Women's genital prolapse and connective tissue disease
Abstract Objective. To study the clinical manifestations of connective tissue disease, and to study the role of CTD development of genital prolapse. Using the results, choose a method of the surgical treatment the genital prolapse (GP).
Material and methods. 246 primigravidas nulliparous (mean age 24.9±0.46 years) and 346 women with genital prolapse (mean age 44.5±10 years) and classified and nonclassified forms of the DSD. We used clinical laboratory methods, physical and instrumental methods (ECG, ultrasound, echocardiography), R-logical research, urodynamics research, MRI, laser flowmetry, morphological methods. All 346 patients had surgical correction of GP.
Results. Genital prolapse – is a heterogeneous disease with various forms of manifestation. In younger patients (44.5±10 years) GP was presented by apical forms –175 (50.7%): complete and incomplete uterine prolapse and vaginal walls – 39 (11.3%) and 83 (23.9%) cases, III degree uterine prolapse – 53 (15.4%) cases. Fascial defects were not identified in 90% of cases. Traumatic birth did not exceed 20%. Electromyography signs of pudendal neuropathy were absent. Anorectal department of the pelvic diaphragm complaints characterized the dissenergy of the pelvic complex. Phenotypic of CTD criteria were identified in 88% of patients with PG. There are the dynamics of phenotypic criteria CTD in patients of different age groups. The form of GP is determined by CTD form and type of hemodynamics. The apical forms of GP correlated with size of mitral valve prolapse (mean size 0.59±0.16 cm) and in 45.5% of cases the MVP was accompanied by mitral regurgitation. The size of PMC correlated with asthenic constitution (–0.517, p=0.048), joints hypermobility, myxomatous degeneration of valves (0.480, p=0.028), apical forms of GP and rectocele, feet (–0.715; p=0.001). The apical forms of GP correlated with increase in end-diastolic volume – 102.7±31.08 ml, reduced ejection fraction, myocardial mass – 135.6±36.6 g. Rapidly births were correlated with apical forms of GP (–0.462, p=0.005). Microcirculation was manifested by: congestive type of blood supply, increase of microcirculation up to 6.6±1.84 perfusion rate – up to 2.2±0.91 coefficient of variation up to 28.9±5.46, an increase in the relative amplitude of HF – up to 21.9±5.1 (control – 18.3±1.29). The recommendations of surgical correction tipe of GP depended from the age, form of CTD, form of GP, forms of urinary incontinence.
Conclusion. PG – is a multifactorial disease with heterogeneous clinical manifestations. Pregnancy and childbirth are the predisposing factors of for the development of GP. Birth trauma in the genesis of PG does not exceed 20%. The form PG is determined by the type of CTD, hemodynamics and microcirculation, which are determined by the form of the CTD. Preference operations are the operation with "rigid" fixation with the use of synthetic materials or own tissue. The presence of GP combined forms require the use of an additional surgical techniques.
Keywords:genital prolapse, connective tissue disease, surgical treatment, mitral valve prolapse, fascial defects, urinary incontinence, childbirth, hemodynamics, microcirculation
Clin. Experiment. Surg. Petrovsky J. 2015. № 2. Р. 53–64.
References
1. Connell K.A., Guess M.K., Chen H., Andikyan V. et al. HOXA11 is critical for development and maintenance of uterosacral ligaments and deficient in pelvic prolapse. Clin Invest. 2008; Vol. 118, N 3: 1050–5.
2. Ashton-Miller J.A., Delancey J.O. On the biomechanics of vaginal birth and common sequelae. Ann Rev Biomed Eng. 2009; Vol. 11: 163–76.
3. Adamyan L.V., Kulakov V.I., Kiselev S.T., Sashin B.E. Laparovaginalny access to the surgical treatment of prolapse of the vaginal walls, insolvency pelvic floor muscles and stress urinary incontinence in women of childbearing age. International Congress on «Endoscopy in the diagnosis and treatment of diseases of the uterus» (with a course of endoscopy). Moscow, 1997: 191–3. (in Russian)
4. Krasnopolskiy VI, Ioseliani MN Rizhinashvili ID, AI Slobodyanyuk Modern aspects of surgical treatment of descent and prolapse of internal genital organs of women/ Akusherstvo i ginekologiya [Obstetrics and Gynecology].1990; Vol. 8: 58–60. (in Russian)
5. Samuelsson E.C., Victor F.T., Tibblin G., Svardsudd K.F. Signs of genital prolapsed in a Swedish population of women 20 to 59 years of age and possible related factors. Am J Obstet Gynecol. 1999; Vol. 180, N 2, Pt l: 99–305.
