al. • Constipation appears to be as important as obstetric trauma in the development of PF damage • A more pro-active approach to recognizing and treating constipation might significantly reduce the prevalence of this distressing problem
Risk factors Parity Parity Pelvic surgery
Mother POP/inc
Conncective tissue weakness Joint hypermobility
POP
Heavy physical work Constipation
Age Intra abdominal pressure…….intra abdominal pressure…….
Kans
Usual care of POP in women ‘watchful waiting’
conservative
Weak PFM
POP
therapy
pessary
physiotherapy??
invasive
surgery
Watchful waiting? Miedel et al., 2011 • Natural regression? • 40 % showed regression after 5 years • Due to?
‘watchful waiting’
– Acceptance? – Less physical active? – Real regression? Handa et al., 2004, especially grade I can regress spontaneously
Pessary
pessary
Clemons 2003
Riskfactors wide hiatus and short vaginal lenght
73/27
73 % success
Cochrane 2005
No evidence
No concensus in pessaries
Need for RCT
Harnsomboon 2011 N=50
25 colpoxin sphere plus PFM 25 PFM 16 weeks
n.s. difference in outcome after 16 weeks
Abdool 2011
359 pessary 195 surgery
n.s. difference in outcome one year after!
N=554
Pessary Clemons 2003
Riskfactors wide hiatus and short vaginal lenght
73/27
73 % success
Cochrane 2005
No evidence
No concensus in pessaries
Need for RCT
Harnsomboon 2011 N=50
25 colpoxin sphere plus PFM 25 PFM 16 weeks
n.s. difference in outcome after 16 weeks
Abdool 2011
359 pessary 195 surgery
n.s. difference in outcome one year after!
N=554
Pessary Clemons 2003
Riskfactors wide hiatus and short vaginal lenght
73/27
73 % success
Cochrane 2005
No evidence
No concensus in pessaries
Need for RCT
Harnsomboon 2011 N=50
25 colpoxin sphere plus PFM 25 PFM 16 weeks
n.s. difference in outcome after 16 weeks
Abdool 2011
359 pessary 195 surgery
n.s. difference in outcome one year after!
N=554
Kans
Pelvic Physiotherapy for POP physiotherapy??
2 hypothesis 1. The knack or bracing preventing descent 2. Increased PFM strength building up structural support Bo & Frawley 2007
PFMF associated with POP Braekken et al. 2009
• Strength, endurance and vaginal pressure were measured • Independently associated with POP
• No measurements were made during coughing…..
PFM strength versus Knack • palpation during involuntary muscle contraction (IMC) during coughing
Effective IMC
absent
weak
normal
strong
p-value
52.9 (18)
61.5 (126)
41.6 (157)
40.6 (13)
< .001
Slieker et al., 2009
PFM strength versus Knack • palpation during involuntary muscle contraction (IMC) during coughing
Effective IMC
absent
weak
normal
strong
p-value
52.9 (18)
61.5 (126)
41.6 (157)
40.6 (13)
< .001
Slieker et al., 2009
Miller et al., 1998 Teaching “the Knack” during IAP increase, women can significantly reduce urine leakage but Reduction in urine loss was not significantly correlated with digital measurement of PFM strength…..
Abstract ICS 45, Frawley et al., 2011 Testing PFM strength in 170 women Multicenter in Australia, Scotland and New Zealand 4 point scale (ICS) and manometry Conclusion: no statistically difference between strength variables and POP(Q)- stage
Voordat we met een interventie beginnen…
Is het voorspannen een spontane, altijd aanwezige competentie van de bekkenbodem?
