Pelvic Brochure 06 COVER - AGES

Australian 

Gynaecological 

Endoscopy 

Society Ltd 

AGES PELVIC FLOOR SYMPOSIUM & WORKSHOP VII 

Anatomy 

& Function 

of the Female Pelvic Floor 

Program 

and Abstracts 

17 & 18 November 2006 

Hilton Brisbane Australia 

International Guest Speakers: 

Professor John DeLancey USA 

Professor Michel Cosson FRANCE 

Platinum sponsor of AGES 

LIVE SURGERY 

CADAVERIC DISSECTION 

INTERACTIVE DISCUSSIONS 

Major Sponsor of AGES

Sponsorship and Exhibition 

AGES gratefully acknowledges the following companies for their support of this meeting: 

Platinum Sponsor of AGES 

Major Sponsor of AGES 

Major Sponsors of 

AGES Pelvic Floor 

Symposium & Workshop VII 

Sponsors of invited speakers 

Johnson & Jonhson Medical 

American Medical Systems 

Femcare 

Bard Australia 

Cook Australia 

Arrow Pharmaceuticals 

GE Ultrasound 

Boston Scientific 

Medtronic Australasia 

Exhibitors 

Olympus 

Experien 

Scanmedics 

B Braun Australia 

Gyrus ACMI 

Smith and Nephew 

ConMed Linvatec 

Hoyland Medical 

Sydmed 

Cytyc (Australia) 

InSight Oceania 

Device Technologies 

Medtel

Contents 

Sponsorship and Exhibition 

inside cover 

Faculty and Committee Members 2 

Welcome Message 3 

Conference Program 4 

Social Program 7 

Abstracts – Friday 17 November 8 

Abstracts – Saturday 18 November 16 

PR&CRM POINTS - CPD POINTS 

The Conference has been approved as a RANZCOG Approved 

O&G Meeting and eligible Fellows of the College will earn 

points for attendance as follows: 

Full attendance: 16 CPD points in the Meetings category 

Attendance one day: 8 points 

Delegates will be required to sign the attendance sheet prior 

to morning tea on both Friday 17 and Saturday 18 November. 

Pre- and Post- Questionnaires 

The College approved Pre- and Post- Questionaires are 

comprised of a number of multiple choice questions from 

lectures to be given on Friday 17 and Saturday 18 November. 

The Pre- Questionnaire is to be handed in at morning tea on 

Friday 17 November. The Post- Questionnaire is to be handed 

in at the close of the Meeting. No exceptions can be made to 

these deadlines. 


Anatomy & Function 


1

CONFERENCE COMMITTEE 

INTERNATIONAL FACULTY 

Assoc. Professor Chris Maher 

Dr Anusch Yazdani 

Assoc. Professor Alan Lam 

Dr Lewis Lander 

Chairman 

Co-Chairman 

Professor John DeLancey 

Professor Michel Cosson 

Assoc. Professor Kaven Baessler 

USA 

France 

Germany 

Dr Melissa Buttini 

Dr Stephen Cook 

Dr David Baartz 

Dr Julie Lindstrom 

Ms Janelle Greitschus 

AUSTRALIAN FACULTY 

Dr David Baartz 

Dr Melissa Buttini 

Dr Marcus Carey 

Queensland 

Queensland 

Victoria 

Dr Greg Cario 

New South Wales 

AGES BOARD 

Dr Robert O’Shea 


Dr Jim Tsaltas 

Dr Geoffrey Reid 

Dr Greg Cario 

Dr Jenny Cook 

Professor David Healy 

Dr Krish Karthigasu 

Assoc. Professor Chris Maher 


President 

Vice President 

Hon. Secretary 

Treasurer 

Dr Barton Clarke 

Dr Jenny Cook 

Dr Stephen Cook 

Dr Eva De Cuyper 

Assoc. Professor Peter Dietz 

Assoc. Professor Peter Dwyer 

Dr Bruce Farnsworth 

Assoc. Professor Malcolm Frazer 

Professor Judith Goh 

Ms Janelle Greitschus 

Assoc. Professor Bernie Haylen 

Professor David Healy 

Queensland 

South Australia 

Queensland 

Queensland 


Victoria 


Queensland 

Queensland 

Queensland 


Victoria 

Professor Paul Hodges 

Queensland 


AGES SECRETARIAT 

– CONFERENCE ORGANISER 

Michele Bender, Director 

Conference Connection 

Phone: +61 2 9967 2928 

Fax: +61 2 9967 2627 

Mobile: +61 4 1111 0464 

E-mail: conferences@ages.com.au 

282 Edinburgh Road 

CASTLECRAG NSW 2068 AUSTRALIA 

MEMBERSHIP OF AGES 

Membership application forms are available from the AGES 

website, www.ages.com.au, or from the AGES Secretariat. 

Dr Krish Karthigasu 

Dr Hannah Krause 


Dr Lewis Lander 

Dr Julie Lindstrom 

Assoc. Professor Christopher Maher 

Assoc. Professor Peter Maher 

Dr David Molloy 

Dr Peter Mactaggart 

Dr Rob O’Shea 

Dr Damien Peterson 

Professor Ajay Rane 

Dr Geoff Reid 

Dr Richard Reid 

Dr Anna Rosamilia 

Ms Ruth Sapsford 

Dr Jim Tsaltas 


Western Australia 

Queensland 


Queensland 

Queensland 

Queensland 

Victoria 

Queensland 

Queensland 

South Australia 

Queensland 

Queensland 



Victoria 

Queensland 

Victoria 

Queensland 



2

Welcome 

– AGES President 

and Conference Chairmen 

Dear Colleagues 

On behalf of the Australian Gynaecological Endoscopy Society, we would 

like to warmly welcome you to the 7 th AGES Pelvic Floor Meeting. 

We are proud to welcome our keynote speaker, the world’s foremost pelvic 

floor anatomist, Professor John DeLancey from Ann Arbour, Michigan, 

USA, on his first visit to Australia. 


Anatomy 

& Function 


Our other international speaker, Professor Michel Cosson from France, is a 

leading researcher of in vivo and clinical evaluation of prosthetic materials 

in pelvic floor surgery. 

The theme of the meeting, ‘Anatomy and Function of the Female Pelvic 

Floor’, has been carefully selected to meet the current needs of our 

members and to complement the strengths of our international visitors. 

We invite you to interact with international and national experts to 

rediscover the anatomy of the pelvic floor using cadaveric dissection, 

ultrasound and MRI, and to debate the relative merits of new diagnostic 

modalities. The evidence-based literature and surgical approaches to each 

compartment will be presented. We have allocated ample time for 

interaction between delegates and experts. 

Finally, enjoy our social program cruising the Brisbane River at sundown to 

the award winning Watts Fine Dining in Newfarm for an evening of 

exceptional food, wine and friendship. We are certain that our surprise 

dinner guest speaker will keep you entertained. 

Again, we extend the warmest of welcomes to Brisbane for the 7 th annual 

AGES Pelvic Floor Meeting. 

Assoc. Professor Christopher Maher Dr Anusch Yazdani Dr Rob O’Shea 

Conference Chairman Co-Chairman AGES President 




3

AGES PELVIC FLOOR 

SYMPOSIUM & 

WORKSHOP VII 

Anatomy 

& Function 

FRIDAY 17 NOVEMBER 

BALLROOM 

HILTON BRISBANE 

Program 




4 

0730 – 0800 Conference Registration 

0800 – 0805 WELCOME AND OPENING A Yazdani 

0805 – 0815 PR&CRM: Pre-questionnaire J Cook 

0815 – 0920 SESSION 1 

How to Assess our Patients 

Chair: R O’Shea, K Karthigasu 

Sponsored by tyco 

0815 – 0830 History & examination: cheap and effective 

K Baessler 

0830 – 0845 Ultrasound: what’s behind the bulge 

P Dietz 

0845 – 0900 Magnetic Resonance Imaging: what are 

the defects 

J DeLancey 

0900 – 0920 Experts on the spot 

0920 – 0955 SESSION 2 

Upper Vaginal Prolapse 

Chair: B Clarke, J Cook 

Sponsored by Stryker 

0920 – 0940 Anatomy of upper vaginal prolapse 

J DeLancey 

0940 – 0955 Literature review of upper vaginal prolapse 

E DeCuyper 

0955 – 1025 Morning Tea and Trade Exhibition 

1025 – 1255 SESSION 2 (Continued) 

Chair: P Maher, A Rosamilia 


1025 – 1215 Live Surgery 

Laparoscopic Sacral colpopexy 

C Maher 

Vaginal prolift mesh M Cosson 

1215 – 1225 Vaginal Apogee repair: Video and analysis 

A Rane 

1225 – 1235 Transvaginal uterosacral repair: Video and analysis 

P Dwyer 

1235 – 1255 Grill the experts Panel 

1255 – 1345 Lunch and Trade Exhibition 

1345 – 1415 SESSION 3 

Plenary Lecture 

Chair: J Tsaltas, A Yazdani 

Sponsored by Johnson & Johnson Medical 

1345 – 1410 Biomaterials in POP surgery: Past, present and 

the future: 

M Cosson 

1410 – 1415 Questions 

1415 – 1500 SESSION 4 

Anterior Compartment Prolapse 

Chair: G Cario, R O’Shea 


1415 – 1435 Anatomy of the anterior compartment 

J DeLancey 

1435 – 1450 Literature review of anterior compartment prolapse 

K Baessler 

1450 – 1500 Laparoscopic paravaginal repair: Video and analysis 

A Lam 

1500 – 1530 Afternoon Tea and Trade Exhibition 

1530 – 1700 SESSION 4 (Continued) 



Synthetic mesh repair perigee A Rane 

1600 – 1610 No mesh thanks! Pelvicol 

Video and analysis 

1610 – 1620 Anterior prolift: Video and analysis 

J Goh 

B Farnsworth 

1620 – 1630 No place for native tissue repair 

C Maher 

1630 – 1640 A challenge for the panel 

1640 – 1700 Questions 

1700 – 1800 Welcome Cocktail Reception 

Tropicana Deck 

Level 8, Hilton Brisbane 

1830 – 2300 Brisbane River Cruise and Gala Conference Dinner 

1830 Meet in Hilton Brisbane lobby for short stroll 

to CityCat wharf, Riverside Terminal, 

Eagle Street, Brisbane 

Cruise to Watt Modern Dining 

On the Riverside of the Brisbane Powerhouse

of the Female 

Pelvic Floor 

SATURDAY 18 NOVEMBER 

BALLROOM 

HILTON BRISBANE 

0800 – 1015 SESSION 5 

Posterior Compartment Prolapse 

Chair: G Reid, S Cook 


0800 – 0820 Anatomy of the posterior compartment 

J DeLancey 

0820 – 0835 Literature review of posterior compartment prolapse 

H Krause 

0835 – 0850 Native tissue repair for all: Video and analysis 

C Maher 

0850 – 0905 Colorectal approach: Video and analysis 

D Peterson 


No mesh posterior wall: how about SIS 

L Lander 

0940 – 0955 Laparoscopic approach to minimize dyspareunia: 

