Urogenitale prolaps (POP) Opereren: IN.of...UIT? Sterkte, kans of dreiging

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1 Urogenitale prolaps (POP) Opereren: IN.of...UIT? Sterkte, kans of dreiging Dr. Marijke C.Ph. Slieker-ten Hove Bekkenfysiotherapeut en wetenschappelijk onderzoeker Profundum Instituut Erasmus MC

2 Introductie Urogenitale prolaps en de etiologie Prevalentie Risicofactoren Conservatieve behandeling Implementatie in EBP Conclusies Take home message

3 Voor de organisaie extern intern Voor het doel hulpvol schadelijk Sterkte Zwakte Kans Dreiging

4 Voor de organisaie extern intern Voor het doel hulpvol schadelijk Sterkte Zwakte Kans Dreiging

5 Voor de organisaie extern intern Voor het doel hulpvol schadelijk Sterkte Zwakte Kans Dreiging

6 Voor de organisaie extern intern Voor het doel hulpvol schadelijk Sterkte Zwakte Kans Dreiging

7 Rationale etiologie POP in vrouwen Instrumentele partus? Spontane partus? Genetische risicofactor? Obstipatie? COPD? Zwakke BB Spreiding Hiatus Genitalis Rek op bindweefsel POP Chen et al., 2006

8 Prevalentie POP signs (POPQ) Svihra et al, abstract ICS 2011, n=785 (mean age 47) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 % 51,3 Slieker-ten Hove et al n = ,7 17,7 S.E. Swift et al., 2000 n = 497 4,2 Stage ,0

9 Prevalentie POP signs (POPQ) Svihra et al, abstract ICS 2011, n=785 (mean age 47) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 % 51,3 Slieker-ten Hove et al n = ,7 17,7 S.E. Swift et al., 2000 n = 497 4,2 Stage ,0 Kans 1

10 Prevalentie POP signs (POPQ) Svihra et al, abstract ICS 2011, n=785 (mean age 47) stage 0-1: 76 % stage 0-1: 60 % stage 0-1: 50 % 51,3 Slieker-ten Hove et al n = ,7 17,7 S.E. Swift et al., 2000 n = 497 4,2 Stage ,0 Kans 1

11 Pelvic Organ Prolapse (POP) common in women 75% 19% chance for at least 1 surgery Medical cost increase (due to global aging) Need for preventive strategies (DeLancey JO, 2005)

12 1:10 POP, asymptomatic 2:10 POP, symptomatic 3:10 no POP, symptomatic Svihra et al., abstract 618 ICS Glasgow symptomatic asymptomatic Slieker et al., stage stage stage 2A 15.4 stage 2B 19.2 stage 2C 6.4 stage stage asymptomatic symptomatic

13 1:10 POP, asymptomatic 2:10 POP, symptomatic 3:10 no POP, symptomatic Svihra et al., abstract 618 Mean age symptomatic asymptomatic Slieker et al., 2009 Mean age 57 0 stage stage stage 2A 15.4 stage 2B 19.2 stage 2C 6.4 stage stage asymptomatic symptomatic

14 Risk factors in women Parity Pelvic surgery Mother POP/inc Conncective tissue weakness Joint hypermobility POP Menopause HRT Hysterectomy Inc surgery Constipation Heavy phys work Age

15 Constipation (vs obstretric injury) a potential cause of PF damage PF damage Constipation Obstetric injury Yes (105) vs No (491) Yes (102) vs No (494) 2 alterations 35 % vs 19 % 32 % vs 20 % 2.38 ( ) P= ( ) P= alterations 18 % vs 9 % 19 % vs 9 % 2.43 ( ) P= ( ) P= alterations 11 % vs 9 % 9 % vs 5 % 3.16 ( ) P= ( ) P=0.87 Amselem et al., 2009

16 Conclusion Amselem et al. Constipation appears to be as important as obstetric trauma in the development of PF damage A more pro-active approach to recognizing and treating constipation might significantly reduce the prevalence of this distressing problem

17 Risk factors Parity Parity Pelvic surgery Mother POP/inc Conncective tissue weakness Joint hypermobility POP Heavy physical work Constipation Age Kans Intra abdominal pressure.intra abdominal pressure.

18 Usual care of POP in women watchful waiting conservative pessary Weak PFM POP therapy physiotherapy?? invasive surgery

19 Watchful waiting? Miedel et al., 2011 Natural regression? 40 % showed regression after 5 years Due to? Acceptance? Less physical active? Real regression? Handa et al., 2004, especially grade I can regress spontaneously watchful waiting

20 Pessary pessary Clemons 2003 Riskfactors wide hiatus and short vaginal lenght Cochrane 2005 No evidence No concensus in pessaries 73/27 73 % success Harnsomboon 2011 N=50 25 colpoxin sphere plus PFM 25 PFM 16 weeks Abdool 2011 N= pessary 195 surgery Need for RCT n.s. difference in outcome after 16 weeks n.s. difference in outcome one year after!