Strength and Knack vs POP »
Stage 0
Stage 1
Strength
No significant difference
Endurance
No significant difference
Coördination, (coughing)
75.2 %
38.2 %
Slieker et al., 2009
Strength and Knack vs POP »
Stage 0
Stage 1
Strength
No significant difference
Endurance
No significant difference
Coördination (coughing)
75.2 %
38.2 %
Kans
Intra abdominale druk en valsalva
Staan in MRI 1 foto nemen duurt 4.20 minuten
liggen
staand
liggen x
staand x
valsalva x
Intervention Detailed description • PFMT: frequency, intensity, control • Intra abdominal pressure, training precontraction • Life style • Follow-up, adherence, self-efficacy
Is PFMT effective? year
Age
n Follow up intervention / control
improve
Piya-anant
2003
>60yr/
330/324
6-24 mths
72/27 %
Hagen (Cochrane)
2006
3 trials
Evidence n.s. to guide practice
Ghroubi
2008
Mean 53
47 total/
2 yrs
QoL sign
Hagen
2009
Mean 56
47 (23/24)
6 months
63/24 %
Braekken
2009
Mean 48.9
109 (59/50)
Stüpp
2011
Mean 55
21/16
14 weeks
PFMF, anatomic
Hagen
2011
Mean 56.8
224/222
6mths-1 yr
QoL, symp↑
19/8 % (1 st)
Conclusion Hagen et al. 2011 abstract 129 ICS Schotland There is now sufficient evidence to conclude that PFMT is effective and cost-effective in reducing POP symptoms and should be recommended as first-line management for POP. Best clinical abstract!
Sterkte
Is het alleen een vrouwenprobleem?
Nee, het gaat over mannen EN vrouwen
Epidemiology rectal prolapse Kaialuoma and Kellokumpu 2005
• Annual incidence complete rectal prolapse mean 2.5 (range 0.79-6.08) per 100.000 population • 90 % women • 10 % men • Median age 69 (range 21-91 yrs) • Anal incontinence 64 % • Constipation 72 % (difficult evacuation)
Risk factors in women parity
Menopause
Mother POP/inc
POP
HRT Hysterectomy Inc surgery Heavy phys work
Age
Risk factors in men? parity
Surgery Mother POP/inc
POP
Heavy phys work Constipation
Age
Risk factors Parity
Mother POP/inc
POP
Heavy physical work Constipation
Age
Kans
What about surgery?
We are at heart ….. surgeons Dr. Jane Schulz, urogynaecoloog Alberta
• “a chance to cut is a chance to cure” • “the only way to heal is cold hard steel” • “when in doubt, cut it out” Dreiging
BBWG NVOG: zouden we POP niet moeten zien als chronische aandoening?
PROLIFT*
POP symptomreleave after surgical procedure • 78.8% women experienced improved OAB symptoms with transvaginal mesh repair of POP • SUI correction (if no cont procedure) 34-91% • Bowel (54% improved evacuation) • Sexual function improves – relation to body image perception Long et al. IUJ May 2011 ICI 2009 Chan et al. J Sex Med Feb 2010 Miedel et al. IUJ Dec 2008
Vaginal pressure during daily activities before & after vaginal repair
Mouritsen et al 2007
Vaginal pressure during daily activities before & after vaginal repair
Mouritsen et al 2007
De novo symptoms after surgery for POP • • • • •
SUI (unmasked) (up to 42%) OAB symptoms (5-22%) Bowel dysfunction Pain Sexual dysfunction
de Boer et al. IUJ Sep 2010 Al-Mandeel et al. Neurourol Urodyn Mar 2011 Miedel et al. IUJ Dec 2008
Is surgery Safe and Effective? • In NL 1:5 women will have POP or incontinence surgery • The women who underwent surgery were more likely to have PF symptoms than women without surgery (45-85 yr) TA de Boer et al., 2011
Why bother adding to surgery? • Surgery is common: lifetime risk for POP/UI surgery: 11 – 20% (Olsen et al 1997, Fialkow et al 2008, de Boer et al 2011)