Video and analysis 

A Lam 

0955 – 1015 Questions and Panel Discussion 

1015 – 1045 Morning Tea and Trade Exhibition 

1045 – 1200 SESSION 6 

The Pelvic Floor Endemic 

Chair: L Lander, R Sapsford 

Sponsored by American Medical Systems 

1045 – 1115 Parturition ageing and the pelvic floor endemic 

J DeLancey 

1115 – 1135 Preventing the endemic: The physiotherapist role 

P Hodges 

1135 – 1200 Embracing the endemic: The sex therapist view 

G Morrissey 

1200 – 1300 Lunch and Trade Exhibition 

1300 – 1405 SESSION 7 

Overactive Bladder 

Chair: D Healy, J Lindstrom 

Sponsored by Fisher & Paykel Healthcare 

1300 – 1310 Aetiology and epidemiology H Krause 

1310 – 1320 Bladder retraining and lifestyle changes 

J Greitschus 

Program 

1320 – 1335 Current & new medical treatments 

A Rosamilia 

1335 – 1345 New therapies (Botox therapy) 

P Dwyer 

1345 – 1355 Neuromodulation M Carey 

1355 – 1405 Questions and Panel Discussion 

1405 – 1535 SESSION 8 

Continence Surgery 

Chair: D Molloy, M Buttini 

Sponsored by Johnson & Johnson Medical 

1405 – 1420 Anatomy of continence J DeLancey 

1420 – 1435 Evidence for continence surgery 

B Haylen 

1435 – 1445 Laparoscopic colposuspension: dead & buried 

M Carey 

1445 – 1455 Are all tapes the same M Frazer 

1455 – 1505 Urologist view: rectus sheath slings for all 

P Mactaggart 

1505 – 1515 Safyre adjustable sling R Reid 

1515 – 1535 Panel Discussion 

1535 – 1600 Afternoon Tea and Trade Exhibition 

1600 – 1645 SESSION 9 

Challenging Cases for the Panel 

Chair: D Baartz, C Maher 

Panel: M Cosson, M Frazer, A Rane, G Cario, 

A Rosamilia, J Goh 

1645 – 1655 PR&CRM: Post-questionnaire and answers 

J Cook 

1655 – 1700 Close C Maher 




5

Social Program 

WELCOME RECEPTION 

Friday 17 November 

1700 – 1800 

Tropicana Deck 

Level 8 

Hilton Brisbane 

BRISBANE RIVER CRUISE & GALA CONFERENCE DINNER 

Friday 17 November 

1830 – 2300 

Watt Modern Dining 

On the Riverside of the Brisbane Powerhouse 

119 Lamington Street, New Farm 

This informal gathering provides a perfect opportunity to 

network with colleagues and sponsors while enjoying canapés 

and a selection of Australia’s fine wines. Join us on the 

Tropicana Deck at the Hilton Brisbane and relax at the end of 

the first day of the conference. 

The evening begins at 6:30pm with a short stroll from the 

conference hotel to the CityCat wharf. Following a relaxing 30 

minute cruise on the picturesque Brisbane River, pre-dinner drinks 

will be served on the riverbank. 

Watt, on the boardwalk in front of the recently restored 

Powerhouse arts venue, has one of the most beautiful outlooks 

of any Brisbane restaurant, across the Brisbane River to the 

Norman Park hills. 

Winner of the Restaurant and Caterers’ inaugural ‘Best Al fresco 

Restaurant 2004’ category, Watt Modern Dining embodies 

Brisbane’s well-earned ‘lifestyle’ tag. 

MELBOURNE AUSTRALIA 

11-14 MARCH 2008 

10TH 

Our vision: 

WORLD CONGRESS 

ON ENDOMETRIOSIS 

The energy of AGES in Surgery, Science 

and Patient Care in the 21st Century. 

Our theme: 

ART AND SCIENCE OF ENDOMETRIOSIS 

Clinical acumen, surgical flare and 

biomedical advances unite to engage 

endometriosis: do not miss this event! 


Artwork: Fiona Hall born Australia 1953 | Paradisus Terrestris Entitled: Miwulngini (Ngan’gikurunggurr) / Nelumbo nucifera / lotus (1996) | aluminium and tin 24.6 x 12.1 x 3.6 cm | Purchased through The Art Foundation 

of Victoria with the assistance of the Rudy Komon Fund, Governor, 1997 | National Gallery of Victoria, Melbourne. | Fiona Hall is a leading Australian contemporary artist with a formidable career spanning three decades. 

ART & SCIENCE 

OF ENDOMETRIOSIS 

WCE 2008 

AGES President: Dr Rob O’Shea 

Chairman: Prof. David Healy 

Organizer: Mrs Michele Bender 

Platinum Sponsor 

World 

Endometriosis 

Society 

Australian 

Gynaecological 

Endoscopy 

Society 



7

PROGRAM ABSTRACTS 

Anatomy & Fucntion of the Female Pelvic Floor 




History & examination: cheap and effective 

Friday 17 November / Session 1 / 0815 – 0830 

Baessler K 

The ideal assessment of a patient’s problems is cheap, effective, 

non-invasive, painless and quick. 

Pelvic floor symptoms like incontinence, incomplete bladder and 

bowel emptying and prolapse sensation can significantly impair 

a woman’s quality of life. When a patient seeks professional help 

we have to assess her symptoms, their severity and 

bothersomeness and their impact on her quality of life. Not all 

patients admit to all symptoms they might have; this is 

particularly true for sexual dysfunction. Therefore, pelvic floor 

function including bladder, bowel and sexual function and 

prolapse symptoms should be explored. 

There are validated self-administered disease-specific 

incontinence questionnaires available that also assess quality of 

life. However, in order to assess bladder, bowel, prolapse and 

sexual symptoms, several questionnaires have to be applied 

which is time-consuming and might strain the patient’s patience. 

In daily routine, the history is often taken employing a 

standardised questionnaire. There is only one pelvic floor 

questionnaire that assesses all aspects of pelvic floor function as 

well as quality of life. This questionnaire will be presented in more 

detail. It is suitable for routine clinics and also for research and is 

available as a self and interviewer administered questionnaire. 

Past medical and surgical history, significant family, neurological 

and drug history and allergies have to be recorded. 

Physical examination should be guided by the patient’s symptoms 

but have to include an abdominal, brief neurological and vaginal 

examination. In case of defaecatory symptoms and significant 

posterior vaginal wall prolapse, a rectal exam should also be 

performed. On inspection, scars, atrophy, anatomical anomalities, 

pelvic organ prolapse and any urinary leakage are noted. A cough 

stress test and pelvic organ prolapse quantification according to 

the ICS standardisation during maximum straining ensures 

systematic exploration of all compartments and allows 

comparisons over time and before and after treatment. Reflex 

activity of the pelvic floor muscle and S3-S5 is evaluated with the 

bulbocavernosus and anal reflexes. Pelvic floor tone and defects 

and palpated at rest. Pelvic floor contraction strength can be 

assessed using the modified Oxford scale (0-5). Pelvic 

examination should also check for any masses, pain, uterus 

enlargement, strictures, vaginal capacity, urethral diverticula or 

cysts. Rectal palpation can localise the exact position of an 

anterior rectocele (above or involving the anal sphincter, 

perineocele, high rectocele etc.) and is also helpful in evaluation 

of the sensation of incomplete bowel evacuation. 

Ultrasound imaging is necessary to visualise any pathological 

masses or anal sphincter defects. Although bladder neck mobility 

and cystoceles can be nicely imaged, they are also easily 

detected on vaginal inspection. Pelvic and perineal ultrasound 

should be performed after failed incontinence surgery especially 

to assess the position of suburethral tapes and other implants. 

Urodynamic studies are only necessary before incontinence and 

prolapse surgery and in cases of inconclusive history and 

examination and failed treatment. 

A complete history and examination alone might yield a diagnosis 

and will guide any further investigations. 

Author address: Kaven Baessler, MD. Charite University Hospital, 

Berlin, Germany 

Pelvic floor ultrasound: What’s behind 

the bulge 


Dietz HP 

Over the last 20 years, ultrasound has largely replaced 

radiological methods in the investigation of pelvic floor disorders. 

Transrectal, transvaginal/ introital and transperineal/ translabial 

methods have been investigated, with the transperineal/ 

translabial approach currently the most widespread due to ease 

of use and the fact that equipment is available almost universally. 

Position and mobility of the bladder neck, bladder wall thickness, 

pelvic floor muscle activity and pelvic organ prolapse can be 

quantified, and Color Doppler may be used to document stress 

urinary incontinence. As a consequence, both preoperative 

assessment and audit activities in the field of pelvic 

reconstructive surgery have been markedly enhanced. This has 

been most evident in the evaluation of new synthetic slings and 

implants which usually are highly echogenic, making ultrasound 

the imaging method of choice for the evaluation of such grafts. 

Most recently, 3D translabial and transvaginal ultrasound have 

given access to the axial plane, allowing imaging of paravaginal 

spaces, the levator hiatus and the pubovisceral muscle, i.e., the 

inferior aspects of the levator ani. The observation of manoeuvres 

-such as a pelvic floor contraction or a Valsalva- in the three 

orthogonal planes, rendered 3D volumes and 4D volume cine clips 

opens up new possibilities for the assessment of functional 

anatomy. With recent advances in soft- and hardware, pelvic floor 

ultrasound has now reached the spatial resolution of MR in all 

three dimensions, while providing far superior temporal 

resolution. It has become clear that there is a wide range of 

‘normality’ in pelvic organ mobility and the dimensions of the 

levator ani and the hiatus itself. Against the background of such 

variability, childbirth has a distinct effect on the dimensions of 

8

FRIDAY 17 AUGUST 


the hiatus and can cause significant soft- tissue trauma that 

may or may not be apparent at the time of delivery. Major 

levator trauma is common (20-30% of vaginally parous women), 

associated with age at first delivery, and very likely constitutes 

the missing link between childbirth and prolapse. It seems to be 

a risk factor for prolapse recurrence and may well require new 

surgical approaches. Even more importantly, these recent 

discoveries open up entirely new opportunities for primary and 

secondary prevention. 

