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Surgical contraception for women of late reproductive age suffering from pelvic organ prolapse--features and benefits.

Introduction

Problem of descent and prolapse of internal genital organs continues to be the focus of gynecologists, not only due to the tendency to increase the frequency and severity of this disease, but also the fact that intervention for prolapse in the structure of gynecological operations frequency ranks third (after benign tumors and endometriosis). In the structure of gynecological morbidity descent and prolapse of internal genital organs makes up to 28% (Kulakov et al., 2000; Adamyan et al., 2004; Patel at al., 2007). Despite the improving the quality of obstetric care, approximately 50% of all women giving birth in time face genital prolapse of varying severity. The disease has a wide age range, in addition, in recent years there has been a noticeable "rejuvenation" of this disease and the increasing number of complicated and recurrent forms (Kulakov et al., 2006; Krasnopolskiy et al., 2007; Loran, 2008; Popov et al., 2000; Petros, 2004; Barber, 2005).

Problem of genital prolapse is becoming increasingly important for women of reproductive age. Insolvency of the pelvic floor, including the omission of sexual organs, is extremely frequent pathologies observed in almost a third of women of reproductive age (Marilova, 2007; Vysotskaya, 2008; Gorbenko, 2008; Dorosh, 2009; Zhuravlev, 2009; Yashchuk, 2009). In the treatment of prolapse and internal genital prolapse the surgery plays a leading role. In literature described in detail more than 300 ways of surgical treatment of descent and prolapse of internal genitals by vaginal., abdominal., laparoscopic or combined access, which indicates a certain degree of imperfection of each. However, the high rate of recurrence of the disease (16 to 43%) indicates a lack of efficacy of currently used surgical techniques (Adamian, 2004; Ailamzyan, 2007; Klyukovkina, 2007). In modern conditions, given the trend toward "rejuvenation" of the disease, genital prolapse seems not only medical but also personal., family, social issues affecting sexual., professional and many other areas of life of patients. Reasons for the high incidence among women of reproductive age--one-third of all patients on given nosology--lie in the general deterioration in the health of women in the population.

The most important factor in maintaining the health of women who have undergone surgery for prolapse is a solution to the problem of unwanted pregnancy. It is believed that carried plastic surgery on the genitals is an absolute indication for cesarean section (Serov, 2000). Thus, women operated on for prolapse of the vaginal walls need to be informed and make a choice about their reproductive goals, ie they need the highly effective methods of contraception, such as voluntary surgical contraception. In this regard, the use of contraception is considered as one of the most important trends in the rehabilitation of women in the process of complex treatment of genital prolapse. It is known that when choosing a method of contraception should be considered reproductive intentions and experiences of patients, which is the driving factor of contraceptive behavior (Prilepskaya, 2000; Benagiano, 2004; Serov, 2000; Peterson, 2004). Researchers were not involved in the study of these issues in women with genital prolapse.

The purpose of this study was to develop differentiated application of the principles of voluntary surgical contraception in women of reproductive age during surgery for prolapse.

Materials and methods

We observed 80 women of reproductive age with genital prolapse. Inclusion criteria were:

-- presence of varying degrees of prolapse

-- prolapse in conjunction with the elongation of the cervix

-- surgical treatment for OiVVPO

-- required a written informed consent of patients for the study and VSC. Exclusion criteria were:

-- heavy extragenital pathology.

-- age older than 49 years

-- contraindications to surgical treatment

-- failure patients from the study

-- mental illness

-- severe bladder dysfunction.

Before the surgery, underwent clinical examination by the standard technique. In order of the comparative assess of effectiveness of different methods of voluntary surgical contraception the surveyed women were divided into two groups: A--50 women, who at the time of surgical treatment of genital prolapse simultaneously transvaginal occlusion of the fallopian tubes (the main group); B--30 women undergoing the first stage before the surgical correction of pelvic organ prolapse held minilaparotomy and VSC (control group).