• Surgery has a failure rate: up to 66% at 3 mths (Iglesia et al 2010) • Symptoms appear MORE prevalent in woman who have previously undergone surgery (de Boer et al 2011) • Previous gynaecological surgery: a ‘risk’ event (Clark et al 2003, Moallie et al 2003, Tegerstedt et al 2004) target these high risk patients • Re-operation affects 1/2 - 1/3 (Olsen et al 1997, Whiteside et al 2004) • Urgent need for strategies to prevent re-operation: 25% improvement in surgical success 2nd operation for 30,000 women (DeLancey 2005)
What does surgery change? (Frawley 2011)
PRE-OP
POST-OP
Defects: structural +/- other PF symptoms
Defects: structural Surgery
+/- other PF symptoms
Risk factors: parity connective tissue
Risk factors: parity connective tissue
Potentially modifiable risk factors:
Potentially modifiable risk factors:
weak PFM chronically raised IAP Obesity Constipation • etc
weak PFM chronically raised IAP Obesity Constipation • etc
Zijn er internationale richtlijnen? • Klinische praktijk: – Surveys van gynaecologen (Fitzgerald et al 2001,Ottesen et al 2001) – Survey van Australische physios (Frawley et al 2005) Inconsistent, grote varieteit Geen EBP richtlijnen Klinische aanbevelingen
• Interventie studies over BFT rond OK (RCTs): Jarvis et al 2005 Frawley et al 2010 Verschillende uitkomsten (Frawley 2010) Nieuwe studies zijn gaande
Evidence from RCTs 1. Jarvis et al 2005: – investigated the effect of pre- & post-op physiotherapy on 60 women undergoing POP/UI surgery – TG received 3 x physiotherapy-supervised PFMT sessions, bladder training, and bowel training. – Outcomes measured changes in continence, quality of life, and general health symptoms 6 months postoperatively. – Results indicated a significant improvement in quality of life and urinary symptoms for the TG – Results were presented for the combined surgical cohort.
Frawley et al., 2011 • Primary outcomes: – CG & TG: improvements in bladder, POP and bowel symptom scores following surgery – differences between groups were not significant after adjusting for baseline differences (trend towards more improvement for TG
• Secondary outcomes: – Between-group differences were significant in favour of TG for: • Pelvic floor muscle strength (digital testing) • Assessment of Quality of life • General exercise participation: frequency of exercise / week
Pessary Abdool 2011
N=554
359 pessary 195 surgery
n.s. difference in outcome one year after!
How do we implement the findings?
Wie moeten we overtuigen? • Medisch specialisten? • Huisartsen? • De vrouwen zelf? Vrouwen moeten leren dat bbdysfunctie niet normaal is of nu eenmaal horend bij ouder worden, maar waar je iets aan kunt doen Vrouwen moeten al in de pre/postnatale fase de noodzaak onderkennen om de bekkenbodem te trainen en de buikdruk te reguleren
De medisch specialist? • Pelvic organ prolapse Kuncharapu et al., 2010 (Texas, USA) publicatie in American Family Physician ‘PFMT may improve pelvic function. The effectiveness of PFMT in reversing or treating POP has not been studied’
Quote B-wijzer 1, nr 41 Interpretatie PORTRET studie en presentatie Doelencongres ondergetekende…. ‘ Fysiotherapie bleek inderdaad veel minder effectief voor de behandeling van SUI…….. ‘Bij de keuze van de behandeling van SUI dient met de pt het lage succes van fysiotherapie tegen de risico’s van een operatie afgewogen te worden……… Dreiging
Quote B-wijzer 2, nr. 41 …..ik verwacht een verschuiving in het gebruik van bekkenfysiotherapie van een primaire behandeling naar een meer ondersteunende rol’. JM van der Ploeg, gynaecoloog
Dreiging
Long term effect of PFMT in SUI (N=21, 16 trials>1 year)
• • • • • • • • • •
• • • • • • • • • • •
Ferguson et al -90 Cammu et al -90 Mouritsen et al -91 Klarskov et al -91 Dougherty et al -93 Hahn et al -93 Burns et al -93 Holley et al -95 Nygaard et al -96 Glavind et al -96
Sterkte!