Author address: HP Dietz, Sydney 

Magnetic Resonance Imaging: What are 

the defects 

Friday 17 Nevember / Session 1 / 0845 – 0900 

DeLancey J 

The pelvic floor is a dynamic unit. Support of the pelvic organs 

comes from the combined actions of the levator ani muscles 

which close the pelvic floor and the action of the connective 

tissue supports that attach the organs to the pelvic sidewalls. The 

connective tissues hold the organs in proper alignment so that the 

muscles can have their supporting effect. Although it has been 

traditional, especially for surgeons, to assume that pelvic organ 

support is entirely provided by connective tissue, this is clearly 

only a part of the overall picture. 

The connective tissues that attach the cervix and vagina to the 

pelvic sidewalls can be roughly divided into three regions: 1) The 

upper one-third of the vagina and the cervix are supported by 

vertical fibers of the cardinal ligaments and dorsally directive 

fibers of the uterosacral ligament. These allow upward mobility of 

the cervix and the vagina while restraining their downward 

descent. 2) The mid portion of the vagina is attached in the 

anterior compartment by the arcus tendineus fascia pelvis and in 

the posterior compartment by the posterior arcus. The distal 

portion of the vagina is fused to its surrounding structures. 

Laterally it attaches directly to the levator ani muscles and 

perineal membrane while dorsally it is fused with the perineal 

body. Anteriorly it is related to the urethra and attachments of the 

urethra to the pubic bones. Dynamic MRIs will be used to 

demonstrate how these supports influence pelvic organ support. 

References: 

DeLancey JO. Anatomic aspects of vaginal eversion after 

hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24; 

discussion 1724-8. PMID: 1615980 

Chen L, Ashton-Miller JA, Hsu Y, DeLancey JO. Interaction among 

apical support, levator ani impairment, and anterior vaginal wall 

prolapse. Obstet Gynecol. 2006 Aug;108(2):324-32 

Author address: John O. L. DeLancey, MD. Norman F. Miller 

Professor of Obstetrics and Gynecology. Director of Pelvic Floor 

Research. University of Michigan Ann Arbor, Michigan, USA 

Anatomy of upper vaginal support 


DeLancey J 

One of the key elements to support the upper third of the vagina is 

the cardinal and uterosacral ligaments. While most of our 

observations about these ligaments are made in supine individuals 

where the uterus is being elevated, the anatomy of these 

connections is best understood in the upright posture. When seen 

in the standing position, the cardinal ligaments are vertical in 

orientation and attached to the cervix and vagina to the pelvic 

sidewalls. These follow the lines of the internal iliac vessels. A 

more dorsally directed attachment comes from the uterosacral 

ligaments. The functional view of these must consider them in the 

standing position with the uterus being pulled downward. 

The uterosacral ligament that is visible laparoscopically is a small 

portion of this supportive complex. It is primarily smooth muscle 

structure in this region. Down below the peritoneum and attaching 

to the upper third of the vagina is a very well defined band of 

connective tissue that is critical to posterior vaginal wall support. 

Downward traction on this in a cadaver can be shown to attach 

the upper vagina to the area of the sacrospinous ligament 

and sacrum. 

As will be demonstrated in the sections on individual 

compartments, support of the apex is critically important to both 

anterior and posterior compartment support. Details of these 

connections and their role in cystocele and rectocele will be 

described in the sections on those compartments. 

References: 

DeLancey JO. Anatomic aspects of vaginal eversion after 

hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717-24; 

discussion 1724-8. PMID: 1615980 

Umek WH, Morgan DM, Ashton-Miller JA, DeLancey JO. Quantitative 

analysis of uterosacral ligament origin and insertion points by magnetic 

resonance imaging. Obstet Gynecol. 2004 Mar;103(3):447-51. PMID: 

14990404 

Bartscht KD, DeLancey JO. A technique to study the passive supports 

of the uterus. Obstet Gynecol. 1988 Dec;72(6):940-3. PMID: 3186104 

Author address: John O. L. DeLancey, MD. Norman F. Miller 

Professor of Obstetrics and Gynecology. Director of Pelvic Floor 

Research. University of Michigan Ann Arbor, Michigan, USA 




9






10 

Surgical treatment of upper vaginal prolapse: 

literature review 


De Cuyper E 

The aim of surgical treatment of pelvic organ prolapse remains 

the restoration of normal vaginal topography while maintaining or 

restoring bowel, bladder and sexual function. Upper vaginal 

prolapse includes uterine and vaginal vault prolapse and is 

caused by failure of the uterosacral and cardinal ligament 

complex. A huge array of abdominal and vaginal procedures have 

been described to correct upper vaginal prolapse. Three 

randomized controlled trials are available comparing the 

abdominal sacral colpopexy and vagina sacrospinous colpopexy 1-3 

and the Cochrane review meta-analysis concluded that the 

abdominal sacral colpopexy was associated with lower recurrent 

prolapse but longer operating time, length of admission, morbidity 

and cost than the vaginal sacrospinous colpopexy 4 . 

Today over 40 years after the abdominal sacral colpopexy was 

first described by Lane 5 many unanswered questions remain. In 

an attempt to reduce hospital stay, postoperative pain and 

recovery time the laparoscopic approach has been proposed. In a 

retrospective case control study Parisio et al have demonstrated 

that the laparoscopic approach was as successful as the open 

approach with prolonged operating time but significantly reduced 

blood loss and hospital stay 6 . Further evaluation of the 

laparoscopic approach is required. 

Many clinicians have routinely performed hysterectomy 

concomitantly at time of sacral colpopexy 1,2,7 . Recently we have 

become aware that the risk of postoperative mesh erosion into the 

vagina is increased 5-7 times if hysterectomy is performed at time 

of sacral colpopexy 8,9 . Alternative abdominal surgical options for 

those with uterine prolapse include a subtotal hysterectomy or 

sacral mesh hysteropexy where the cervical stump or cervix, 

respectively are suspended from the sacrum. For those requiring 

hysterectomy the vaginal approach is suitable and effective. 

Roovers et al in a randomized surgical trial comparing the sacral 

mesh hysteropexy and vaginal hysterectomy and vault suspension 

in those with uterine prolapse found that the vaginal approach 

was superior 10 . Perhaps the sacral colpopexy should be reserved 

for those with post hysterectomy vaginal vault prolapse as was 

initially described by Lane over 40 years ago. 

The vaginal approach to uterine and vaginal vault prolapse 

remains a viable alternative especially, but not limited to, those 

undergoing hysterectomy, and where abdominal approach may 

be contraindicated including the elderly, infirm, those with 

multiple previous abdominal surgeries and those not suitable for 

general anesthesia. A wide variety of vaginal vault suspending 

procedures are available including sacrospinous or 

iliococcygeus ligament fixation, high uterosacral ligament 

suspension or McCall culdoplasty 11 all of which are appropriate 

alternatives depending upon the training and outcomes of the 

surgery for the individual clinician. 

The posterior intravaginal slingplasty (PIVS) uses a multifilament 

polypropylene mesh to suspend the upper vagina via a novel 

transgluteal approach and was first described by Petros in 1997 12 . 

Meschia and colleagues compared the vaginal sacrospinous 

colpopexy and PIVS and at 2 years found both to be equally 

effective at correcting the prolapse. The PIVS was quicker to 

perform but associated with a 9% mesh erosion complication rate. 

New Prosthetic Systems: 

Following the success of mid urethral tapes for continence 

surgery, Eglins work in using the transobturator approach for 

securing the mesh in the anterior compartment and Petros’s work 

in securing the vaginal vault with the transgluteal PIVS two new 

procedures have been introduced: Anterior, Posterior or total 

Prolift (Gynecare, Ethicon, Sommerville, USA) and Apogee/ 

Perogee (American Medical Systems, Minnetonka, MN, USA). 

Both employ polypropylene mesh secured with 2 arms through the 

obturator foramen anteriorly and secured around the ischial spine 

at the vault via a transgluteal approach. Despite the widespread 

use of these devices in everyday clinical practice there is a very 

significant paucity of data available on the efficacy and safety. 

Cosson et al reported a 95% success rate using the Prolift system 

in 687 patients at 3.6 month follow-up with a mesh erosion rate of 

6.7% and mesh shrinkage of 2.8%. The authors stressed the 

importance of avoiding simultaneous hysterectomy and minimizing 

the length of vaginal incisions to decrease complications such as 

mesh erosions and granulomas. 

The abdominal sacral colpopexy remains an excellent procedure for 

the management of upper vaginal prolapse. Vaginal vault procedures 

including sacrospinous, iliococcygeus, and high uterosacral 

ligament suspensions remain viable alternatives. As hysterectomy at 

time of sacral colpopexy is associated with high rates of mesh 

erosions perhaps the sacral colpopexy should remain as a vault 

suspending procedure as initially described by Lane in 1962 with 

primary repairs being performed vaginally using native tissue 

repairs. Vaginal mesh repairs require significant further evaluation. 

References: 

1. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal 

reconstructive surgery for the treatment of pelvic support 

defects: a prospective randomized study with long-term 

outcome evaluation. Am J Obstet Gynecol 1996;175(6):1418-21. 

2. Lo TS, Wang AC. Abdominal colposacropexy and 

sacrospinous ligament suspension for severe uterovaginal 

prolapse; A comparison. Journal of Gynecologic Surgery 

1998;14(2):59-64. 

3. Maher CF, Qatawneh A, Dwyer PL, Carey MP, Cornish A, 

Schluter P. Abdominal sacral colpopexy or vaginal 

sacrospinous colpopexy for vaginal vault prolapse. A 

prospective randomized trial. Am J Obstet Gynecol 

2004;190:20-6. 

4. Maher CF, Baessler K, Glazener C, Adams E, Hagan S. 

Surgical management Pelvic organ prolapse in women. 

The Cochrane databases of systemic reviews. 2004(4).



5. Lane F. Repair of post hysterectom vaginl vault prolapse. 

Obstet Gynecol 1962;89:501-506. 

6. Paraiso MFR, Walters MD, Rackley RR, Melek S, Hugney C. 

Laparoscopic and abdominal sacral colpopexies: a 

comparative cohort study. American Journal of Obstetrics & 

Gynecology 2005;192(5):1752-8. 

7. Brizzolara S, Pillai Allen A. Risk of mesh erosion with sacral 

colpopexy and concurrent hysterectomy. Obstet Gynecol 

2003;102(2):306-10. 

8. Wu JM, Wells EC, Hundley AF, Connolly A, Williams KS, Visco 

AG. Mesh erosion in abdominal sacral colpopexy with and 

without concomitant hysterectomy. American Journal of 

Obstetrics & Gynecology 2006;194(5):1418-22. 