21 Pessary Clemons 2003 Riskfactors wide hiatus and short vaginal lenght Cochrane 2005 No evidence No concensus in pessaries 73/27 73 % success Harnsomboon 2011 N=50 25 colpoxin sphere plus PFM 25 PFM 16 weeks Abdool 2011 N= pessary 195 surgery Need for RCT n.s. difference in outcome after 16 weeks n.s. difference in outcome one year after!

22 Pessary Clemons 2003 Riskfactors wide hiatus and short vaginal lenght Cochrane 2005 No evidence No concensus in pessaries 73/27 73 % success Harnsomboon 2011 N=50 25 colpoxin sphere plus PFM 25 PFM 16 weeks Abdool 2011 N= pessary 195 surgery Need for RCT n.s. difference in outcome after 16 weeks n.s. difference in outcome one year after! Kans

23 Pelvic Physiotherapy for POP 2 hypothesis physiotherapy?? 1. The knack or bracing preventing descent 2. Increased PFM strength building up structural support Bo & Frawley 2007

24 PFMF associated with POP Braekken et al Strength, endurance and vaginal pressure were measured Independently associated with POP No measurements were made during coughing..

25 PFM strength versus Knack palpation during involuntary muscle contraction (IMC) during coughing absent weak normal strong p-value Effective IMC 52.9 (18) 61.5 (126) 41.6 (157) 40.6 (13) <.001 Slieker et al., 2009

26 PFM strength versus Knack palpation during involuntary muscle contraction (IMC) during coughing absent weak normal strong p-value Effective IMC 52.9 (18) 61.5 (126) 41.6 (157) 40.6 (13) <.001 Slieker et al., 2009

27 Miller et al., 1998 Teaching the Knack during IAP increase, women can significantly reduce urine leakage but Reduction in urine loss was not significantly correlated with digital measurement of PFM strength..

28 Abstract ICS 45, Frawley et al., 2011 Testing PFM strength in 170 women Multicenter in Australia, Scotland and New Zealand 4 point scale (ICS) and manometry Conclusion: no statistically difference between strength variables and POP(Q)- stage

29 Voordat we met een interventie beginnen Is het voorspannen een spontane, altijd aanwezige competentie van de bekkenbodem?

30 Strength and Knack vs POP Strength Endurance Coördination, (coughing)» Stage 0 Stage 1 No significant difference No significant difference 75.2 % 38.2 % Slieker et al., 2009

31 Strength and Knack vs POP Strength Endurance Coördination (coughing)» Stage 0 Stage 1 No significant difference No significant difference 75.2 % 38.2 % Kans

32 Intra abdominale druk en valsalva Staan in MRI 1 foto nemen duurt 4.20 minuten

33

34 liggen staand

35 liggen staand valsalva x x x

36 Intervention Detailed description PFMT: frequency, intensity, control Intra abdominal pressure, training precontraction Life style Follow-up, adherence, self-efficacy

37 Is PFMT effective? year Age n intervention / control Follow up improve Piya-anant 2003 >60yr/ 330/ mths 72/27 % Hagen (Cochrane) trials Evidence n.s. to guide practice Ghroubi 2008 Mean total/ 2 yrs QoL sign Hagen 2009 Mean (23/24) 6 months 63/24 % Braekken 2009 Mean (59/50) 19/8 % (1 st) Stüpp 2011 Mean 55 21/16 14 weeks PFMF, anatomic Hagen 2011 Mean /222 6mths-1 yr QoL, symp

38 Conclusion Hagen et al abstract 129 ICS Schotland There is now sufficient evidence to conclude that PFMT is effective and cost-effective in reducing POP symptoms and should be recommended as first-line management for POP. Best clinical abstract! Sterkte

39 Is het alleen een vrouwenprobleem?

40 Nee, het gaat over mannen EN vrouwen

41 Epidemiology rectal prolapse Kaialuoma and Kellokumpu 2005 Annual incidence complete rectal prolapse mean 2.5 (range ) per population 90 % women 10 % men Median age 69 (range yrs) Anal incontinence 64 % Constipation 72 % (difficult evacuation)

42 Risk factors in women parity Mother POP/inc POP Menopause HRT Hysterectomy Inc surgery Heavy phys work Age

43 Risk factors in men? parity Mother POP/inc POP Surgery Heavy phys work Constipation Age

44 Risk factors Parity Mother POP/inc POP Heavy physical work Constipation Age Kans

45 What about surgery?

46 We are at heart.. surgeons Dr. Jane Schulz, urogynaecoloog Alberta a chance to cut is a chance to cure the only way to heal is cold hard steel when in doubt, cut it out Dreiging BBWG NVOG: zouden we POP niet moeten zien als chronische aandoening?

