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Recurrent pelvic organ prolapse: a case reportKristina Drusany Starič, Petra Bukovec,Andrej Zore, Adolf LukanovićDivision of Gynecology and Obstetrics,University Medical Centre, Ljubljana,Slovenia

AbstractPelvic organ prolapse (POP) is a com-

mon female condition, which is seen as pro-trusion of pelvic organs into or beyond thevagina. Its incidence is increasing and everywoman has an 11% lifetime risk of needingsurgical treatment because of this condition.POP that is recurrent several times is a rarecondition; however it can have major nega-tive impact on quality of life. We present thecase of a 77-year old Caucasian womanwith repeated POP. She underwent sixgynecologic operations for correction ofrecurrent POP. Presentation of this caseclearly demonstrates dramatic recurrencesof POP and how difficult its treatment andprevention can be. We do not know what thereason for multiple reoccurrence of thiscondition might be. We need to emphasizethat there are no researches on specific riskfor an individual patient, which may poten-tiate occurrence of POP and may affectdecisions about surgical procedure.

IntroductionPelvic organ prolapse (POP) is a com-

mon gynecologic phenomenon, in whichthere is a protrusion of organs into orbeyond the vagina due to dysfunction ofsuspensory ligaments and/or fascial sup-port.1 Women with vaginal prolapse experi-ence a dragging feeling in the vagina, backpain and protrusion from the vagina, whichpredispose vaginal mucosa to ulcer forma-tion.2

There are numerous risk factors for theoccurrence of POP. Bump and Nortondescribed a model for the onset of pelvicfloor dysfunction, which consists of predis-posing, inciting and promoting factors.Race, anatomy and collagen distribution areconsidered predisposing factors. Radicalsurgery and vaginal delivery are due to pos-sible damage of neuromusculature and con-nective tissue, which both lead to pelvicfloor weakening, considered inciting fac-tors, obesity and aging are promoting fac-tors.3,4 Gyhagen and his colleagues foundout that for each increased unit of body

mass index (BMI), there was a 3% increasein the likelihood of developing POP.5 Therelative importance of other factors is yet tobe determined.4 There are only a few studiesin the literature that analyze factors whichpotentially influence prolapse recurrence.Whiteside et al. showed that womenyounger than 60 years and those with highergrades of prolapse have a higher risk ofanatomical recurrence. However, they didnot investigate the relationship with func-tional recurrence.6 Anatomical recurrencewas also associated with complicated deliv-ery and the presence of urinary inconti-nence before surgery.7

There are several treatment options forPOP.8 Conservative methods were mostlyfound to improve symptoms of mild tomoderate POP.9 For patients with a severedegree of POP and for patients to whomconservative methods of treatment did nothelp, surgical treatment options can beused.1 Surgery is the definitive treatment ofPOP. It can be reconstructive in terms ofrestoration of vaginal anatomy and coitalfunction or obliterative with vaginal clo-sure.

In case of anterior vaginal wall prolapseanterior and posterior colporrhaphy are pos-sible. In site-specific defect repair identifi-cation and repair of specific sites of recto-vaginal fascial deficiency is possible. Forapical support, there are numerous possibletypes of operations: sacrocolpopexy, sacro-colpoperineopexy, levator myorrhaphy withapical plication, iliococcygeus fascia fixa-tion, sacrospinous ligament suspension pro-cedures and uterosacral ligament suspen-sion.10 For a successful operation, it isessential to identify patients with a higherrisk of recurrence after surgery to indicateindividualized treatment. However, very lit-tle is known about factors associated withsurgical failure. It has been reported that thehigher rate of recurrence appears in theanterior compartment.4,11 Potential factorsfor recurrence are factors that lead to POPin the first place, preoperative grade of pro-lapse, type of surgery, experience of sur-geons and complications in the early post-operative period.4 Despite the large numberof possible surgical procedures, it is crucialthat the most appropriate method is selectedfor each individual patient. A wrong selec-tion of method can lead to a higher proba-bility of re-prolapse and consequent needfor reoperation.