9. Bensinger G, Lind L, Lesser M, Guess M, Winkler HA. 

Abdominal sacral suspensions: analysis of complications 

using permanent mesh. American Journal of Obstetrics & 

Gynecology 2005;193(6):2094-8. 

10. JP Roovers CHV, JG. Bom, JH Schagen van Leeuwen, PC 

Scholten, APM Heintz . A randomised controlled trial 

comparing abdominal and vaginal prolapse surgery: effects 

on urogenital function. BJOG 2004;111(1):50-6. 

11. Colombo M, Milani R. Sacrospinous ligament fixation and 

modified McCall culdoplasty during vaginal hysterectomy for 

advanced uterovaginal prolapse. American Journal of 

Obstetrics & Gynecology 1998;179(1):13-20. 

12. Petros PE. New ambulatory surgical methods using an 

anatomical classification of urinary dysfunction improve 

stress, urge and abnormal emptying. International 

Urogynecology Journal 1997;8(5):270-7. 

Author address: Dr. Eva M. J. De Cuyper. Fellow Urogynaecology. Royal 

Brisbane and Mater Hospitals 

Bilateral extraperitoneal uterosacral 

suspension for post-hysterectomy vaginal 

vault prolapse 


Dwyer P 

The post-hysterectomy vaginal vault is normally suspended to the 

pelvic wall by the ligamentous complex of the paracolpos and 

lateral cervical-uterosacral complex. In post-hysterectomy vaginal 

vault prolapse there is detachment of these ligamentous supports. 

The sacrospinous ligament and the iliococcygeal fascia have both 

been used as anchor points to suspend the vaginal vault but both 

procedures have been found to have a high rate of recurrence 

particularly of the anterior compartment. The uterosacral ligament 

complex can be used for vault suspension and can be approached 

either transperitoneally as described by Shull or extraperitoneally. 

These ligaments provide strong natural support for the vault and 

give the vagina a normal axis. 

The transvaginal extraperitoneal uterosacral ligament vault 

suspension has been our main operation for post-hysterectomy 

for vault prolapse over the last 4 years. In women with complete 

vaginal eversion a midline incision is made extending from the 

urethra anteriorly onto the vault and down the posterior wall to 

the perineum. Little or no vagina needs to be excised. The bladder, 

enterocele sac and rectum are dissected off the vagina and the 

uterosacral ligaments are identified, and are usually present high 

on the lateral pelvic side walls. Midline fascial repairs are 

performed on the anterior and posterior compartments, reinforced 

where necessary with polypropylene mesh. Two sutures of 0 PDS 

are placed into each ligament bilaterally and the vagina to 

suspend the vault. 

Our experience using this procedure over the last 4 years will be 

discussed and a video of the procedure will be shown. 

Anatomy of anterior compartment 


DeLancey J 

The anterior compartment is bounded anteriorly by the pubic 

bones, laterally by the pelvic sidewalls, and posteriorly by the 

vaginal wall. The downward descent of the anterior 

compartment occurs because of the descent of the anterior 

vaginal wall. This supportive layer is relatively trapezoidal in 

shape. The narrow portion of the trapezoid is the attachment of 

the arcus tendineus fascia pelvis to the pubic bone in the front 

and the attachment of vagina to the arcus tendineus on the 

sides. The primary support comes from the upper elevation of 

the broad area of the trapezoid near the cervix by the cardinal 

ligaments. Anterior compartment descent occurs primarily 

because of downward descent of the vaginal apex. Recent 

research shows that 50% of cystocele size is directly 

determined by apical descent (Summers 2006). This apical 

descent results in a widening of the gap between the vagina 

and the arcus tendineus fascia pelvis. Therefore, there is a 

direct relationship between apical descent and the development 

of paravaginal defect. Support of the mid and distal portions of 

the anterior vaginal wall is also influenced by the actions of the 

levator ani muscle. Contraction of the levator ani muscles 

elevates the anterior vaginal wall in this area. The integrity of 

levators, as will be discussed below, is a critical element of 

pelvic organ prolapse and cannot be completely separated from 

an analysis of connective tissue support any more than the 

action of the quadriceps muscle can be separated from the 

muscles connection to the bone by the muscle tendon. 

References: 

DeLancey JO. Fascial and muscular abnormalities in women with 

urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet 

Gynecol. 2002 Jul;187(1):93-8. PMID: 12114894 

Summers A, Winkel LA, Hussain HK, DeLancey JO. The relationship 

between anterior and apical compartment support. Am J Obstet 

Gynecol. 2006 May;194(5):1438-43. Epub 2006 Mar 30. PMID: 16579933 




11



Author address: John O. L. DeLancey, MD. Norman F. Miller Professor of 

Obstetrics and Gynecology. Director of Pelvic Floor Research. University 

of Michigan Ann Arbor, Michigan, USA 

Laparoscopic paravaginal repair in 

anterior compartment 


Surgical management of anterior vaginal 

wall prolapse 


Baessler K, MD 

The aim of this review is to summarize the available literature on 

surgical management of anterior compartment prolapse. A 

Medline search from 1966 to 2006 and a hand-search of 

conference proceedings of the International Continence Society 

and International Urogynecological Association from 2001 to 2006 

was performed. The success rates for the anterior colporrhaphy 

vary widely between 37% and 100%. Augmentation with 

absorbable mesh (polyglactin) significantly increases the success 

rate for cystoceles. For other mesh overlays, the review of single 

studies with rather small numbers revealed heterogeneous data: 

anterior colporrhaphy with and without Pelvicol overlay 

demonstrated a significantly higher success rate for the Pelvicol 

group with one Pelvicol rejection requiring surgical removal. 

Success rates were similar for anterior colporrhaphy with and 

without Tutoplast (solvent dehydrated cadaveric fascia lata) and 

also for Prolene Soft or Pelvicol overlay. Dyspareunia occurred in 

30% in the Prolene group and in 14% in the Pelvicol group; mesh 

erosions in 8% and 3%, respectively. Pelvicol was superior to 

Vicryl overlay in one trial with failure rates at 10% and 31%. 

Abdominal sacrocolpopexy combined with paravaginal repair 

significantly reduced the risk for further cystocele surgery 

compared to anterior colporrhaphy and sacrospinous 

colpopexy. The abdominal and vaginal paravaginal repair has 

success rates between 76% and 100% but no randomized trials 

have been performed. 

The reviewed studies were too diverse in their inclusion criteria, 

surgical techniques, meshes used, outcome variables and length 

of follow up to recommend the routine use of any graft in primary 

repairs. Complications like mesh erosion, infection and rejection 

have to be tempered against anatomical success rates. 

Author address: Kaven Baessler, MD. Charite University Hospital, 

Berlin, Germany 

Friday 17 November / Session 4 / 1450 - 1500 

Lam A 

In the anterior pelvic compartment, the vagina is normally 

attached to the lateral pelvic wall by connecting tissue or 

endopelvic fascia called pubocervical fascia. The line of 

attachment, called the arcus tendineous pelvic fascia (white line), 

runs along a line from behind the pubic symphysis to the ischial 

spine. Detachment of this vaginal lateral suspension results in loss 

of the vaginal sulcus and formation of paravaginal defects. 

The objective of paravaginal defect repair is to reattach the 

anterolateral vaginal sulcus to the arcus tendineus pelvic 

fascia. This can be achieved either by vagina, abdominal or 

laparoscopic approach. 

In this presentation, the objectives will be: 

• To identify the anatomical landmarks in the anterior pelvic 

compartment as they are related to paravaginal repair 

• To learn the surgical principles of laparoscopic 

paravaginal repair 

• To analyze the outcomes, adequacy, deficiency and 

potential complications of this technique 

Author address: Alan Lam. Clinical Associate Professor, Royal North 

Shore Hospital, Northern Clinical School, University of Sydney 



12



No Mesh Thanks! Pelvicol 


Farnsworth B 

Why do the surgery 

Pelvicol and Pelvisoft are used as an alternative to polypropylene 

mesh in prolapse surgery. Pelvicol is a natural cross linked 

collagen material with a three dimensional structure that 

facilitates ingrowth. Pelvicol acellular matrix acts as a scaffold for 

host tissue and is modified with HMDI (hexamethylene diisocyanate) 

in order to resist enzymatic attack, preserve its 

structure and volume, and reduce antigenicity. The graft remains 

intact and is separate but infiltrated by the surrounding tissue and 

effects a permanent repair 1 . 

Pelvicol is an implant that provides both immediate support for 

repair and longterm reinforcement, and a scaffold for ingrowth of 

the patient’s cells and for angiogenesis. The acellular collagen 

matrix can be cut, shaped, stretched, sutured and stapled to 

match a specific anatomical configuration. Test results 

demonstrate that the tensile and suture pull through strengths of 

Pelvicol tissue, Prolene mesh, and human dermal allografts are 

similar 2 . Explanted grafts showed greater tensile strength than the 

surrounding host tissue. 

Patient selection: 

Pelvicol can be used as a level 1 ligamentous replacement 

material where strips of material are reattached to the pelvic 

brim or as a Level 2 fascial replacement when sheets of 

material are implanted behind the vaginal epithelium to recreate 

the fascial layers. 

Pelvicol can be used as an alternative prosthesis in patients 

where there is poor quality epithelium or a contraindication to the 

use of synthetic mesh. Younger patients may benefit from the use 

of Pelvicol in order to avoid long term complications from 

synthetic mesh. Elderly patients may benefit from biological mesh 

where epithelial quality is poor and durability less of an issue. 

Contraindications: 

There are few contraindications to the use of Pelvicol. The only 

absolute contraindication is a sensitivity to porcine material. 

Complications: 

Pelvisoft is the most recent development of Pelvicol. Clinicians 

using Pelvicol soon recognised that in a small number of patients 

failure of integration led to seroma formation and early disruption 

of the prosthesis. By creating a pattern of small incisions in the 

Pelvicol tissue integration is facilitated because the surface area 

available for integration is increased 3 . In addition, there is greater 

vascular reaction, and a greater tensile strength of the fibrous 

tissue is achieved. Early studies have shown that rates of 

infection, vaginal wound dehiscence and operation revision are 

less using Pelvisoft compared to Pelvicol 4 . 

References: 

1. Harper C. Permacol: clinical experience with a new 

biomaterial. Hospital Medicine 2001;62:90-95 

2. British Journal of Plastic Surgery (1982) 35: 519-523 

3. Macleod TM et al. The diamond CO2 laser as a method of 

improving the vascularisation of a permanent collagen 

implant. Burns. 204 Nov;30(7):704-12 

4. Dell JR. O’Kelley KR. Pelvisoft BioMesh augmentation of 

rectocoele repair: the initial clinical experience in 35 patients. 

