Caring for the FPMRS Patient of Childbearing Age

NYU Case of the Month, January 2020

Case of the Month Caring for the FPMRS Patient of Childbearing Age NYU Case of the Month, January 2020 Dominique Malacarne Pape, MD Division of Female Pelvic Medicine and Reconstructive Surgery (FPRMS) and the Department of Obstetrics and Gynecology, NYU Langone Health, New York, NY [Rev Urol. 2020;22(1):32–34] ® © 2020 MedReviews , LLC A 39-year-old healthy woman presented for evaluation of vaginal prolapse symptoms and urinary incontinence 4 months following the birth of her first child. The patient underwent an uncomplicated vaginal delivery of an 8 lb 9 oz boy. The patient now feels a vaginal bulge when she walks for long periods and when she exercises. She is also wearing pads daily due to loss of urine with any exertion or exercise. The patient is considering future childbearing but is significantly bothered by her symptoms. Management Patient History Comment The patient has no history of prolapse or urinary incontinence. She did have a complete work-up for microscopic hematuria 2 years prior to the current presentation. Cystoscopy was normal, and CT urogram revealed normal renal and reproductive anatomy, with no pertinent findings. Evaluation Urinalysis: negative Body mass index (BMI): 26.4 Post-void residual volume (PVR): 30 mL Pelvic Organ Prolapse Quantification system (POP-Q): Aa: 0 GH: 4 Ap: −2 Ba: +1 PB: 3 Bp: −2 C: −1 TVL: 10 D: −3 + Cough stress test: large volume stress urinary incontinence (SUI) The patient was counseled about options for treatment of her Stage II uterovaginal prolapse and SUI. She elected to undergo vaginal uterine-sparing prolapse repair with a uterosacral ligament suspension hysteropexy and anterior colporrhaphy. She opted for urethral bulking injection for her SUI. She remains asymptomatic and is currently attempting pregnancy. In recent years we have become increasingly aware of risk factors for pelvic floor disorders (PFD), including urinary incontinence and pelvic organ prolapse (POP). It is well known that age, pregnancy, vaginal delivery, and weight can affect the pelvic floor and have been directly linked to various forms of pelvic floor dysfunction. What is not as well-known is how the pelvic floor physiology is affected when various risk factors begin to occur at later time points. Women are delaying childbearing at increasing rates. In a recent New York Times article, data shows that the average age of first-time birth is 26.3 years across the country, yet this number exceeds 30 years in most major cities. Women are having a first birth in their 30s and even into their 40s at increasing rates.1 This means multiparity also happens later if women decide to have more than 1 child. Also, America is going through an obesity epidemic, and 32 • Vol. 22 No. 1 • 2020 • Reviews in Urology 4170020_08_RIU0870A_V1_rev02.indd 32 5/5/20 11:01 PM The FPMRS Patient of Childbearing Age therefore women of childbearing potential whom we encounter may also start with pre-pregnancy BMIs of 25 or greater. This compilation of risk factors is unique to our current culture, and many effects of these factors on pelvic floor dysfunction may very well begin to appear at higher rates and in the setting of a desire for fertility preservation. A newer epidemiologic study reports 25% of US women describe the presence of 1 or more PFD. The prevalence of 1 or more PFD was 6.3% in the 20- to 29-year-old cohort, and this increased to 23.4% in 40- to 49-year-old participants. In this analysis, 31% of women with 1 or more PFD had a BMI .30.0. Lastly, 86% of women reporting more than 1 PFD were multiparous.2 More and more evidence points to the theory that pregnancy and delivery at an older age may be associated with a higher prevalence of PFD, including urinary incontinence and POP. Various trials have found associations with maternal age .30 at first delivery and an increased risk of 1 or more PFD. The data reveals urinary incontinence to be the most prevalent condition in this group. PFDs before and during pregnancy are a major risk factor for the persistence of PFDs postpartum, and women found to have urinary incontinence are more likely to also screen positive for occult levator ani defects, which can worsen during subsequent pregnancies. There is scarce data looking at absolute risk of PFD with first