Examination of women started with the study of history. From history we found out the age of deferred gynecological and extragenital diseases, surgery. The attention was paid to duration of the disease, the nature and effectiveness of the earlier curative measures. In the study of menstrual function the attention was given to age at menarche, menstrual function (menstruation duration, intensity, presence of pain), rhythm, duration of the cycle. Noted data included the age of onset of sexual activity, contraceptive methods used previously. In the analysis of the reproductive function paid attention to the number of pregnancies, births, abortions, especially of their course, complications. Especially the attention was paid to obstetric injury of soft tissues of the birth canal and the effectiveness of their recovery. There were excluded chronic inflammatory diseases of the pelvic organs, pregnancy and delivery complications, operative vaginal delivery methods, benefits and other conditions of the body, which could lead to obstetric injuries of the cervix and vaginal walls. Further explored data included: occupation, residence, professional activity, features of working and living conditions, the availability of physical activity, the types of additional loads (work in the garden and suburban areas, the content of the farm cattle and small domestic cattle). Hereditary predisposition emerges from history. The age range was within 20-45 years. Basically, these were women age category of 31-40 years (52%). The mean age was 37.3[+ or -]2.5 years.

Results and discussion

From the total number of patients surveyed residents of the city made 50 (62.5%), residents of the village--30 (37.5%). 46 women (57.5%) pointed on hereditary predisposition to prolapse. Most patients had 2-3 births (48.7%). 22 (27.5%) women had a history of one delivery, and 19 (23.8%)--4 or more. Parity was 2.52[+ or -]0.7, i.e. one woman had 2.52[+ or -]0.7 childbirth. Reproductive function experienced a large number of births, which were accompanied by high perineal injuries (64%) (weight of a newborn over 4000gr was 28%), high frequency of abortion. Gynecological disorders of an inflammatory nature were detected in 100% of cases. Out of 80 women with a history of childbirth, all 80 patients associated their disease with childbirth. Almost half of the patients--42 (52.5%) had a history of 1 to 4 artificial and spontaneous abortion. According to the International Classification of Diseases diagnoses in the studied group of patients were distributed as it represented in Table 1.

All patients in the scheduled order underwent surgical treatment. Types of surgery performed in the examined women are shown in Table 2. As the table shows the predominant method of surgical treatment of genital prolapse in women of reproductive age is a front and back colpoperineorrhaphy. Restoration of the pelvic floor was performed in all women using their own tissues. All patients used vaginal access. All patients received general or spinal anesthesia. 70 patients made colpoperineorrhaphy with levatoroplastics with strengthening vesicovaginal fascia by the method of Boom, 10 "The Manchester operation."

The proposed colpoperineolevatoroplastics technique with the strengthening of vesicovaginal fascia and sterilization by Pomeroy transvaginal access is clearly represented below.

-- Stage I--baring vagina using mirrors, grabbing a cervix vulsella and reducing it. Making the front vaginal vault incision of 2-3 cm long and penetrating into the abdominal cavity.

-- Stage II--with pipe hook Ramathibodi grabbing the fallopian tube and reducing it in the vagina. Examination of ampulla and fimbriae, fixing the relegated pipe and choosing avascular area.

-- Stage III--in the avascular portion of the pipe creating a loop of 1-2 cm, imposing stranglehold free chromic catgut (simple O-shaped ligature) around the pipe and tightening a square knot. Loop tube is cut off, holding the ligature stretched. Inspection of the stump tubes for the absence of bleeding, cut the ligature at 1 cm from the tube and immersing the tube into the peritoneal cavity. Performing the same procedure on the other side of the wound and suturing anterior vaginal vault with continuous catgut suture.

-- Stage IV--cervix sending down to the entrance of the vagina. Cutting the vaginal wall to be loose layer of fiber. This procedure made in the midline, at 1.5-2 cm distance from the outer opening of urethra and toward the outer zevu cervix until reaching the border of cervical and vaginal vault. Exfoliating the vaginal wall from the underlying fascia gallbladder. Separatization area depends on the flap of the vaginal wall, which will be deleted as redundant.