Int Urogynecol J Pelvic Floor Dysfunction 2005 Jan- 

Feb;16(1):44-7 

Author address: Dr Bruce Farnsworth. Centre for Pelvic Reconstructive 

Surgery Sydney Adventist Hospital, Sydney, Australia 

No place for native tissue repair 


Maher C 

The surgical management of anterior compartment prolapse 

remains controversial. The surgeon is exposed to a huge variety 

of native surgical techniques and biological, absorbable and 

non-absorbable synthetic grafts to correct the defects. 

As early as 1909 Ahlfelt stated that the only problem left 

unresolved in plastic Gynecology was the permanent cure of 

cystocele. Today the surgical treatment of anterior vaginal 

compartment remains problematic. The traditional anterior 

colporrhaphy involves the central plication of paravesical 

tissue. The success rate of anterior colporrhaphy (AC) in case 

series ranges from 80-100% 1, 2 . After more rigorous evaluation 

in randomized control trials Weber et al 3 and Sand et al 4 

reported the AC to be successful in the management of anterior 

compartment prolapse in only 42% and 57% respectively. While 

no women in either study required further surgery to correct 

anterior compartment prolapse these results were met with 

widespread concern. Interestingly, in 1996 when Benson 

published his RCT comparing the sacral colpopexy and 

sacrospinous colpopexy the ideal success rate of the sacral 

colpopexy was lower than that reported for anterior 

colporrhaphy above and was meet with widespread acclaim. 

The reoperation in Benson’s study was over 10% at 2 years 5 . 

Following the success of synthetic mesh at continence surgery 

and at sacral colpopexy many clinicians have employed biologic 

or synthetic grafts in an attempt to improve the surgical 

outcome of anterior compartment prolapse surgery. Julian et al 




13






14 

demonstrated in a prospective case control study that in women 

who had undergone at least 2 previous vaginal repairs the 

overlaying of Marlex (Bard, Billerica, MA, USA) mesh to the 

anterior colporrhaphy reduced the recurrence rate of cystocele 

from 33% to 0%. The Marlex mesh was associated with a mesh 

erosion rate of 25% 12 . Many authors have described the use of 

tensionless polypropylene mesh with a success rate of over 

90% and mesh erosion rates of between 6-13% 13-15 . 

Eglin et al was the first to describe fixing the polypropylene 

mesh through the obturator membrane with an Emmet needle in 

103 consecutive cases 16 . The recurrence rate at 18 months was 

only 3% and the mesh erosion rate was 5%. De Tayrac et al 17 

pursued the theme of fixing the mesh through the obturator 

membrane and used a specifically designed low weight 

polypropelene mesh coated in an absorbable hydrophilic film to 

minimize acute inflammation of the pelvic viscera on 132 women 

with anterior compartment prolapse. At 1-year the recurrence 

rate was 6.8% and the vaginal erosion rate was 6.3%. The 

authors claimed the hydrophilic coating reduced early postoperative 

local morbidity. 

The use of absorbable or biologic grafts has arisen from a 

desire to obtain the benefit of the permanent synthetic grafts 

without the morbidity. Two well conducted randomized control 

trials (RCT) 3, 4 have evaluated the safety and efficacy of 

absorbable Polyglactin 910 mesh (Vicryl, Ethicon, 

Sommerville,USA) and although the results were conflicting 

meta-analysis from the Cochrane review 18 concluded the 

Polyglactin 910 was effective in reducing the rate of recurrent 

cystocele as compared to the traditional anterior colporrhaphy. 

Donor allograft and xenografts material including Porcine 

dermis (Pelvicol) and small intestine submucosa (SIS) have 

been favored as they may reduce the risk of vaginal erosion but 

have a potential risk of prion or viral transmission. Gandhi et al 19 

in a RCT demonstrated that augmenting the anterior 

colporrhaphy with solvent dehydrated cadaveric fascia lata 

(2x4cm Tutoplast) failed to be effective in minimizing recurrent 

anterior wall prolapse (16/76) as compared to AC alone (23/78). 

Similarly, SIS overlay in a small case control study failed to 

demonstrate any reduction in anterior compartment prolapse as 

compared to the AC alone 20 . The assumption that allografts and 

xenografts cause little morbidity is challenged by a 

retrospective cohort study that demonstrated no benefit from 

the use of predominately biologic grafts (SIS, Pelvicol and 

cadaveric fascia lata) as compared with AC. The graft infection 

rate was 18% and granulation tissue was seen in 39% 21 . 

Alternatively Meschia et al 22 demonstrated, in a large well 

conducted RCT, that augmenting the AC with Porcine skin 

dermis (Pelvicol TM ) significantly decreased the rate of anterior 

compartment recurrence (7/98) as compared to anterior 

colporrhaphy alone (20/103) (RR 0.37 95% CI 0.16-0.83). Morbidity 

was similar between the groups with one case of graft erosion 

that required oversewing. 

References: 

1. MACER GA. Transabdominal repair of cystocele, a 20 year 

experience, compared with the traditional vaginal approach. 

Am J Obstet Gynecol 1978;131:203-7. 

2. WALTER S, OLESEN KP, HALD T, JENSEN HK, PEDERSEN PH. 

Urodynamic evaluation after vaginal repair and 

colposuspension. Br J Urol 1982;54:377-80. 

3. WEBER AM, WALTERS MD, PIEDMONTE MR, BALLARD LA. 

Anterior colporrhaphy: a randomized trial of three surgical 

techniques. Am J Obstet Gynecol 2001;185:1299-304. 

4. SAND PK, KODURI S, LOBEL RW, et al. Prospective 

randomized trial of polyglactin 910 mesh to prevent 

recurrence of cystoceles and rectoceles. Am J Obstet 

Gynecol 2001;184:1357-62. 

5. BENSON JT, LUCENTE V, MCCLELLAN E. Vaginal versus 

abdominal reconstructive surgery for the treatment of pelvic 

support defects: a prospective randomized study with long-term 

outcome evaluation. Am J Obstet Gynecol 1996;175:1418-21. 

6. BRUCE RG, EL GALLEY RE, GALLOWAY NT. Paravaginal defect 

repair in the treatment of female stress urinary incontinence 

and cystocele. Urology 1999;54:647-51. 

7. RICHARDSON AC, EDMONDS PB, WILLIAMS NL. Treatment of 

stress urinary incontinence due to paravaginal fascial defect. 

Obstet Gynecol 1981;57:357-62. 

8. SHULL BL, BENN SJ, KUEHL TJ. Surgical management of 

prolapse of the anterior vaginal segment :An analysis of 

support defects, operative morbidity, and anatomical 

outcome. Am J Obstet Gynecol 1994;171. 

9. WHITE GR. An anatomic operation for the cure of cystocele. 

Am J Obstet Dis Women Children 1912;65:286-90. 

10. MALLIPEDDI PK, STEELE AC, KOHLI N, KARRAM MM. 

Anatomic and functional outcome of vaginal paravaginal 

repair in the correction of anterior vaginal wall prolapse. Int 

Urogynecol J Pelvic Floor Dysfunct 2001;12:83-8. 

11. YOUNG SB, DAMAN JJ, BONY LG. Vaginal paravaginal repair: 

one-year outcomes. Am J Obstet Gynecol 2001;185:1360-6. 

12. JULIAN TM. The efficacy of Marlex mesh in the repair of 

severe, recurrent vaginal prolapse of the anterior midvaginal 

wall. Am J Obstet Gynecol 1996;175:1472-5. 

13. DE TAYRAC R, GERVAISE A, CHAUVEAUD A, FERNANDEZ H. 

Tension-free polypropylene mesh for vaginal repair of anterior 

vaginal wall prolapse. Journal of Reproductive Medicine 

2005;50:75-80. 

14. MILANI R, SALVATORE S, SOLIGO M, PIFAROTTI P, MESCHIA 

M, CORTESE M. Functional and anatomical outcome of 

anterior and posterior vaginal prolapse repair with prolene 

mesh.[see comment]. BJOG: An International Journal of 

Obstetrics & Gynaecology 2005;112:107-11. 

15. DWYER PL, O'REILLY BA. Transvaginal repair of anterior and 

posterior compartment prolapse with Atrium polypropylene 

mesh. BJOG: An International Journal of Obstetrics & 

Gynaecology 2004;111:831-6.



16. EGLIN G, SKA JM, SERRES X. [Transobturator subvesical 

mesh. Tolerance and short-term results of a 103 case 

continuous series]. Gynecologie, Obstetrique & Fertilite 

2003;31:14-9. 

17. DE TAYRAC R, DEVOLDERE G, RENAUDIE J, et al. prolapse 

repair by the vaginal route using a new protected low-weight 

polypropelene mesh; 1-year functional and antomical 

outcome in prospective multicentre study. Int Urogynecol J 

Pelvic Floor Dysfunct 2006;(epub ahead of print). 

22. MESCHIA M, PIFFAROTTI P, MAGATTI F, BERNASCONI F, 

KOJANCIC E. Porcine Skin Collagen Implant (Pelvicol TM) to 

prevent anterior vaginal wall prolapse recurrence; A 

randomized trial. Neurourol Urodyn 2005;24:587-88. 

Author address: Associate Professor Christopher Maher. Mater, Royal 

Women’s and Wesley Urogynaecology, Brisbane 

18. MAHER C, BAESSLER K, GLAZENER CM, ADAMS EJ, HAGEN 

S. Surgical management of pelvic organ prolapse in women. 

Cochrane Database Syst Rev 2004:Cd004014. 

19. GANDHI S, GOLDBERG RP, KWON C, et al. A prospective 

randomized trial using solvent dehydrated fascia lata for the 

prevention of recurrent anterior vaginal wall prolapse. 

American Journal of Obstetrics & Gynecology 2005;192:1649-54. 

20. CHALIHA C, KHALID U, CAMPAGNA L, DIGESU A, AJAY B, 

KHULLAR V. SIS graft for anterior vaginal wall prolapse repair 

- a case control study. Int Urogynecol J Pelvic Floor Dysfunct 

2006:(Epub prior to print). 

21. VAKILI B, HUYNH T, LOESCH H, FRANCO N, CHESSON RR. 

Outcomes of vaginal reconstructive surgery with and without 

graft material. American Journal of Obstetrics & Gynecology 

2005;193:2126-32.






Anatomy of the posterior compartment 

Saturday 18 November /Session 5 / 0800 – 0820 

DeLancey J 

The posterior compartment can be roughly considered as a boxshaped 

area occupied by the cul-de-sac and rectum. The bottom 

of the box is the perineal body and closure of the anus by the anal 

sphincter. The front of the box is the posterior vaginal wall and the 

lateral sides and back of the box are formed by the levator ani 

muscles and levator plate. The box is opened superiorly to receive 

the sigmoid colon in the posterior cul-de-sac. Unlike the anterior 

compartment where the ventral and lateral sides are formed by 

the pelvic sidewalls that don’t move, in the posterior compartment 

the sides and posterior part formed by the levator ani muscle 

which are movable structures. 