delivery at an older age; however, women of advancing age are more likely to experience levator ani muscle avulsion, hiatal overdistension, and obstetric anal sphincter injuries. In a study by Rahamanou and colleagues looking at the association between age at first delivery and risk of obstetric trauma, the odds ratio was 1.064 for overall risk of injury for each increasing year of age past age 18 years (P 5 0.003). The mean age at first birth was 30.5 years (SD 5.1; range, 18.8-42.5 years), mean BMI was 27.9 kg/m2 (range, 18.0-28.6 kg/m2) at the time of recruitment, and the mean gestation at delivery was 39.7 weeks (range, 36.3–42.2 weeks).3 There is a greater incidence of acute POP in pregnancy when compared with POP presenting prior to pregnancy, and early identification of incontinence and prolapse can improve short- and long-term health outcomes in subsequent pregnancies and beyond. Data suggests that POP in a subsequent pregnancy, if left unmanaged, can lead to various complications, including preterm labor, cervical ulcerations, and obstructed labor.4 Traditionally when these patients present to FPMRS specialists for management of their POP or incontinence in the setting of potential future fertility, self-maintenance with a pessary or pelvic floor physical therapy have been the mainstays of treatment. There is a growing body of evidence to support the option of surgical and procedural management of incontinence and prolapse in women who potentially desire future fertility. When discussing POP specifically, there is increasing patient interest in uterine conservation and hysteropexy procedures. Various cross-sectional studies reveal 30% to 60% of women would decline hysterectomy for prolapse repair if they were assured equal efficacy to removal. Women in one study cited various reasons for uterine preservation. However, one main reason for this choice was the desire for future fertility.5 Several uterine-sparing prolapse repair techniques have been described, including a sacrospinous hysteropexy, which is an extraperitoneal procedure where the cervix or uterosacral complex is transfixed to the sacrospinous ligament. Conversely, there is the uterosacral hysteropexy, which involves plication or shortening of uterosacral ligaments with uterine preservation. This, in contrast, is an intraperitoneal technique and has been described both vaginally and abdominally. Lastly, a sacral mesh hysteropexy is described as the attachment of mesh graft material to the cervix and uterus to the anterior longitudinal ligament overlying the sacrum. This can be performed abdominally, laparoscopically with or without robotic assistance, and commands increasing popularity among FPMRS specialists.6 Although there are no randomized controlled trials to compare various hysteropexy procedures, the largest retrospective comparative study, done in 2016, revealed overall short-term prolapse recurrence to be 12% with uterine preservation, with the lowest recurrence rate of 3.6% in the robot-assisted group. There was no difference in mesh exposure or anatomic outcomes. In a more recent multicenter prospective cohort comparing vaginal hysteropexy with laparoscopic sacral hysteropexy, there was no difference in anatomic cure.7-9 There is an even more profound paucity of data looking at prolapse recurrence after subsequent pregnancy; however, several small reports have been published. There are case reports of vaginal and cesarean delivery following sacrohysteropexy, both with native tissue and with mesh. No major delivery complications have been noted, and of patients who developed pelvic pain in the third trimester, all cases were relieved with pessary placement. There are varying reports of recurrent prolapse (7%–26%), with repeat surgery ensuing in up to 22% of cases. A retrospective analysis of childbirth after pelvic floor surgery Vol. 22 No. 1 • 2020 • Reviews in Urology • 33 4170020_08_RIU0870A_V1_rev02.indd 33 5/5/20 11:01 PM The FPMRS Patient of Childbearing Age continued was published in 2012. However, this study analyzed all FPMRS surgeries together. In this study, 603 women with childbirth after FPMRS surgery were evaluated, and the overall need for repeat surgery was 6.9%. The need for repeat surgery was higher in the vaginal delivery group (13.6% vs 4.4%; OR 3.38; CI, 1.87-6.10).10 For women who desire future