-- Stage V--connecting midline perivesical tissue with purse-string catgut suture and through piercing the fascia and muscle layer; thereby provided "strengthening" of the bladder and hemostasis simultaneously.

-- Stage VI--removing redundant tissue of the vaginal wall, connecting the wound edges with catgut suture. Evaluation of hemostasis, removal of bullet forceps.

-- Stage VII--determining the boundaries of the removing triangular flap in the posterior vaginal wall with Kocher clamps: two clips at the outer corners of the triangle imposed on the lower sections of the labia minora, above the boundaries of posterior commissure, at the level where the future will be re-formed back spike. The vertex of the triangle is located to the rear vaginal wall along the midline. By reducing bottom clips together, we define the width of the resulting postoperative vaginal entrance.

-- Stage VIII--through stretching the clamps base of a triangle with a scalpel we proceed a thin cut along the junction of the vaginal mucosa and perineal skin. Imposing clips on the resulting flaps, stretching injury, and penetrating into the rectovaginal tissue, separating the vaginal wall from the rectum. The flap is cut off with scissors, starting from the top corner, and then moving to the side corners.

-- Stage IX--suturing the wound with continuous catgut from its upper corner, connecting only the edges of the mucosa. After a few (4-5) stitches we pass the end of the thread to assistant and then proceed to levatoroplastics.

-- Stage X--levatoroplastics is performed in two ways, depending on the muscle. If at a palpation the leg muscles are not broken, they should be isolated from the fascia. If at a palpation the abdomen muscles, lifting the anus, are poorly defined, the remaining parts of the muscle were ligated together with the fascia covering. In the first case from the vaginal wound over the abdomen muscles (determined by palpation) cut tissue and fascia. Found on both sides of the levator under them carried a thick ligature and pulled up into the wound of the vagina, while freeing them from the fascia perirectal parts into which imposed tightening 2-3 main seam. In the second case, not separating the muscles using steep thick needle, a first summing it with one hand muscle, gouged and grasped from the other side arm.

-- Stage XI--maintaining the connection of vaginal wound edges using continuing catgut sutures to the boundary of the skin. Departing to the perineal muscles to suture them

-- Stage XII--suturing perineal skin by Dutzman method.

As a control, 30 patients underwent VSC of the first stage, before vaginal surgery, according to the standard technique of minilaparotomy. Comparative results of both operations are presented in Table 3. The observed tendency to improving the quality of sexual life witnesses on the positive impact of removing genital prolapse with simultaneous VSC on quality of life of women.

Conclusion

Optimization of surgical treatment with both transvaginal VSC in women of reproductive age with descent and prolapse of the vaginal walls allows not only to eliminate this pathology, but also to provide the patient a constant and reliable method of contraception VSC produced by vaginal access requires more skill of the surgeon, but significantly reduces the duration of surgery, blood loss, the number of intra-and postoperative complications.

References

Adamyan, L.V., 2000. "Modern concepts of surgical treatment of descent and prolapse of female genital mutilation", Proceedings of the International Congress: Endoscopy in the diagnosis, treatment and monitoring of women's diseases, Moscow, pp.622-635

Adamyan, L.V., Smolnova, T.Yu., 2006. "State structures of the pelvic floor in patients with genital prolapsed", Modern technologies in diagnosis and treatment of gynecological diseases, Moscow, pp.142-143

Adamyan, L.V., Kozachenko, I.F., Sashin, B.E., Arslanyan, K.N., 2008. "Current treatment options for genital prolapse and urinary incontinence sressovogo", Problems of reproduction, Special Issue, pp.109-110

Barber, M.D., Visco, A.G., 2002. "Sexual function in women with urinary incontinence and pelvic organ prolaps", Gynecol., Vol.99(2), pp.281-289, http://dx.doi.org/10.1016/ S00297844(01)01727-6