6. Deeb M.E., Awwad J., Yeretzian J.S., Kaspar H.G. Prevalence of reproductive tract infections, genital prolapse, and obesity in a rural community in Lebanon. Bull. World Health Organ. 2003; Vol. 81, N 9: 639–45.
7. Mawajdeh S.M., Al-Qutob R., Schmidt A. Measuring reproductive morbidity: a community-based approach, Jordan. Health Care Women Int. 2003; Vol. 24, N 7: 635–49.
8. Sajan F., Fikree F.F. Perceived gynecological morbidity among young ever married women living in squatter settlements of Karachi, Pakistan. J Рак Med Assoc. 1999; Vol. 49, N 4: 92–7.
9. Talaat M., Watts S., Mekheimar S., Faiook Ali H., et al. The social context of reproductive health in an Egyptian hamlet: a pilot study to identify female genital schistosomiasis. Soc Sci Med. 2004; Vol. 58: 515–24.
10. Scherf C., Morison L., Fiander A., Ekpo G., Walraven G. Epidemiology of pelvic organ prolapse in rural Gambia, West Africa. BJOG. 2002; Vol. 109, N 4: 431–6.
11. Carley M.E., Turner R.J., Scott D.E., Alexander J.M. Obstetric history in women with surgically corrected adult urinary incontinence or pelvic organ prolapse. J Am Assoc Gynecol Laparosc. 1999; Vol. 6, N 1: 85–9.
12. Pierce C.B., Hallock J.L., Blomquist J.L., Handa V.L. Longitudinal changes in pelvic organ support among parous women. Female Pelvic Med Reconstr Surg. 2012; Vol. 18, N 4: 227–32.
13. Mladenovic-Segedi L., Segedi D. Most important etiologic factors in the development of genital prolapsed. Srp Arh Celok Lek. 2010. Vol. 138, N 5–6. P. 315–8.
14. Aytan H., Tok E.C., Ertunc D., Yasa O. The effect of episiotomy on pelvic organ prolapse assessed by pelvic organ prolapse quantification system. Eur J Obstet Gynecol Reprod Biol. 2014; Vol. 173: 34–7.
15. Ugboma H.A., Okpani A.O., Anya S.E. Genital prolapse in Port Harcourt, Nigeria. Niger J Med. 2004; Vol. 13, N 2: 124–9.
16. Sewell C.A., Chang E., Sultana C.J. Prevalence of genital prolapse in 3 ethnic groups. J Reprod Med. 2007; Vol. 52, N 9: 769–73.
17. Alnaif B., Drutz H.P. The association of smoking with vaginal flora, urinary tract infection, pelvic floor prolapse, and post-void residual volumes. J Low Genit Tract Dis. 2001; Vol. 5, N 1: 7–11.
18. Araco F., Gravante G., Sorge R., De Vita D., Piccione E. Risk evaluation of smoking and age on the occurrence of postoperative erosions after transvaginal mesh repair for pelvic organ prolapses. Int Urogynecol J Pelvic Floor Dysfunct. 2008; Vol. 19, N 4: 473–9.
19. Norton P.A., Baker J.E., Sharp H.C., Warenski J.C. Genitourinary prolapse and joint hypermobility in women. Obstet Gynecol. 1995; Vol. 85, N 2: 25, 26, 225–8.
20. Smolnova T.Yu. Pathogenetic rationale for the choice of the method of surgical correction of genital prolapse in women of reproductive age: Diss. Moscow, 1999: 165 р. (in Russian)
21. Adamyan L.V., Smolnova T.Yu. Clinical and pathogenetic aspects of descent and prolapse of internal genital organs in the undifferentiated forms of connective tissue dysplasia. Kubanskiy nauchnyy meditsinskiy vestnik [Kuban Research Medical Messenger]. 2009; Vol. 6: 69–73. (in Russian)
22. Buchsbaum G.M., Duecy E.E., Kerr L.A., Huang L.S., et al. Urinary incontinence in nulliparous women and their parous sisters. Obstet Gynecol. 2005; Vol. 106, N 6: 1253–8.
23. Taksande A.M., Vilhekar K.Y., Batra P., Jain M.J. Neonatal genital prolapse. Indian Med Assoc. 2011; Vol. 109, N 7: 502–3.