47 PROLIFT *

48 POP symptomreleave after surgical procedure 78.8% women experienced improved OAB symptoms with transvaginal mesh repair of POP SUI correction (if no cont procedure) 34-91% Bowel (54% improved evacuation) Sexual function improves relation to body image perception Long et al. IUJ May 2011 ICI 2009 Chan et al. J Sex Med Feb 2010 Miedel et al. IUJ Dec 2008

49 Vaginal pressure during daily activities before & after vaginal repair Mouritsen et al 2007

50 Vaginal pressure during daily activities before & after vaginal repair Mouritsen et al 2007

51 De novo symptoms after surgery for POP SUI (unmasked) (up to 42%) OAB symptoms (5-22%) Bowel dysfunction Pain Sexual dysfunction de Boer et al. IUJ Sep 2010 Al-Mandeel et al. Neurourol Urodyn Mar 2011 Miedel et al. IUJ Dec 2008

52 Is surgery Safe and Effective? In NL 1:5 women will have POP or incontinence surgery The women who underwent surgery were more likely to have PF symptoms than women without surgery (45-85 yr) TA de Boer et al., 2011

53 Why bother adding to surgery? Surgery is common: lifetime risk for POP/UI surgery: 11 20% (Olsen et al 1997, Fialkow et al 2008, de Boer et al 2011) Surgery has a failure rate: up to 66% at 3 mths (Iglesia et al 2010) Symptoms appear MORE prevalent in woman who have previously undergone surgery (de Boer et al 2011) Previous gynaecological surgery: a risk event (Clark et al 2003, Moallie et al 2003, Tegerstedt et al 2004) target these high risk patients Re-operation affects 1/2-1/3 (Olsen et al 1997, Whiteside et al 2004) Urgent need for strategies to prevent re-operation: 25% improvement in surgical success 2 nd operation for 30,000 women (DeLancey 2005)

54 What does surgery change? (Frawley 2011) PRE-OP Defects: structural +/- other PF symptoms Risk factors: parity connective tissue Potentially modifiable risk factors: weak PFM chronically raised IAP Obesity Constipation etc Surgery POST-OP Defects: structural +/- other PF symptoms Risk factors: parity connective tissue Potentially modifiable risk factors: weak PFM chronically raised IAP Obesity Constipation etc

55 Zijn er internationale richtlijnen? Klinische praktijk: Surveys van gynaecologen (Fitzgerald et al 2001,Ottesen et al 2001) Survey van Australische physios (Frawley et al 2005) Inconsistent, grote varieteit Geen EBP richtlijnen Klinische aanbevelingen Interventie studies over BFT rond OK (RCTs): Jarvis et al 2005 Frawley et al 2010 Verschillende uitkomsten (Frawley 2010) Nieuwe studies zijn gaande

56 1. Jarvis et al 2005: Evidence from RCTs investigated the effect of pre- & post-op physiotherapy on 60 women undergoing POP/UI surgery TG received 3 x physiotherapy-supervised PFMT sessions, bladder training, and bowel training. Outcomes measured changes in continence, quality of life, and general health symptoms 6 months postoperatively. Results indicated a significant improvement in quality of life and urinary symptoms for the TG Results were presented for the combined surgical cohort.

57 Frawley et al., 2011 Primary outcomes: CG & TG: improvements in bladder, POP and bowel symptom scores following surgery differences between groups were not significant after adjusting for baseline differences (trend towards more improvement for TG Secondary outcomes: Between-group differences were significant in favour of TG for: Pelvic floor muscle strength (digital testing) Assessment of Quality of life General exercise participation: frequency of exercise / week

58 Pessary Abdool 2011 N= pessary 195 surgery n.s. difference in outcome one year after!

59 How do we implement the findings?

60 Wie moeten we overtuigen? Medisch specialisten? Huisartsen? De vrouwen zelf? Vrouwen moeten leren dat bbdysfunctie niet normaal is of nu eenmaal horend bij ouder worden, maar waar je iets aan kunt doen Vrouwen moeten al in de pre/postnatale fase de noodzaak onderkennen om de bekkenbodem te trainen en de buikdruk te reguleren

61 De medisch specialist? Pelvic organ prolapse Kuncharapu et al., 2010 (Texas, USA) publicatie in American Family Physician PFMT may improve pelvic function. The effectiveness of PFMT in reversing or treating POP has not been studied

