Urogynecology
Figure 1: Removal of the Gellhorn Pessary is Aided by Ring Forceps, with One Finger Bending the Pessary Base to its Stem
medications, an injection of a periurethral bulking agent or a switch to an incontinence pessary. The authors commonly use a ring pessary with a knob or a Marland pessary for this purpose. Women with persistent urinary incontinence will require perineal protection. The authors use a mixture of 30 g of Mycostatin powder, one packet of Questran light, 120 g of Aquaphor ointment, and 60 cc mineral oil, to be applied as needed.
Choosing Surgery
A woman’s decision to undergo surgical correction for vaginal prolapse is predicated on many factors. The most common indications for a woman choosing surgical management of symptomatic prolapse is often related to failure to tolerate a pessary. The reasons for pessary failure include the effort of maintenance, limited manual dexterity for placement and removal, and advanced-stage prolapse.
The choice of surgical procedure to correct prolapse must take into consideration a number of factors. These include the patient’s baseline health, social support system, the specific defect within the pelvic floor, her desire for sexual function, and the surgeon’s training and skill at performing advanced pelvic surgery. As with any surgical procedure, the goal is to minimize patient risk while maximizing the surgical outcome.
Several surgical options exist for the management of vaginal prolapse. The choice of procedure varies in terms of the route (vaginal, abdominal, or laparoscopic), utilization of graft material, and associated risk to benefit profile of each technique.
Vaginal Reconstructive Surgery
A-P repair is the procedure most commonly used for vaginal prolapse. This comprises an anterior (A) and posterior (P) colporrhaphy repair with or without a hysterectomy.
Use of Forceps
When cleaning gellhorn pessaries, the authors regularly use ring forceps to facilitate both removal and insertion. The forceps are inserted into the vagina and grasp the gellhorn stem. A quick rotation of the stem will confirm that vaginal epithelium has not been included in the grasp of the forceps. Simultaneous pulling on the forceps and using one finger to bend the gellhorn base to the stem (see Figure 1) decreases the surface area of the pessary presenting to the introitus during removal and increases the patient’s comfort.
Pessaries for Vaginas with Unusual Geometry Some patients cannot be fitted with a ring pessary as they have a vagina with an unusual geometry. For those with a narrow calibre vagina, there has been success with an oval-shaped pessary. For women with anterior-dominant prolapse, the use of a Marland pessary has been successful. For those with a short vaginal length, causing the gellhorn stem to protrude beyond the hymen, a short-stem gellhorn is often used. This can be either directly purchased or created by trimming a long stem with a scalpel.
Managing Urinary Incontinence De novo or worsening urinary incontinence is a common reason for discontinuing pessary use and can be of the stress, urge, or mixed type. This bothersome complication can be managed with anticholinergic
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The anterior colporrhaphy was first described by Howard Kelly as an incontinence procedure with the original intent of narrowing the bladder neck, as incontinence was thought to result from funneling at this site. The objective of the procedure is to plicate the underlying layers of the vaginal muscularis and adventitia overlying the bladder in such a way as to reduce the protrusion of the bladder and vagina. Unfortunately the long-term failure rates for incontinence are high, ranging from 36–65 %.13–15
When employed for correction of anterior vaginal wall defects, failure rates range from 0–63 %.16–19
Due to the high failure rates of the anterior colporrhaphy, more contemporary procedures focus on the vaginal apex and its role in pelvic organ prolapse. Vaginal procedures, such as uterosacral ligament fixation or sacrospinous ligament suspension, or abdominal procedures, such as a sacral colpopexy, are designed to support of the vaginal apex while ensuring optimal post-procedure vaginal length and function.
For older patients who do not desire vaginal (sexual) function, colpectomy/colpocleisis may be an appropriate alternative.
Vaginal Obstructive Surgery
Colpectomy (removal of the vaginal mucosa) and colpocleisis (narrowing or closure of the vaginal canal) are procedures that can be offered to
US OBSTETRICS & GYNECOLOGY
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