Benagiano, G., Primiero, F., Farris, M., 2004. "Clinical profile of contraceptive progestins", Eur J Contracept Reprod Health Care, Vol.9(3)pp.182-193, http://dx.doi.org/10.1080/13625180400007736

Patel, D., Xu, X., Thomason, A., 2007. "Childbirth and pelvic floor dysfunction: an epidemiologic approach the assessment of prevention opportunities at delivery", Am. J. Obstet, Gynecol., Vol.196, No.3, pp.22, http://dx.doi.org/10.1016/j.ajog.2006. 09.007

Vysotskaya, E.I., 2008. "Prevention of postoperative infectious complications in perimenopaus women with surgical correction of descent and prolapse of internal genital organs", the dissertation of the candidate of medical of sciences, Moscow

Gorbenko, O.Y., 2008. "New approaches to surgical treatment of descent and prolapse of internal genital organs", the dissertation of the candidate of medical sciences, Moscow

Dorosh, T.N., 2009. "Effect of surgical treatment of prolapse of internal genital organs on the quality of life of women", Dissertation of candidate of medical sciences, Tomsk

Zhuravlev, A., 2009. "Principles for the selection of surgical techniques for the correction of complicated forms of genital prolapse and evaluate their effectiveness", the dissertation of the candidate of medical sciences, Moscow

Krasnopolskii, V.I., Popov, A.A., 2007. "Vaginal extraperitoneal colpopexy (method PROLIFT)--a new look at surgery descent and prolapse of internal genital organs", Obstetrics and Gynecology, pp.51-55

Klyukovkina, O.V., 2007. "Elongation of the cervix: pathogenesis, clinical and morphological characteristics", the dissertation of the candidate of medical sciences, St. Petersburg Kulakov, V.I., Adamyan, L.V., 2000. "Surgical treatment of descent and prolapse of the vagina and uterus", Operative gynecology--surgical energy, Source in Russian, Moscow: Medicina--Antidor Kulakov, V.I., Serov, V.N., 2001. "Manual and other reproductive health services", Moscow: Triada-X

Kulakov, V.I., Adamyan, L.V., Strizhakova M.A., 2006. "Surgical correction of the insolvency of the pelvic floor and functional disorders of the pelvic organs in gynecological patients", Modern technologies in diagnosis and treatment of gynecological diseases, Source in Russian, Moscow: pp.153-157

Loran, O.B., Antsiferova, E.V., 2008. "Assessment of the quality of social and sexual life of patients undergoing surgery on the perineum", Russian Herald of Obstetrician, pp. 37 Marilova, N.A., 2007. "Effect of repeated births condition of the pelvic floor", Dissertation of the candidate of medical sciences, Source in Russian, Moscow

Popova E.L., 2000. "Application of transvaginal reconstructive plastic surgery to preserve women's reproductive health", Problems of theoretical and practical medicine, Abstracts, Source in Russian, Ufa, p.90

Zlidar, V., Upadhyay, U., Lande, R., 2008. "Family Planning--Universal guide for providers of family planning services", Edited USA, Baltimore

Prilepskaya, V.N., Kosarev, E.A., 2000. "Reproductive behavior of women: Current Trends", Contraception and women's health, Source in Russian, No.2 (6), pp.18-26

Peterson, H.B., 2004. Minilaparotomy and endoscopic techniques for tubal sterilization: RHL commentary (last revised: November 1, 2004). WHO Reproductive Health Library; Geneva: World Health Organization

Serov, V.N., Habarov, S.V., 2000. "Experience of the voluntary surgical sterilization", Contraception and women's health, Source in Russian, No.2, pp.40-43

Tarasova, M.A, Shapovalov, KA, Lekareva, T.M., 2008. "Counseling on reproductive health and contraceptive methods: A practical guide for physicians", Source in Russian, Moscow