62 Quote B-wijzer 1, nr 41 Interpretatie PORTRET studie en presentatie Doelencongres ondergetekende. Fysiotherapie bleek inderdaad veel minder effectief voor de behandeling van SUI.. Bij de keuze van de behandeling van SUI dient met de pt het lage succes van fysiotherapie tegen de risico s van een operatie afgewogen te worden Dreiging

63 Quote B-wijzer 2, nr. 41..ik verwacht een verschuiving in het gebruik van bekkenfysiotherapie van een primaire behandeling naar een meer ondersteunende rol. JM van der Ploeg, gynaecoloog Dreiging

64 Long term effect of PFMT in SUI (N=21, 16 trials>1 year) Ferguson et al -90 Cammu et al -90 Mouritsen et al -91 Klarskov et al -91 Dougherty et al -93 Hahn et al -93 Burns et al -93 Holley et al -95 Nygaard et al -96 Glavind et al -96 Sterkte! Bø & Talseth -96 (5 years) Lagro-Janssen & v Weel -98 Cammu et al -00 (10 years) Pages et al - 01 Kiss et al -02 Alewijnse et al -03 Parkkinen et al -04 Bø et al -05 (15 years) Kondo et al -07 Borello-France et al -08 Elliott et al -09 (7 years)

65 Quality of surgery Rhoads and Sokol, 2011 Surgical care for uterovaginal POP surgery Compliance rates on Evidence Based surgical procedures were low in all hospitalsettings!

66 The general practitioner? Dutch GP s follow the guidelines partially. Compliance in diagnostics is fairly good (for SUI) Compliance in treatment advice is low Albers-Heitner et al., 2008

67 The patient? Pakbaz et al., 2010 Obstacles to seeking health care - Lack of information - Blaming oneself - Feeling ignored by the doctor - Having a covert condition - Adapting to succesive impairment - Trivializing of symptoms and de-prioritizing own health

68 The patient? Pakbaz et al., 2010 Facilitators to seeking health care - Confirmation and support by others - Difficulty in accepting an ageing body - Feeling sexually unattractive - Having an unnatural body - Reaching the point of action

69 Adherence Patients General practitioners Gynaecologists Adherence is probably human

70 WHEN????? You only have one chance to make a first impression

71 Univariate en multivariate analysis on symptom of seeing/feeling vaginal bulge (POP), Slieker et al., 2010 Population Attributable Risk (PAR) OR (95 % CI) OR (95 % CI) PAR Heavy physical work 1.39 ( ) 1.48 ( ) 8.5% POP-symptoms in pregnancy 2.29 ( ) 2.06 ( ) 17.8% Mother with POP 1.99 ( )* 1.67 ( ) 19.7% 46% + 46:100 POP can be explained by three symptoms early detection of women at risk!!!

72 Pre en postpartum periode 1 e contact met de risicogroep 1 e kans om vrouwen te informeren 1 e kans om te trainen 1 e kans om te werken aan oefentrouw Als men niks weet, dan kun je immers geen actie verwachten

73 Pre en postpartum periode 1 e contact met de risicogroep 1 e kans om vrouwen te informeren 1 e kans om te trainen 1 e kans om te werken aan oefentrouw Kans!

74 Chronic disease and health promotion Heartdisease, stroke, COPD and diabetes Pelvic floor issues are in 2011 still not on the list of Health topics

75 What WHO does Promote Prevent Treat Care

76 No information Healthy women Asymptomatic women With POP no information, no treatment Pessary or surgical treatment Symptomatic women Stage 2-4 (Bob Shull, IUGA 2005)

77 the biggest challenge? Urologist Sexologist PFPT Surgeon Gynaecologist Gastroenterologist Inc.nurses Psychologist

78 Conclusie POP: Yes, we can! Bekkenfysiotherapie is 1 e optie Conservatieve behandeling is 1 e optie Adherence is een probleem, maar komt voor bij hulpverleners en patiënten Niet blind afgaan op resultaten uit beperkte studies/presentaties

79 Take home message Studies die het raadsel van adherence problemen kan oplossen zijn nodig bij patienten, huisartsen, medisch specialisten EN de WHO Preventieve acties zijn nodig om de ongecongroleerde IAD te voorkomen Samenwerken op alle nivo s en alert blijven, ook als we gevraagd worden mee te doen met een studie

80 POP zoveel kansen, zoveel goede bekkenfysiotherapeuten en ZwangerFit docenten! Evidence beschikbaar Zwakte Veel aanbod, veel kansen voor preventie en behandeling Dreiging

81 Laten we de POP populair maken!

82 Tot slot Mijn overgang.

83 Van ziek naar gezond Van onderwijs naar praktijk en onderzoek Van moeder naar oma Van naar Mick Abel Een boeiende overgang

84