Algorithm for diagnosing and treatment for pelvic floor dysfunction
AbstractAim of the study was to develop and mathematically justify a therapeutic and diagnostic algorithm for the management of patients of reproductive age with pelvic floor insufficiency.
Design: cohort prospective randomized comparative study.
Material and methods. The study was carried out from September 2020 to November 2023 at the Department of Obstetrics and Gynecology with a course of perinatology of the Russian People’s Friendship University named after Patrice Lumumba, in the gynecological department of the City Clinical Hospital No. 29 named after N.E. Bauman at Moscow and in the treatment and diagnostic center of LLC “Medicine”. The sample was formed according to pre-formed inclusion and exclusion criteria during outpatient preparation of women for admission to the hospital. 112 patients of reproductive age (18–45 years) met the inclusion criteria. Patients with PFI (pelvic floor incompetence) were divided into 2 groups depending on the method of surgical correction: the first group – colpoperineolevatoroplasty (n=65), the second group – perineal thread lifting (n=47). The choice of surgical tactics depended on the severity of clinical symptoms and ultrasound criteria for musculofascial defects of the pelvic floor. For statistical analysis, a control group of women comparable in the main parameters but without PFI was recruited by solid sampling (n=29). All patients underwent a standard clinical and instrumental examination of gynecological patients, expanded by a comprehensive perineological examination (physical examination of the perineum, manometry, transperineal sonography, POP-Q score) to verify the diagnosis of N81.8 (insufficiency of pelvic floor muscles) and exclusion of severe degrees of PTO (stage 3–4 according to POP-Q). Additionally, a comprehensive assessment of the vaginal biotope was performed. In order to evaluate the effectiveness of surgical treatment after 6 months, we analyzed the efficiency of the above methods of correction of pelvic floor architectonics disorders. All patients underwent a gynecologic examination followed by a comprehensive perineologic examination and re-assessment of vaginal biocenosis. Statistical analysis was performed using StatTech v.3.1.6 program (developer – StatTech LLC, Russia) and R-version 4.1.2.
Results. An algorithm for management of patients of reproductive age with PFI was developed and mathematically substantiated. Patients who, at the stage of collecting an anamnesis, have a high risk of PFI, determined using the developed mathematical model, should be referred for a comprehensive perineological examination. In case of targeted verification of PFI, management should be based on the detection/exclusion of pelvic floor musculofascial defects. In the presence of PFI without anatomical changes in the supporting structures, the first line of therapy should be conservative techniques, in case of ineffectiveness or impossibility of which perineal thread lifting may be recommended (second line). This makes it possible to statistically significantly improve the vaginal biocenosis in patients with PFI (p=0.04) and achieve clinically good results (p<0.05). In case of verification of anatomical defects of the pelvic floor musculofascial complex, the operation of choice is colpoperineolevatoroplasty (significant anatomical results, p=0.023) with subsequent control and restoration of the lactobacilli population in the vaginal biotope.
Keywords: pelvic floor insufficiency; genital prolapse; vaginal biocenosis
Funding. The study had no sponsor support.
Conflict of interest. The authors declare no conflict of interest.
Contribution. All authors made significant contributions to the study concept, conduct of the study and drafting of the article, read and approved the final version before publication. Development of the study design, revision, editing of the manuscript – Toktar L.R., Orazov M.R., Aryutin D.G.; checking critical content, approval of the manuscript for publication – Toktar L.R.; selection, examination and treatment of patients – Pak V.E., Lee K.I.; collection of clinical material – Pak V.E., Lee K.I., Gaifulin R.F.; review of publications on the topic of the article – Pak V.E., Lee K.I., Gaifulin R.F.; analysis and interpretation of results, statistical data processing, text writing – Pak V.E.; review of literature data, statistical data processing, text writing and manuscript design – Samsonova I.A.