Bø & Talseth -96 (5 years) Lagro-Janssen & v Weel -98 Cammu et al -00 (10 years) Pages et al - 01 Kiss et al -02 Alewijnse et al -03 Parkkinen et al -04 Bø et al -05 (15 years) Kondo et al -07 Borello-France et al -08 Elliott et al -09 (7 years)
Quality of surgery Rhoads and Sokol, 2011 Surgical care for uterovaginal POP surgery • Compliance rates on Evidence Based surgical procedures were low in all hospitalsettings!
The general practitioner? • Dutch GP’s follow the guidelines partially…. • Compliance in diagnostics is fairly good (for SUI)
• Compliance in treatment advice is low Albers-Heitner et al., 2008
The patient?
Pakbaz et al., 2010
Obstacles to seeking health care - Lack of information - Blaming oneself - Feeling ignored by the doctor - Having a covert condition - Adapting to succesive impairment - Trivializing of symptoms and de-prioritizing own health
The patient? Pakbaz et al., 2010 Facilitators to seeking health care - Confirmation and support by others - Difficulty in accepting an ageing body - Feeling sexually unattractive - Having an unnatural body - Reaching the point of action
Adherence • Patients • General practitioners • Gynaecologists Adherence is probably human……
WHEN?????
You only have one chance to make a first impression
Univariate en multivariate analysis on symptom of seeing/feeling vaginal bulge (POP), Slieker et al., 2010
Population Attributable Risk (PAR) OR (95 % CI) • • •
OR (95 % CI)
PAR
Heavy physical work 1.39 (.94 - 2.05) 1.48 (0.98 - 2.23) 8.5% POP-symptoms in pregnancy 2.29 (1.59-3.29) 2.06 (1.42 - 3.00) 17.8% Mother with POP 1.99 (1.31 - 3.04)* 1.67 (1.10 - 2.54) 19.7%
+
46% 46:100 POP can be explained by three symptoms
early detection of women at risk!!!
Pre en postpartum periode • • • •
1e contact met de risicogroep 1e kans om vrouwen te informeren 1e kans om te trainen 1e kans om te werken aan oefentrouw
Als men niks weet, dan kun je immers geen actie verwachten
Pre en postpartum periode • • • •
1e contact met de risicogroep 1e kans om vrouwen te informeren 1e kans om te trainen 1e kans om te werken aan oefentrouw
Kans!
Chronic disease and health promotion • Heartdisease, stroke, COPD and diabetes • Pelvic floor issues are in 2011 still not on the list of Health topics
What WHO does… • • • •
Promote Prevent Treat Care
No information Healthy women
no information, no treatment Asymptomatic women With POP
Pessary or surgical treatment Symptomatic women Stage 2-4 (Bob Shull, IUGA 2005)
the biggest challenge? Urologist Sexologist
PFPT
Surgeon Gynaecologist
Gastroenterologist
Inc.nurses
Psychologist
Conclusie • • • •
POP: Yes, we can! Bekkenfysiotherapie is 1e optie Conservatieve behandeling is 1e optie ‘Adherence’ is een probleem, maar komt voor bij hulpverleners en patiënten • Niet blind afgaan op resultaten uit beperkte studies/presentaties
Take home message • Studies die het raadsel van adherence problemen kan oplossen zijn nodig bij patienten, huisartsen, medisch specialisten EN de WHO • Preventieve acties zijn nodig om de ongecongroleerde IAD te voorkomen
• Samenwerken op alle nivo’s en alert blijven, ook als we gevraagd worden mee te doen met een studie
POP… zoveel kansen, zoveel goede bekkenfysiotherapeuten en ZwangerFit docenten!
Evidence beschikbaar
Veel aanbod, veel kansen voor preventie en behandeling
Zwakte
Dreiging
Laten we de POP populair maken!
Tot slot
Mijn overgang….
• • • •
Van ziek naar gezond Van onderwijs naar praktijk en onderzoek Van moeder naar oma Van naar
Een boeiende overgang…………………………
Mick Abel
www.bekkenbodemonline.nl www.profunduminstituut.nl