Case ReportA 77-year old red-haired, Caucasian

woman had six gynecologic surgeries due toPOP. Her obstetric history includes four

vaginal childbirths without any complica-tions. She had no miscarriages, blood trans-fusions or allergies. She had myocardialinfarction in 2003. In 2005, she underwentcholecystectomy. She has been treated forarterial hypertension and diabetes type 2(on insulin therapy) for 10 years. Her bodymass index is 26 and has not changed dras-tically in the past few years. At the age of 50(in 1989), she underwent her first gyneco-logic surgery because of primary uterineprolapse, with dragging sensation, com-plaint of bowel symptoms and urinaryincontinence. Abdominal hysterectomywith bilateral adnexectomy and Burch col-posuspension was performed. Burch colpo-suspension is the procedure for the treat-ment of stress urinary incontinence. Byitself, it is not indicated for the treatment ofPOP, for which we use alternative treat-ment, in this case a hysterectomy. As wepreformed the abdominal hysterectomy, wedecided to preform also Burch colposuspen-sion for further prevention of urinary incon-tinence. In 2006, vaginoplasty of enteroceleand Richter’s sacrospinous ligament fixa-tion of vaginal vault prolapse was made,

Urogynaecologia 2017; volume 30:194

Correspondence: Kristina Drusany Starič,Division of Gynecology and Obstetrics,University Medical Centre, Šlajmerjeva 3,Ljubljana, Slovenia.Tel.: +386.68.615.579.E-mail: drusany@yahoo.com

Key words: Recurrent pelvic organ prolapse;anterior and posterior corporaphy; sacro-colpopexy; colposuspension; total colpocleisis.

Acknowledgements: the authors would like tothank Mr. Andrew Jackson for proofreadingthe article.

Contributions: KDS, manuscript writing, casereport selecting; PB, manuscript writing; AZ,manuscript writing, taking photographs; AL,manuscript writing and discussing. All authorsread and approved the manuscript.

Conflict of interest: the authors declare nopotential conflict of interest.

Received for publication: 2 January 2017.Revision received: 2 May 2017.Accepted for publication: 1 June 2017.

This work is licensed under a CreativeCommons Attribution NonCommercial 4.0License (CC BY-NC 4.0).

©Copyright K. Drusany Starič et al., 2017Licensee PAGEPress, ItalyUrogynaecologia 2017; 30:194doi:10.4081/uij.2017.194

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due to prolapse of the vaginal vault. In 2010she again presented with total prolapse ofthe vaginal vault, and after the usual preop-erative preparation total colpocleisis wasperformed. After two years due to recurrentprolapse of the vaginal vault and entero-coele, the total colpocleisis was again per-formed. Each time the total colpocleisis waspreformed according to standards of thisprocedure. Results in the early postopera-tive period, as well as on check-up visitstwo months after the surgery, were perfectand she had no specific symptoms. Re-occurrence of vaginal prolapse was due toelongation of the vagina from the sides, andit happened again in 2013. Vaginal prolapsecould not be satisfactorily reduced and itcaused serious difficulties in passing urineand feces. The patient claimed that theseproblems were far worse than symptomsbefore previous operations. After the pro-lapse reduction, the vagina fell out immedi-ately. At the end of 2013, she underwentlaparoscopic sacrocolpopexy withresorbable sutures to the vagina andresorbable screws to the sacrum. On follow-up in February 2014, her gynecologic statewas uneventful. In January 2016 recurrentvaginal prolapse was found. In June 2016she was admitted to the Department forGynecology for operative treatment forstage 3 POP (Figure 1) and large postopera-tive umbilical hernia. At that time she pre-sented with difficult urination and defeca-tion. The mesh could be seen eroding thevagina (Figure 2). POP Q on the examina-tion was Aa -2.0, Ba -2.0, C -4.5, gh 3.0, tvl8.0, Ap 3.0, Bp 3.0 (Figure 3) Perineal,vaginal and endoanal ultrasound showedloose mesh on the rectum and on the anteri-or wall of the vaginal vault; damaged pub-orectalis muscle on both sides was shown.After the usual preoperative preparation,

hernia plasticity was performed. The poste-rior mesh was removed from the abdominalcavity. Afterwards vaginal prolapse wasagain corrected by total colpocleisis.

All stated surgeries took place withoutany complications or greater blood loss.Each time postoperative period was carriedout without complications. During hospital-ization, she received analgesics, antibiotics,anti-thrombotic protection, laxatives andher regular therapy. We discouraged greaterphysical exertion and heavy lifting for atleast four months after surgery. We advisedher to drink sufficient amount of fluids andto take care of regular bowel movements.Two months after surgery she had a follow-up visit, where she had no specific prob-lems. All surgeries were performed by avery experienced senior surgeon.