Yashchuk, A.G., 2009. "Scientific rationale and implementation of treatment and rehabilitation in women genital prolapse (clinical and genetic aspects)", Dissertation the candidate of medical sciences, Source in Russian , Moscow

Nigina Nasinova

Samarkand State Medical Institute, Uzbekistan

Source: Nigina Nasimova, 2014. "Voluntary surgical contraception women of late reproductive age suffering from pelvic organ prolapse--features and benefits", Medical and Health Science Journal., Vo.15(2), pp.44-49, DOI: http://dx.doi.org/ 10.15208/mhsj.2014.07
TABLE 1. DISTRIBUTION OF STUDY PATIENTS BY DIAGNOSIS

The diagnosis                                          n      %

Elongation of the cervix in conjunction with the old   15   18.75
perineal tear

Omission of the vaginal walls with cicatricial         45   56.25
deformity of the cervix, cystocele

Omission of the vaginal walls with elongation of the   12    15
cervix, cystocele

Omission of the cervix in conjunction with the old     8     10
perineal

Total                                                  80    100

TABLE 2. TYPES OF SURGICAL INTERVENTIONS IN WOMEN SURVEYED

Type of surgery                                      Abs.    %

Front colporraphy, back colpoperineorrhaphy with      40     50
levatoroplastics and sterilization by Pomeroy
transvaginal access

Hysterotrachelectomy with transfer the vaults and     10    12.5
sterilization by Pomeroy transvaginal access

Front colporraphy, back colpoperineorrhaphy with      30    37.5
levatoroplastics + minilaparotomy sterilization by
Pomeroy

Total                                                 80    100

TABLE 3. COMPARISON OF VSC IN WOMEN WITH SIMULTANEOUS
COLPOPERINEOLEVATOROPLASTICS WITH STRENGTHENING VESICOVAGINAL FASCIA
PRODUCED VAGINAL AND TRANSABDOMINAL ACCESS

Indicator                                Core group
                                          (n = 20)

Duration of operation                 58.3 [+ or -] 2.1

Hemorrhage                           220.4 [+ or -] 15.4

Intraoperative complications:
--Bladder injury                             --
--Bleeding                                 1 (2%)

Postoperative complications:
--Gapping                                  2 (4%)
--Temperature Rise                           --
--Exacerbation of chronic cystitis           --

The average number of bed-days        4.6 [+ or -] 1.1

LONG-TERM RESULTS (1 YEAR AFTER SURGERY)

Recurrence of prolapse                       --

Pregnancy                                    --
(efficiency VSC)

Satisfaction with sexual life             46 (92%)

Pain during intercourse                      --

Bladder control during sexual             48 (96%)
intercourse

Rejection of sexuality for fear of           --
unwanted pregnancy

Indicator                               Control group
                                          (n = 50)

Duration of operation                 94.2 [+ or -] 5.3    P<0.01

Hemorrhage                           235.1 [+ or -] 10.7   p>0.5


Intraoperative complications:
--Bladder injury                           1 (5%)          P<0.01
--Bleeding                                 1 (5%)

Postoperative complications:
--Gapping                                  1 (5%)
--Temperature Rise                         3 (15%)         P<0.01
--Exacerbation of chronic cystitis         2 (10%)

The average number of bed-days        7.8 [+ or -] 1.6     P<0.01

LONG-TERM RESULTS (1 YEAR AFTER SURGERY)

Recurrence of prolapse                       --             --

Pregnancy                                    --             --
(efficiency VSC)

Satisfaction with sexual life             19 (95%)         P>0.5

Pain during intercourse                      --             --

Bladder control during sexual             18 (90%)         P>0.5
intercourse

Rejection of sexuality for fear of           --             --
unwanted pregnancy
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Author:Nasinova, Nigina
Publication:Medical and Health Science Journal
Article Type:Report
Date:Apr 1, 2014
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