There are two broad categories of posterior compartment failure. 

These are rectocele and enterocele. An enterocele occurs 

because of loss to the apical supports of the posterior vaginal wall 

where the vaginal apex comes to lie anteriorly and caudally. In 

this instance, either the upper rectum or the cul-de-sac descend 

and form either a high rectocele or enterocele. The rectocele that 

occurs in the mid and lower portion of the vagina occurs due to 

failure of the perineal body or posterior vaginal wall in this region 

to restrain the rectum in a normal position. 

There is an important interaction between the activity of the 

levator ani muscle and the apical supports in the determination of 

enterocele. The flap-valve closure mechanism is a part of normal 

pelvic support formed by the dorsal connections of the vagina 

through the vaginal portion of the uterosacral ligaments to the 

inside of the sacrum that hold the vagina over the levator plate. 

When damage to the levators happens, the levator plate tips 

downwards and when damage to the cardinal and uterosacral 

ligaments happens, the vagina moves forward. This disturbs this 

relationship and results in progressive loss of posterior vaginal 

wall support in the area of the upper posterior vaginal wall. The 

interplay between muscle and connective tissue is therefore 

critically important to posterior wall support. 

References: 

DeLancey JO. Structural anatomy of the posterior pelvic compartment 

as it relates to rectocele. Am J Obstet Gynecol. 1999 Apr;180(4):815-23. 

PMID: 10203649 




Literature review of posterior compartment 

prolapse 

Saturday 18 November / Session 5 / 0820 – 0835 

Krause H 

The posterior vaginal compartment consists of the perineum, 

posterior vagina, anterior rectum and all intervening tissues. 

Posterior vaginal prolapse may be asymptomatic, or the woman 

may present with symptoms of a vaginal lump, pelvic heaviness 

and defecatory dysfunction. 

Management options of the posterior compartment prolapse 

include conservative management or surgery. Conservative 

options include vaginal pessary, pelvic floor rehabilitation and 

conservative treatment of anorectal symptoms. 

There are a number of surgical treatments for the woman with a 

posterior vaginal prolapse. 

• Transvaginal repair 

- Midline placation 

- Site specific 

- With or without augmentation using synthetic or 

biological grafts 

• Transanal repair 

• Abdominal repair 

• Transperineal repair 

Current literature indicate that for the transvaginal repair using 

native tissue, the midline repair has superior results compared to 

the site-specific approach. The transanal repair does not reduce 

the sexual dysfunction compared to the transvaginal approach but 

has a higher rate of recurrence of prolapse. 

Author address: Dr Hannah Krause. Suite 5a, Greenslopes Private 

Hospital Brisbane 

Native tissue repair for all: Video & analysis 


Maher C 

At posterior vaginal compartment prolapse the rectum and small 

bowel underlie the protruding vaginal skin with the perineum 

frequently being deficient. The traditional posterior colporrhaphy 

(PC) described by Francis and Jeffcoate 1 plicated the levator ani 

muscle and was highly effective but associated with unacceptably 

high rates of dyspareunia 1-3 . To minimize dyspareunia many 

Gynaecologist performed a midline fascial plication as seen in 

16

SATURDAY 18 AUGUST 


Figure 4 4, 5 while others performed defect specific repairs of the 

fascia 6-8 both reporting success rates between 80-100% without 

the dyspareunia of the levator-ani plication. Abramov et al 

retrospectively compared the 2 techniques and found a 

significantly higher recurrence rate of rectoceles following the 

discrete site-specific repair (32%) as compared to the midline 

fascial plication (13%) (P=0.015) 9 . 

As the success rate of native tissue repair in the posterior 

compartment is significantly higher than the anterior compartment 

and coupled with concerns regarding increased dyspareunia and 

erosion of synthetic mesh into the rectum many clinicians are 

apprehensive when considering graft placement in the posterior 

vaginal compartment. Polyglactin 910 (Vicryl, Ethicon, 

Sommerville, USA) does not decrease the recurrence rate of 

posterior compartment prolapse as compared to posterior 

colporrhaphy alone 10 . At 3 year review the anatomical and 

functional results of porcine dermis (Pelvicol) graft were 

disappointing with 41% recurrence rate and 50% recurrence of 

incomplete bowel emptying 11 . Efficacy of polypropylene mesh 

gafts have been described in retrospective case series. Milani 

found that the use of prolene mesh overlay produced satisfactory 

anatomical outcomes but the morbidity was unacceptably high 

including mesh complications in 10%, sexual activity decreasing 

by 12% and dyspareunia increasing in 63% 12 . Atrium mesh overlay 

and lateral extension to the pelvic side wall and to the 

sacrospinous ligament also resulted in a 90% anatomical success 

rate with a 9% erosion rate and one rectovaginal fistula 13 . 

De Tayrac used the same low weight polypropylene mesh with an 

absorbable hydrophilic film in the posterior compartment as 

described above in the anterior compartment. At 1 year the failure 

rate was 2.6% with a vaginal erosion rate of 6.3% and de novo 

dyspareunia rate of 12% 14 . Altman et al 11 reported disappointing 

anatomical and functional outcomes following Pelvicol overlay in 

the posterior compartment. 

Gynaecologist can feel confident that the native tissue fascial 

plication remains an excellent option in the management of 

posterior compartment prolapse. 

References: 

1. FRANCIS WJA, TNA. J. Dyspareunia following vaginal 

operations. J Obstet gynaecol Br Comnwlth 1961;68:1-10. 

2. KAHN MA SS. Posterior colporrhaphy:its effects on bowel 

and sexual function. Br J Obstet Gynaecol 1997;104:82-6. 

3. MELLGREN A, ANZEN B, NILSSON BY, et al. Results of rectocele 

repair. A prospective study. Dis Colon Rectum 1995;38:7-13. 

4. MAHER CF, QATAWNEH AM, BAESSLER K, SCHLUTER PJ. 

Midline rectovaginal fascial plication for repair of rectocele 

and obstructed defecation. Obstet Gynecol 2004;104:685-9. 

5. SINGH K, CORTES E, REID WM. Evaluation of the fascial 

technique for surgical repair of isolated posterior vaginal wall 

prolapse. Obstet Gynecol 2003;101:320-4. 

6. KENTON K, SHOTT S, BRUBAKER L. Outcome after rectovaginal 

fascia reattachment for rectocele repair. Am J Obstet Gynecol 

1999;181:1360-3. 

7. PORTER WE, STEELE A, WALSH P, KOHLI N, M. K. The 

anatomic and functional outcomes of defect-specific 

rectocele repair. Am J Obstet Gynecol 1999;181:1353-9. 

8. RICHARDSON AC. The rectovaginal septum revisited: its 

relationship to rectocele and its importance in rectocele 

repair. Clin Obstet Gynecol 1993;36:976-83. 

9. ABRAMOV Y, GANDHI S, GOLDBERG RP, BOTROS SM, 

KWON C, SAND PK. Site-specific rectocele repair 

compared with standard posterior colporrhaphy. Obstet 

Gynecol 2005;105:314-8. 

10. SAND PK, KODURI S, LOBEL RW, et al. Prospective 

randomized trial of polyglactin 910 mesh to prevent 

recurrence of cystoceles and rectoceles. Am J Obstet 

Gynecol 2001;184:1357-62. 

11. ALTMAN D, ZETTERSTROM J, MELLGREN A, GUSTAFSSON C, 

ANZEN B, LOPEZ A. A three-year prospective assessment of 

rectocele repair using porcine xenograft. Obstetrics & 

Gynecology 2006;107:59-65. 

12. MILANI R, SALVATORE S, SOLIGO M, PIFAROTTI P, MESCHIA 

M, CORTESE M. Functional and anatomical outcome of 

anterior and posterior vaginal prolapse repair with prolene 

mesh.[see comment]. BJOG: An International Journal of 

Obstetrics & Gynaecology 2005;112:107-11. 

13. DWYER PL, O'REILLY BA. Transvaginal repair of anterior and 

posterior compartment prolapse with Atrium polypropylene 

mesh. BJOG: An International Journal of Obstetrics & 

Gynaecology 2004;111:831-6. 

14. DE TAYRAC R, DEVOLDERE G, RENAUDIE J, et al. prolapse 

repair by the vaginal route using a new protected low-weight 

polypropelene mesh; 1-year functional and antomical outcome 

in prospective multicentre study. Int Urogynecol J Pelvic Floor 

Dysfunct 2006;(epub ahead of print). 

Author address: Christopher Maher. Mater, Royal Women’s and Wesley 

Urogynaecology Brisbane 

Laparoscopic approach to minimize 

dyspareunia 

Saturday 18 November / Session 5 / 0940 - 0955 

Lam A 

Dyspareunia is potential complication of any pelvic 

reconstructive surgical technique. The actual incidence of this 

complication is unknown but in one series the reported 

incidence was up to 27%. 

This complication is predictable but may not be always 

preventable. Dyspareunia may result from undue narrowing of 

the introitus, painful scar formation, vaginal stenosis, chronic 

inflammation or recurrent infection secondary to foreign 

body reaction. 

As the trend in pelvic reconstructive surgery moves towards the 

increasing use of permanent suture materials and mesh to achieve 

higher anatomical cure rates, one should be mindful of the 

increasing potential of dyspareunia as a complication which can 

cause major disruption and disharmony to patient’s sexual life. 




17



The objectives of this presentation are: 

• To study the variety of laparoscopic techniques to pelvic 

floor repair 

• To examine the mesh materials currently employed 

• To analyse and determine if, how and which technique 

and material should be considered in order to 

minimize dyspareunia 

• To look at some case examples of how dyspareunia arose 

and how the problems were managed 

Author address: Alan Lam. Clinical Associate Professor. Royal North 

Shore Hospital, Northern Clinical School, University of Sydney 

DeLancey JO. The hidden epidemic of pelvic floor dysfunction: 

achievable goals for improved prevention and treatment. Am J Obstet 

Gynecol. 2005 May;192(5):1488-95. Review. PMID: 15902147 




Preventing the endemic: 

The physiotherapist role 

Saturday 19 November / Session 6 / 1115-1135 

Parturition, aging and pelvic floor endemic 

Hodges P 





DeLancey J 

There is no hour during a woman’s life when the pelvic floor is at 

greater risk for injury than during the second stage of labor. This 

critical moment is directly under the supervision of obstetricians, 

gynecologists and midwives. As a team we are responsible for 

safeguarding the mother and the infant. Substantial improvements 

have been made in general maternal and fetal safety during labor, 

but there has been relatively little scientific research that allows 

us to understand injury mechanisms during vaginal birth. Changes 

that occur in the pelvic floor, as a result of vaginal delivery, are 

responsible for an eight-fold increase in pelvic organ prolapse. 