For citation: Toktar L.R., Orazov M.R., Aryutin D.G., Pak V.E., Li K.I., Samsonova I.A., Gaifulin R.F. Algorithm for diagnosing and treatment for pelvic floor dysfunction. Akusherstvo i ginekologiya: novosti, mneniya, obuchenie [Obstetrics and Gynecology: News, Opinions, Training]. 2024; 12 (3): 77–85. DOI: https://doi.org/10.33029/2303-9698-2024-12-3-77-85 (in Russian)
References
1. Weintraub A.Y., Glinter H., Marcus-Braun N. Narrative review of the epidemiology, diagnosis and pathophysiology of pelvic organ prolapse. Int Braz J Urol. 2020; 46 (1): 5–14. DOI: https://doi.org/10.1590/S1677-5538.IBJU.2018.0581
2. Barber M.D., Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013; 24 (11): 1783–90. DOI: https://doi.org/10.1007/s00192-013-2169-9
3. Radzinsky V.E. Non-surgical design of the perineum. In: V.E. Radzinsky (ed.). Moscow: GEOTAR-Media, 2020: 256 p. (in Russian)
4. Radzinsky V.E. Gynecology. In: V.E. Radzinsky, A.M. Fuks (eds). Moscow: GEOTAR-Media, 2022: 1096 p. (in Russian)
5. Toktar L.R., Orazov M.R. Lologaeva M.S., Azova M.M., Tskhovrebova L.V., Li K.I., et al. Genetic aspects of pelvic organ prolapse in females of different age groups. Akusherstvo i ginekologiya: novosti, mneniya, obuchenie [Obstetrics and Gynecology: News, Opinions, Training]. 2021; 3 (33): 5–10. DOI: https://doi.org/10.33029/2303-9698-2021-9-3-5-10 (in Russian)
6. Tegerstedt G., Maehle-Schmidt M., Nyrén O., Hammarström M. Prevalence of symptomatic pelvic organ prolapse in a Swedish population. Int Urogynecol J Pelvic Floor Dysfunct. 2005; 16 (6): 497–503. DOI: https://doi.org/10.1007/s00192-005-1326-1
7. Nygaard I., Barber M.D., Burgio K.L., Kenton K., Meikle S., Schaffer J., et al. Prevalence of symptomatic pelvic floor disorders in US women. JAMA. 2008; 300 (11): 1311–6. DOI: https://doi.org/10.1001/jama.300.11.1311
8. Toktar L.R., Aryutin D.G, Volkova S.V., Lologaeva M.S., Karimova G.A. Current paradoxes in perineology. Doktor.Ru. [Doctor.Ru]. 2019; 7 (162): 46–51. DOI: https://doi.org/10.31550/1727-2378-2019-162-7-46-51 (in Russian)
9. Shah A.D., Kohli N., Rajan S.S., Hoyte L. The age distribution, rates, and types of surgery for pelvic organ prolapse in the USA. Int Urogynecol J Pelvic Floor Dysfunct. 2008; 19 (3): 421–8. DOI: https://doi.org/10.1007/s00192-007-0457-y
10. Zhang Y.H., Lu Y.X., Liu X., Liu J.X., Shen W.J., Zhao Y., et al. [A five-year analysis of effect on transvaginal high uterosacral ligament suspension with or without native-tissue repair for middle compartment defect]. Zhonghua Fu Chan Ke Za Zhi. 2019; 54 (7): 445–51. DOI: https://doi.org/10.3760/cma.j.issn.0529-567x.2019.07.003 PMID: 31365956. (in Chinese)
11. Pushkar D.Y., Kasyan G.R., Popov A.A. Robotic sacrocolpopexy in pelvic organ prolapse: a review of current literature. Curr Opin Urol. 2021; 31 (6): 531–6. DOI: https://doi.org/10.1097/MOU.0000000000000932 PMID: 34506336.
12. Dietz H.P., Chavez-Coloma L., Friedman T., Turel F. Pelvic organ prolapse in nulliparae. Aust N Z J Obstet Gynaecol. 2022; 62 (3): 420–5. DOI: https://doi.org/10.1111/ajo.13481
13. Toktar L.R. Female pelvic propalse: from a pathogenesis to efficiency of prophylaxis and treatment. Akusherstvo i ginekologiya: novosti, mneniya, obuchenie [Obstetrics and Gynecology: News, Opinions, Training]. 2017; 3 (17): 101–10. DOI: https://doi.org/10.24411/2303-9698-2017-00042 (in Russian)
14. Ultrasound diagnosis of genital prolapse and urinary incontinence in women. In: M.A. Chechneva, S.N. Buyanova, A.A. Popov, I.V. Krasnopolskaya; V.I. Krasnopol’sky (ed.). 2nd ed. Moscow: MEDpress-inform, 2019: 136 p.: ill. (in Russian)
15. Perineology. Aesthetic gynecology. In: V.E. Radzinsky, M.R. Orazov, L.R. Toktar, et al.; V.E. Radzinsky (ed.). Moscow: Redaktsiya zhurnala StatusPraesens, 2020: 416 p. (in Russian)