24. Abdelsalam S.E., Desouki N.M., Abd alaal N.A. Use of Foley catheter for management of neonatal genital prolapse: case report and review of the literature. J Pediatr Surg. 2006; Vol. 41, N 2: 449–52.
25. Smolnova TY, Adamyan LV Phenotype and its rela- tionship with clinical manifestations of women defined functional and pathophysiological features of the cardiovascular system in connective tissue dysplasia. Spravochnik vracha obshchey praktiki [General practice formulary]. 2014; Vol. 10: 52–8. (in Russian)
26. Dietz H.P., Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005; Vol. 106, N 4: 707–12.
27. Buyanova S.N., Shchukinа N.A., Chechneva M.V. Ten-year experience in the use of mesh prosthesis for correction of complicated forms of genital prolapse: early and late results / New tech- nologies in the treatment of gynecological diseases: Abstracts / Edited by G.T. Sukhikh, L.V. Adamyan. Moscow, 2011: 130–1. (in Russian)
28. Dietz H.P., Steensma A.B. Posterior compartment prolapse on two-dimensional and three-dimensional pelvic floor ultrasound: the distinction between true rectocele, perineal hypermobility and enterocele. Ultrasound Obstet Gynecol. 2005; Vol. 26, N 1: 73–7.
29. Dietz H.P., Clarke B. Prevalence of rectocele in young nulliparous women. Aust NZ J Obstet Gynaecol. 2005; Vol. 45, N 5: 391–4.
30. Dietz H.P., Pang S., Korda A., Benness C. Paravaginal defects: a comparison of clinical examination and 2D/3D ultrasound imaging. Aust N Z J Obstet Gynaecol. 2005; Vol. 45, N 3: 187–90.
31. Smolnova T.Yu., Adamyan L.V. The dynamics of phenotypic traits connective tissue dysplasia syndrome at different ages. The urgency of the problem in obstetrics and gynecology. Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2013; Vol. 4. С. 74–9. (in Russian)
32. Smolnova T.Yu., Adamyan L.V. The criteria for the diagnosis of connective tissue dysplasia in women // Proceedings of the I All- Russian scientific-practical conference “Actual problems of internal pathology. Connective tissue dysplasia”: collection of scientific papers. Omsk, 2005: 156. (in Russian)
33. Ashton-Miller J.A., DeLancey J.O. Functional anatomy of the female pelvic floor. Ann N Y Acad Sci. 2007; Vol. 1101: 266–96.
34. Adamyan L.V., Smolnova T.Yu., Fomenko O.Yu. Functional characteristics of the obturator muscle apparatus of the rectum in women with genital prolapse // New technologies in diagnostics and treatment of gynecological diseases: Abstracts XVII Interna- tional Congress with a course of endoscopy / Edited by G.T. Sukhikh, L.V. Adamyan. Moscow, 2014: 110–1. (in Russian)
35. Smolnova T.Yu., Adamyan L.V., Sidorov V.V. Features macrocirculation during descent and prolapse of internal genital organs of women of reproductive age.Akusherstvo i ginekologiya [Obstetrics and Gynecology]. 2007; Vol. 1: 39–44. (in Russian)
36. Tsukanov Yu.T. Vennaya disease of the lower half of the body: the conceptual and pragmatic aspects. Omsk Scientific Bul- letin. 2005. Appendix. 2005; Vol. (30): 77–80. (in Russian)
37. Smolnova T.Yu. Clinical and pathogenetic aspects of descent and prolapse of internal genital organs and structures of the pelvic pathology in women with complex connective tissue dysplasia Management of patients: Autoabstract of diss. Moscow, 2009: 56 р. (in Russian)
38. Maher C., Feiner B., Baessler K., Schmid C. Surgical management of pelvic organ prolapse in women (Cochrane Review). Co- chrane Library. 2013. Issue 4.
39. Siddiqui N.Y., Grimes C.L., Casiano E.R., Abed H.T. et al.; Society of Gynecologic Surgeons Systematic Review GroupMesh sacrocol- popexy compared with native tissue vaginal repair: a systematic review and meta-analysis. Obstet Gynecol. 2015; Vol. 125, N 1. P. 44–55.
40. Slieker-ten Hove M.C., Pool-Goudzwaard A.L., Eijkemans M.J.C., Steegers-Theunissen R.P.M. et al. The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct. 2009; Vol. 20, N 9: 1037–45.