Clinicopathologic characteristics and treatment patterns of pelvic organ prolapse in South Korea

Introduction We investigated the clinicopathologic features, method of treatment, and complications related to the conservative treatment and surgical treatment of patients with pelvic organ prolapse (POP). Methods We retrospectively analyzed 288 patients who were diagnosed with POP from January 2007 to December 2017. The patients were divided into two groups according to the treatment method (Group A received conservative treatment and Group B received surgical treatment). The patients' clinicopathologic characteristics, treatment method, and post-treatment complications were compared between groups A and B. Results Of the total 288 patients, 83 and 205 patients were assigned to Groups A and B, respectively. The most common symptom was a bearing-down sensation (n = 205, 71.2%), which was reported in 51 (61.4%) and 154 (75.1%) patients from Groups A and B, respectively. Among underlying diseases, hypertension was the most common in both groups (40 and 102 patients in Groups A and B, respectively). Overall, 205 patients underwent surgery, 23 underwent vaginal pessary, and 60 performed pelvic floor muscle exercises. The incidence of treatment-related complications was not significantly different between Groups A and B (13.3% vs. 17.6%, p = 0.37). Perioperative complications were noted in 20 (17.8%) patients and vault prolapse requiring subsequent surgery was noted in 16 (14.1%) patients. Conclusion As surgical treatment is associated with recurrence and complications, conservative treatment methods can be initially considered for patients with POP. In this study, there was no difference in the incidence of complications between surgical and conservative treatments. Thus, if required, surgical treatment can be safely performed in patients with POP.


Introduction
Pelvic organ prolapse (POP) is the descent of one or more of the female pelvic organ (vagina, uterus, bladder, rectum) into the vagina.
As age increases, the prevalence of POP also increases. The cause of POP is multifactorial and established risk factors for POP include vaginal childbirth, advancing age, increasing body mass index (BMI), and prior hysterectomy [1,2]. Most patients with POP are asymptomatic and do not require treatment. Symptoms associated with POP vary and the feeling of vaginal bulging or pressure is the common and specific symptom [3,4]. Treatment should be individualized according to the severity of symptoms and patient preferences. The severity of symptoms is not consistent with the stage of prolapse [5]. Potential options for POP treatment include expectant management, conservative treatment, including vaginal pessaries or pelvic floor muscle exercises, and various methods of surgery [6]. POP is a common disease in elderly patients with comorbidities. Surgery has traditionally been associated with a recurrence or re-operation rate of up to 30% after the initial surgery therefore, conservative treatments are attempted first [7,8], but POP is a chronic problem that eventually requires surgery. The overall cumulative incidence of a subsequent surgery within five years was 7.8% for women < 65 and 9.9% for ≥ 65 years in a recent retrospective cohort study [9]. Our present study investigated the clinicopathologic characteristics, USA) and a p-value of less than 0.05 was considered to be significant. There were no significant differences between the two groups. Among  [11], the proportion of patients treated with a pessary was lower in this study. The large number of patients in tertiary hospitals, like ours, referred for surgery created a selective bias, resulting in fewer patients using pessaries. All patients treated with pessaries in our study used ring pessaries. No space-filling pessaries, such as Gellhorn were used. Other studies reported successful pessary-fitting trial rates from 56 to 64% [12][13][14], which were higher than our overall rate of 52.18 percent (n=12). In our study, the successful pessaryfitting rate was 52.2% in Group A. The successful pessary-fitting rates were low due to the inability to use space-filling pessaries, such as Gellhorn. Jeffrey et al. reported that higher success rates were achieved with the use of a space-filling pessary, such as Gellhorn, and donuts in women who are unsuccessfully fitted with a support pessary (ring) [10]. We could not use these space-filling pessaries because our hospital does not supply them. However, space-filling pessaries are difficult to remove and manage by the patient alone. Those types of pessaries were not a good choice for sexually active and older patients. The common complications for discontinued pessary use after successful pessary fitting were urinary incontinence, vaginal erosion, vaginal discharge, pelvic pain, and prolapse around the pessary (aggravation of symptoms) [15]. In our study, complications after pessary use included prolapse around the pessary (n=7), Early postoperative complications were transient and reversible and mostly improved, except in one case. One patient required surgery due to newly-occurring urinary incontinence. Vault prolapse is defined by the International Continence Society as a descent of the vaginal cuff below a point that is 2 cm less than the total vaginal length above the plane of the hymen [19]. Vaginal vault prolapse is a complication following both vaginal and abdominal hysterectomies. The risk factors of vault prolapse are increasing parity, advancing age, and previous surgery due to pelvic organ support defects [20]. The prevalence of post-hysterectomy vault prolapse has been reported to range from 0.2% to 43% [21]. Recent data reported that its incidence was 11.6% following hysterectomy for prolapse and 1.8% for other pathologies [22]. A recent retrospective cohort study reported that the incidence rate of repeat surgery due to vault prolapse within five years was 7.8% in women with POP < 65 years old and 9.9% in women ≥ 65 years old [9]. A total of 16 (7.84%) patients in this study experienced vault prolapse. Our study showed a similar or lower incidence of repeat surgery compared to Western countries. Among patients who underwent surgical treatment for POP in this study, approximately 8.29% (n=17) of the patients required re-operation.

Results
Sixteen patients had vault prolapse and one patient had urinary incontinence. However, according to other reports, of those who received surgical treatment for POP, 29% will undergo another surgical treatment for POP during their life [6,16]. Long-term followup research is needed to determine what proportion of patients will require re-operation. This study had several limitations. First, this study was conducted in a single tertiary hospital. Therefore, there was a selection bias due to the large number of patients transferred to our hospital for surgery. Second, this study did not identify the risk factors associated with unsuccessful pessary-fitting. Third, there is a wide

Conclusion
POP is a chronic problem that eventually requires surgery. However, patients with POP initially choose conservative treatment, which may be due to the increased risk due to the complications and recurrences that may arise from surgical treatment. This study showed no statistically significant difference between the incidence of complications in Group A and Group B (13.3% vs 17.6%, respectively; p=0.370). Surgical treatment did not increase the post-treatment rate of complications compared to conservative therapy. Surgical treatment may be effectively used to treat patients with POP.

What is known about this topic
• Surgery incurs the risk of recurrence and complications and therefore, conservative treatment is attempted first; • Surgical candidates with symptomatic POP are those who have failed or declined conservative management; • Surgery has traditionally been associated with a recurrence or re-operation rate of up to 30% after the initial surgery.

What this study adds
• Surgical treatment did not increase treatment-related complication rates compared to conservative treatment; • Unlike earlier reports, surgical treatment can be safely performed with a re-operation incidence rate of 7.8% in women with POP.

Competing interests
The authors declare no competing interests.

Authors' contributions
Baek  Table 1: characteristics of the two groups with conservative treatment and surgical treatment