DiscussionPelvic organ prolapse is a common

female health problem. Experts estimatethat every woman has an 11% lifetime riskof needing surgical treatment because ofPOP. The incidence of pelvic organ pro-lapse is expected to increase by 46% from2010 to year 2050. The incidence of recur-rent POP is still unknown.12 Price et al.demonstrated that the rate of re-operationwas greatest in the first three years after ini-tial surgery.8,13 So far, little is known aboutspecific risk factors for each individualwhich predispose them to recurrence ofPOP.13 However, recent meta-analyses haveshown that surgical procedures can improvequality of life of women with POP, andappropriate choice of surgical techniquewas found to be among the most importantfactors on which success of surgerydepends. Evidence about which surgical

method is the most appropriate for eachpatient is still lacking. In addition, it is dif-ficult to identify patients with the samedegree of POP due to the lack of a universaldefinition of POP to perform uniform sur-gery for all of them.12 Nevertheless, we triedseveral surgical techniques to improve ourpatient’s condition; however the proper sur-gical technique suitable for her could not befound and reoperations were needed. Ingeneral, in our hospital recurrences aftersacropexy are 4.5%, and after totalcolpocleisis are less than 1%. To date vagi-nal hysterectomy is still standard practice,even though descent of the uterus is a result,not a cause of, prolapse. So far, there aresome data, which show that the history ofPOP at the time of hysterectomy has beenestablished as a strong and independent fac-tor for POP recurrence.12 In addition, subto-tal abdominal hysterectomy does not pre-vent development of POP compared to totalhysterectomy.14 Conversely, vaginal apicalsupport procedure is possible to reducelong-term risks for its recurrence.15 The suc-cess rate of apical fixation procedures is 82-92%. Increasingly, women wish to avoidhysterectomy, because of delay in child-bearing and the belief that the uterus isimportant for sexual satisfaction. To resolvePOP and preserve fertility, a sacrospinousuterine fixation is possible. The obliterativeprocedures such as partial and total colpec-tomy are reserved for women with stage III-IV POP who no longer want to preservecoital function, and have a cure rate of 90-97%. In comparison, sacrocolpopexy with apolypropylene mesh has a statistically high-er success rate (up to 91%) and less post-operative dyspareunia.1 However, meshrepairs are also linked with high rates ofsurgical complications and postoperativeadverse effects, and vaginal mesh is banned

Case Report

Figure 1. The patient with Stage 3 POP with leading posteriorwall.

Figure 2. On the examination the posterior mesh that is not fixedto the sacrum anymore and it is eroding trough the mucosa.

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in some countries.16

The early postoperative period is funda-mental for proper wound healing afterpelvic surgery. An increase in abdominalpressure, which may occur at the mobiliza-tion, coughing, vomiting and straining atbowel movements, can all threaten normalwound healing. This may influence the suc-cess of the surgical procedure and can leadto revision surgeries.12 To reduce this risk,some recommend use of vaginal supportdevices for at least four weeks aftersurgery.12 In our institution, we do not regu-larly prescribe post-operative use of vaginalsupport devices, however our patient wasalways given precise instructions at dis-charge about how to deal with early and latepostoperative periods, such as discourage-ment of greater physical exertion and heavylifting, taking care of regular bowel move-ments and dissuasion of sexual intercoursein the early postoperative period.

Nowadays the influence of genetics onoccurrence of POP is emphasized. Vetuschiand coworkers have confirmed a significantinfluence of collagen imbalance on occur-rence of POP.17 They have shown that mus-cularis propria of the vaginal wall in POPpatients has more type III collagen than

type I, which consists of much thinnerfibers, less elastic fibers, and smooth mus-cle cells were found to be more disorgan-ized. This all results in alternations of archi-tecture and function of muscularis propria.17

Presentation of this case clearly demon-strates dramatic recurrences of POP andhow difficult its treatment and preventioncan be. Even though such extreme cases areinfrequent, we wanted to draw attention tothem with this case. We need to emphasizethat to date the literature of recurrent pro-lapse does not exist. Our paper is the firstcontribution, which in detail described theproblem of recurrent POP. To understandwhy relapse occurs and why in our patient,despite so many different surgeries, relapsealways occurred, we would need clinicalstudies focusing on identifying risk factorsfor each patient. Only individual treatmentand individual selection of therapy couldavoid recurrence of POP. To avoid develop-ment and reoccurrences of POP it is neces-sary to identify high-risk populations andfocus on modification of risk factors. It isimportant to develop new techniques for thepatients with recurrent prolapse, to sparepatients future re-admissions for future sur-geries.

ConclusionsPOP is one of the leading pathologies,

which can have extremely negative impacton quality of life of individual women.Despite the fact that we expect markedincrease in the incidence of POP over thenext 30 years, little is known about modifi-able and non-modifiable risk factors andappropriate treatment options for each indi-vidual. Therefore, we recommend theimplementation of future researches withuniform definition of POP, which would bemore explicit and easier to compare withone another. In addition, randomized stud-ies about recurrence of POP are needed,since there is no data on this topic in the lit-erature yet.

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Case Report

Figure 3. The loose posterior mesh is seen on the picture. The anterior mesh is still in theplace. Both meshes are presented in blue color.

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[Urogynaecologia 2017; 30:194] [page 9]

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Case Report

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