Recent research in our unit has resulted in discovery of damage to 

the levator ani muscles that occur as a result of vaginal birth. This 

involves the pubic portion of the levator ani muscle and its 

attachments to the vagina, perineal body, and anal sphincters. Loss 

of this muscle’s activities can result in a loss of pelvic organ support. 

Obstetrical factors that are associated with increases in levator ani 

muscle injury include forceps delivery, advanced maternal age, 

prolonged second stage, and are also associated with increases in 

other perineal lacerations such as 3 rd and 4 th degree tears. 

Computer simulations have shown that the mechanism of injury 

seem to be over lengthening of the levator ani muscles. 

Remarkable changes in pelvic floor soft tissue occur during birth 

that stretch muscles far beyond the usual rupture threshold. 

Those portions of the muscle that are seen to be ruptured on 

magnetic resonance images are those portions of the muscle that 

undergo the greatest degree of stretch. There is also elongation of 

the pelvic nerves as well which may be responsible for 

neuromuscular dysfunction. 

References: 

Patel DA, Xu X, Thomason AD, Ransom SB, Ivy JS, DeLancey JO. 

Childbirth and pelvic floor dysfunction: an epidemiologic approach to 

the assessment of prevention opportunities at delivery. Am J Obstet 

Gynecol. 2006 Jul;195(1):23-8. Epub 2006 Mar 30. PMID: 16579934 

There is increasing evidence for the efficacy of physiotherapy 

management of stress urinary incontinence (SUI). A recent 

systematic review suggests that 73% of women achieve 

significant improvement in symptoms with interventions that target 

retraining the function of the pelvic floor muscles (Neumann et al, 

2006). While the interventions are effective, recent studies 

highlight the need to consider the role of muscles that surround 

the abdominal cavity in addition to the muscles of the pelvic floor 

in women with SUI. Activity of the abdominal and diaphragm 

muscles influences the continence mechanism as their activity 

increases intra-abdominal pressure (IAP), which in turn increases 

intra-vesicle pressure and challenges the control of the position of 

the pelvic floor and base of the bladder. Thus, activity of these 

muscles increases the demand on the pelvic floor muscles to 

maintain continence and may lead to compromise. 

Recent data suggest that activity of the superficial abdominal 

muscles is increased in women with SUI (Smith et al, 2006), 

particularly those with moderate/severe symptoms. In these studies 

women either caught a mass in a bucket or performed arm 

movements to challenge postural control. Pelvic floor and 

abdominal muscle activity is initiated in association with these 

challenges to postural stability to increased IAP to control the 

spine. As abdominal muscle activity was not increased in women 

with mild symptoms, the data indicate that increased activity of the 

abdominal muscles may contribute to the severity of symptoms of 

SUI. Recent data also point to increased activity of the abdominal 

muscles during the voluntary contractions of the pelvic floor in 

symptomatic women who depressed the bladder base compared to 

control subjects (Thompson et al, 2006). Furthermore, pelvic floor 

muscle activity is modified by posture of the lumbar region. Taken 

together these data suggest that exercise management of stress 

urinary incontinence requires consideration of the entire lumbopelvic 

system to ensure optimal function. 

Interestingly the changes in abdominal muscle activity that have 

been observed on women with moderate-severe SUI are similar to 

that identified in women with low back pain. This may provide an 

18



explanation for increased incidence of low back pain in women 

with incontinence (Smith et al, 2006) and the increased risk for 

future development of low back pain in women with existing 

incontinence (Smith et al, unpublished data). Theoretically this 

association may be explained physiologically due to the 

competition between the roles of the trunk muscles in continence 

and control of the stability of the spine. 

In summary, physiotherapy retraining of pelvic floor muscle 

function requires consideration of the interaction between the 

activity of these muscles and the other muscles that surround the 

abdominal wall. 

References: 

Hodges, P.W., Sapsford, R., Pengel, L.H.M. (2006) Postural and 

respiratory functions of the pelvic floor muscles. Neurourol Urodyn, 

in press. 

Patricia B Neumann, P.B., Grimmer, K.A., Deenadayalan, Y. (2006) 

Pelvic floor muscle training and adjunctive therapies for the treatment 

of stress urinary incontinence in women: a systematic review. BMC 

Women's Health 2006, 6:11 

Sapsford RR, Richardson CA, Stanton WR. Sitting posture affects 

pelvic floor muscle activity in parous women: an observational study. 

Aust J Physiother 2006;52(3):219-22. 

Smith, M. D., Russell, A., Hodges, P.W. (2006) Disorders of breathing 

and continence have a stronger association with back pain than 

obesity and physical activity. Aus J Physiother, 52:11-16. 

Smith, M. D., Coppieters, M., Hodges, P.W. (2006) Postural response of 

the pelvic floor and abdominal muscles in women with and without 

incontinence. Neurourol Urodyn, in press. 

Thompson JA, O'Sullivan PB, Briffa NK, Neumann P. Differences in 

muscle activation patterns during pelvic floor muscle contraction and 

Valsalva maneuver. Neurourol Urodyn 2006;25(2):148-55 

Author address: Paul W Hodges, Division of Physiotherapy, The 

University of Queensland, Brisbane, Qdl 4072 

Aetiology and epidemiology of 

overactive bladder 


Krause H 

Overactive bladder is associated with symptoms of urgency with 

or without urge incontinence, frequency and nocturia. It is a 

common condition with approximately 17% of women suffering 

from this condition. The prevalence increases with age. 

The main causes of overactive bladder symptoms are neurogenic, 

obstructive voiding and idiopathic. This overview will deal with 

idiopathic detrusor overactivity. 

There are several theories for the aetiology of detrusor 

overactivity. The 2 main current theories are: 

1. Altered levels of neurotransmitters and purinergic fibres 

• Higher concentrations of non-adrenergic 

non-cholinergic fibres 

• Altered levels of ATP 

• Deficiency of various purinoceptor subtypes within 

bladder smooth muscle 

2. Abnormal function of bladder interstitial cells 

• Aberrant pace-maker signals generated by these cells 

• Abnormal electrical coupling between these cells 

These 2 concepts will be discussed in more detail. 

Author address: Dr Hannah Krause. Suite 5a Greenslopes Private 

Hospital Brisbane 

Bladder retraining and lifestyle changes 


Greitschus J 

The overactive bladder (OAB) presents as symptoms of urinary 

frequency, nocturia, urgency +\- urge urinary incontinence 

(Ouslander 2004). 

Recommendations for first line management of this condition are 

conservative and fall into 2 categories: pharmacological and 

behavioural. (Burgio 2000, Madersbacher 2004) 

I will address the components of the Behavioural Management for 

Overactive Bladder. 

Loss of bladder control has a marked effect on quality of life and 

can cause sufferers to severely restrict their social outings. 

Behavioural treatments are particularly empowering for patients 

giving a great sense of achievement. Burgio et al (1998) when 

comparing behaviour therapy for the management of OAB to drug 

therapy reported the highest perceived improvement and 

satisfaction with progress in the behavioural group. 

Behavioural therapy involves a multifaceted approach to 

management including: 

• Bladder Retraining 

• Pelvic Floor Muscle Exercises 

• Urge Control Strategies 

• Life-style modifications 

Bladder Retraining is a systematic approach of deferring voiding 

to increase the functional bladder capacity and hence reduce the 

symptoms of frequency and urgency (Wallace 2004). Voiding 

diaries are used to record the time of void, voided volume, degree 

of perceived urgency and episodes of incontinence. Fluid intake is 

also recorded. Voiding diaries allow for a clear comparison 




19






between the patient’s records and normal voiding parameters 

providing immediate feedback to the patient. 

Pelvic Floor muscle (PFm) training has been found to be beneficial 

for improving the outcome of patients with OAB (Hay-Smith 2006). 

Activity in the pelvic floor muscles has an inhibitory effect on the 

detrusor (Mahoney 1977) and can increase intra-urethral closing 

pressure hence preventing urge incontinence (Burgio 1998). 

Individual assessment of PF muscle activity should be performed 

to ensure for correct exercise technique. The most common 

assessment used by physiotherapists is a digital vaginal palpation. 

EMG biofeedback or ultrasound imagings using either a 

transabdominal or translabial approach are also suitable methods. 

A home program of pelvic floor muscle exercises is then given. 

PFm contractions can then be implemented as an urge control 

strategy. This is especially successful to suppress the onset of 

urgency at predictable times eg when turning on a tap or arriving 

at the front door. 

Other useful urge control strategies include cognitive control, 

perineal pressure and foot intrinsic muscle contraction. 

High caffeine intake and being a current or ex-smoker have been 

associated with urge urinary incontinence. (Jayna 2004) There is 

also some debate as to the influence of alcohol on urinary 

symptoms. The usual recommendations are for patients to 

significantly reduce their intake of caffeine and alcohol and 

embark on a quit smoking program. Obesity is correlated with 

higher levels of both stress and urge incontinence. Weight loss 

programmes should be recommended for obese patients. 

Success with behavioural therapy requires a motivated, compliant 

patient but has no negative side effects and is associated with a 

high level of satisfaction and willingness to continue the program 

long term (Burgio 1998). There is some suggestion that bladder 

retraining may result in better reduction of frequency than drug 

therapy and that drug therapy may be more beneficial in reducing 

episodes of incontinence (Ghei 2006) so it follows that combining 

both treatments may improve patient outcomes. The BE-DRI study 

(Kraus 2006) is a trial of combination behavioural and drug therapy 

with the aim of withdrawing drug management but sustaining the 

treatment effect. 

Clinically combination therapy is how we manage many clients. 

The anticholinergic effect helps the compliance and success of 

bladder retraining to normalise voiding parameters. Once normal 

volumes and voiding frequency are gained and incontinence 

ceases, the medication is weaned. Good voiding habits have been 

re-established and can hopefully be maintained in the long term. 