fertility, recent evidence reveals childbirth after sling surgery is not associated with a significantly higher rate of SUI when compared with women who do not have a subsequent pregnancy (22%–25% vs 17%–18%). When looking at mode of delivery, vaginal childbirth after mid-urethral sling does not seem to increase SUI when compared with caesarean delivery. Very few pregnancy-related complications have been described in pregnancy with prior mid-urethral sling, and those possibly related to the sling procedure itself (urinary retention, obstructive voiding) are very infrequent. Having more than one delivery after mid-urethral sling may impact continence status; however, more work is needed in this area.11,12 Although data are emerging about the prevalence of PFDs in women of advanced maternal age (.35 years), and we are gathering more evidence regarding outcomes of prolapse and anti-incontinence surgery for PFD in women who subsequently become pregnant, there is more work to be done. As our population continues to have a first live birth at an advancing age, more data will emerge on how best to intervene if a patient desires correction of a PFD amidst fertility preservation. Women should be counseled on an individual basis, and the plan of care should be chosen with the patient’s future childbearing desires at the forefront. In the current case, the patient was thoroughly counseled on conservative and surgical options. Ultimately, after weighing the pros and cons of each, she decided to have a non-mesh vaginal uterine-sparing surgical procedure for correction of her prolapse. She was considering mid-urethral sling surgery for her SUI; however, she ultimately chose a less invasive option of urethral bulking injection, which has cured her symptoms at present. As this cultural shift continues, we may find women wanting to address PFDs more definitively, as these conditions could greatly affect a patient’s comfort with intimacy and, moreover, overall continued childbearing potential. It is of paramount importance during this time as an FPMRS specialist to be cognizant of a patient’s concomitant desire to address PFD and preserve fertility. As a subspecialty, we should strive for a future of refining optimal PFD treatment techniques that address both improvement of quality of life and maintenance of reproductive choice. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Bui Q, Miller CC. The age that women have babies: how a gap divides America. The New York Times. August 4, 2018. https://www.nytimes. com/interactive/2018/08/04/upshot/up-birth-age-gap.html. Accessed April 22, 2020. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123:141-148. Rahmanou P, Caudwell-Hall J, Kamisan Atan I, Dietz HP. The association between maternal age at first delivery and risk of obstetric trauma. Am J Obstet Gynecol. 2016;215:451.e1-451.e7. Sangsawang B, Sangsawang N. Stress urinary incontinence in pregnant women: a review of prevalence, pathophysiology, and treatment. Int Urogynecol J. 2013;24:901–912. Korbly NB, Kassis NC, Good MM, et al. Patient preferences for uterine preservation and hysterectomy in women with pelvic organ prolapse. Am J Obstet Gynecol. 2013;209:470.e1-470.e6. Ridgeway BM. Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse. Am J Obstet Gynecol. 2015;213:802–809. Bradley S, Gutman RE, Richter LA. Hysteropexy: an option for the repair of pelvic organ prolapse. Curr Urol Rep. 2018;19:15. Gutman RE, Rardin CR, Sokol ER, et al. Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study. Am J Obstet Gynecol. 2017;216:38.e1-38.e11. Kow N, Goldman HB, Ridgeway B. Uterine conservation during prolapse repair: 9-year experience at a single institution. Female Pelvic Med Reconstr Surg. 2016;22:126-131. Pradhan A, Tincello DG, Kearney R. Childbirth after pelvic floor surgery: analysis of Hospital Episode Statistics in England, 2002-2008. BJOG. 2013;120:200–204. Bergman I, Westergren Söderberg M, Lundqvist A, Ek M. Associations between childbirth and urinary incontinence after mid-urethral sling surgery. Obstet Gynecol. 2018;131:297–303. Dyrkorn OA, Staff AC, Kulseng-Hanssen S, et al. Childbirth after mid-urethral sling surgery: effects on long-term success and complications. Int Urogynecol J. 2020;31:485–492. 34 • Vol. 22 No. 1 • 2020 • Reviews in Urology 4170020_08_RIU0870A_V1_rev02.indd 34 5/5/20 11:01 PM