References: 

1. Burgio K et al (2003) Predictors of Outcome in the behavioural 

treatment of urinary incontinence in women. Obstetrics & 

Gynecology 2003;102:940-947 

2. Burgio K et al (1998) Behavioural vs Drug Treatment for Urge 

Urinary Incontinence in OlderWomen. A randomised 

controlled trial JAMA 1998;280:1995-2000 

3. Ghei M et al (2006) Case series data to encourage randomized 

trials of bladder retraining compared to antimuscarinic 

agents. J Urol 2006;Apr;175(4):1411-5 

4. Goode PS et al (2002) Urodynamic changes associated with 

behavioural and drug treatment of urge incontinence in older 

women. J Am Geriatr Soc. 2002 May;50(5):808-16 

5. Hay-Smith EJ, Dumoulin C (2006) Pelvic floor muscle training 

versus no treatment, or inactive control treatments, for 

urinary incontinence in women. Cochrane Database Syst Rev 

2006 Jan 25;(1):CD005654 

6. Kraus (2006) Design of the Behavior Enhances Drug Reduction of 

Incontinence (BE-DRI) study. Contemp Clin Trials 2006;Jun 18. 

7. Madersbacher H (2004) Overactive bladder – a practical 

approach to evaluation and management. J Med Liban 2004 

Oct-Dec;52(4):220-6 

8. Ouslander J (2004) Management of Overactive Bladder. Drug 

Therapy 2004; vol 350(8)786-799 

9. Wallace S et al (2004) Bladder training for urinary 

incontinence in adults. Cochrane Database Syst Rev. 

2004;(1):CD001308 

Author address: Janelle Greitschus (Physiotherapist). Royal Brisbane 

and Women’s Hospital 

Current and new medical treatments 


Rosamilia A 

The prevalence of overactive bladder is approximately 17% of the 

populaton over 40 years with one third having urge incontinence. 

Pharmaceutical company derived data suggest that there are 

approximately 22,000 patients per month taking antimuscarinics in 

Australia. Up until 2005 the two options in Australia were 

probanthine and oxybutynin (ditropan). In that year tolterodine 

(detrusitol) was made available as was oral DDAVP (Minirin). In 

2006 the available options now also include transdermal 

oxybutynin (oxytrol) and the most recent introduction of 

solifenacin(vesicare) and darifenacin( enablex). An overview of 

the major strengths and weaknesses of these alternatives will be 

presented including prescribing information, side effect profile 

and current cost in Australia. 

Oxybutynin is the most commonly prescribed drug currently; it is 

well established with a known side effect profile of constipation, 

dry mouth etc which limit dosage and are a associated with 

discontinuation. It has Pharmaceutical Benefits Scheme listing. 

Transdermal oxybutynin has similar efficacy but avoids many of 

these side effects; patch irritation occurs in about 15 %. 

Tolterodine immediate release twice daily is available in Australia 

for approximately $55-65 per month; it has a reduced side effect 

20



profile compared with oxybutynin but may not be quite as 

efficacious. Extended release tolterodine is not yet available in 

Australia but is the market leader in many countries. 

Solifenacin has been compared to placebo, tolterodine immediate 

and extended release with favourable results. It is associated with 

a ‘dry rate’ in urge incontinence of over 50% in 12 weeks and 60% 

over 12 month usage. Five mg daily has a favourable side effect 

profile but costs approximately $ 48 per month. About 40% of 

patients in trial settings request an increase of the dose to 10mg 

which increases the dry rate by about 10% but increases side 

effects such as constipation. 

Darifenacin is also prolonged release once daily dose and has 

similar reduction in incontinence episodes of over 60% over 12 

weeks. In all these studies the placebo response is between 35 

and 55% reduction. 

There has been a boom recently in the options available for 

treatment of bladder overactivity as the pharmaceutical industry 

acknowledges the extent of the problem of bladder overactivity 

and position themselves to increase market share. Further 

experience of clinicians locally will continue to inform us as to 

how effective and tolerable these medications are. 

Botox therapy for overactive bladder 


Dwyer P 

Botulinum toxin, the product of the bacteria Clostridium botulinum, 

was first isolated in 1897 and remains today one of the most 

powerful neurotoxins known to man. A number of serotypes have 

been isolated from type A to G. Types A and B are in clinical use 

with only type A used in urogynaecological practice, as it has a 

longer duration of action and less side effects. Type A is available 

as Botox (Allergan) or Dysport (Ipsen). Botox is administered in a 

standard dosage of 100 units and Dysport in 500 units. Botulinum 

toxin (BTX) is a neurotoxin which inhibits release of acetylcholine 

(ACH) from motor nerve neuromuscular junctions causing 

relaxation and chemical denervation of skeletal and smooth 

muscle. If also inhibits release of transmitters of sensory nerves. 

These affects are temporary but can last between 6 and 12 

months. BTX has been used in the treatment of Strabismus, 

spastic neurological diseases and diseases of the autonomic 

nervous system. In female urology it has been used for 

neurogenic and non-neurogenic overactive bladder, detrusor 

sphincter dyssynergia and urinary retention and the painful 

bladder syndrome. 

In this presentation I will review its use for treatment of the 

neurogenic and non-neurogenic overactive bladder. 

BTX is normally administered as an intramuscular or submucosal 

injection into the posterior bladder wall in the form of 20 - 30 

aliquots injections of diluted BTX, avoiding the trigone. Injection or 

near the ureters is avoided because of the fear of creating 

ureteric obstruction or reflux. BTX has also been administered in 

an intravesical infusion. Published studies on the use of BTX have 

mainly been retrospective in nature and uncontrolled. Reitz et al, 

in a large multicentre study of 231 patients with neurogenic 

detrusor overactivity were treated with Botox 300 units. They 

found an objective on urodynamic follow-up that there was a 

significant improvement in bladder function with a low incidence 

of complications. 

Ropp et al reported a series of 35 patients with non-neurogenic 

refractory overactive bladder who had 300 units of BTX injected at 

30 sites. At six months follow-up 34% reported that their OAB 

symptoms had resolved, in 26 were improved and 40% were the 

same at six month follow-up. 

More recent prospective randomised studies will also be 

presented. Popat et al compared 44 patients with neurogenic 

detrusor overactivity (NDO) with 31 patients with idiopathic 

detrusor overactivity (IDO). Owing to the increased risk of needing 

clean intermittent self-catheterization reported in previous 

studies, a lower dose of 200 u of Botox (20 injections of 1 ml) was 

used in the IDO group compared with 300 u (30 injections) in the 

NDO group. Urodynamic assessment at 4 and 16 weeks was 

carried out alongside bladder diaries. Both groups showed an 

excellent response to the treatment, with improved urodynamic 

parameters and reduced daytime frequency, urgency and 

episodes of urine leak. No significant difference was noted 

between the groups. At 4 weeks, 25 of 39 patients with NDO 

(64.1%) and 13 of 24 patients with IDO (54.2%) were dry. At 16 

weeks these figures were 55.2% for patients with NDO and 57.1% 

for those with IDO. All but two patients reported at least an 

improvement in number of incontinence episodes at both visits. 

Botox has shown considerable promise for the short term 

treatment of neurogenic and non-neurogenic overactive bladder. 

However, potential risks include urinary retention can occur so 

some authors suggest a lower dose if there is urodynamics 

evidence of voiding dysfunction or the use of simultaneous 

injection of BTX into the urethral sphincter. There are few 

prospective randomised studies using validated instruments to 

assess effectiveness that have been published to date. 

References: 

Reitz A et al (2004) European experience of 200 cases treated with 

Botulinum – A toxin injections into the detrusor muscle for urinary 

incontinence due to neurogenic detrusor overactivity. EUR 

Urol 45:510 

Ropp et al Urol 2004 

Popat R, Apostolidis A, Kalsi V, et al. A comparison between the 

response of patients with idiopathic detrusor overactivity and 

neurogenic detrusor overactivity to the first intradetrusor injection of 

botulinum-A toxin. J Urol 2005; 174:984–989. 

Author address: Associate Professor Peter Dwyer, Urogynaecology 

Department, Mercy Hospital for Women, Melbourne 




21






22 

Sacral Neuromodulation (SNS) 


Carey MP 

Sacral nerve stimulation (SNS) has become established therapy 

for the management of severe and refractory over active bladder 

syndromes (urge incontinence, urgency-frequency syndrome) and 

idiopathic urinary retention. More recently, SNS has been used for 

interstitial cystitis and neuropathic faecal incontinence. The 

precise mechanism of action of SNS remains unknown. The 

implanted sacral nerve stimulator device comprises a pulse 

generator, extension cable and lead with quadripolar electrodes. 

Recent lead modifications have seen a tread towards a two 

staged implant procedure using small skin incisions. These recent 

modifications allow for surgery to be completed under local 

anaesthesia. This new minimal access surgical approach to SNS 

implantation is likely to result in more accurate patient screening 

and reduced wound morbidity. 

Anatomical Considerations: 

The third sacral nerve root is the target for SNS. This sacral nerve 

root has a width of 3 to 4 mm and exits from the third sacral 

foramen. Occasionally, needle insertion into S3 can result in 

vascular and nerve damage. This damage can be minimized by 

employing a lateral entry into foramen and by ensuring the needle 

enters the foramen at an acute angle rather than vertically. The 

sacral nerves provide many branches to the pelvis and lower 

limbs. The pudendal nerve, which is the main sensory and motor 

nerve to the pelvic floor, receives contributions from S2, S3 and 

S4. Stimulation of S3 results in both a motor and sensory 

responses. The motor response includes contraction of the 

levator ani muscle complex (‘bellows response’) and flexion of 

the toes via stimulation of the tibial branch of the sciatic nerve. 

The sensory response includes a sensation of ‘tingling’ in the 

vagina, rectum and labia majora. In clinical practice, accurate 

placement of electrodes into the third sacral foramen is 

confirmed by the appropriate motor and sensory responses and 

by fluoroscopy (if available). 

The most easily identified surface anatomy landmark of the S3 

foramen is the greater sciatic notch. The S3 foramen is located 

medial to the upper edge of the greater sciatic notch and a middle 

finger’s breadth from the spine of the sacrum (midline). 

Mechanism of action of SNS: 

The precise mechanism of action of SNS is unclear and a number 

of theories have been advanced. Sacral nerve neuromodulation 

stimulates the afferent somatic nerve fibres responsible for the 

modulation of sensory processing and the micturition reflex in the 

spinal cord. It has been postulated that SNS depends on the 

electrical stimulation of afferent nerve fibres in the spinal roots 

that, in turn, modulate voiding and continence reflex pathways in 

the central nervous system. 

SNS may cause suppression of bladder over activity by the 

neuromodulation of several reflex mechanisms. Firstly, direct 

inhibition of bladder preglangionic neurons suppresses unstable 

bladder contractions. Secondly, inhibition of unstable bladder 

contractions by suppression of interneuronal transmission in the 

afferent limb of the micturition reflex. SNS does not interfere with 

voluntary voiding mediated by descending excitatory efferent 

pathways from the brain to the sacral parasympathetic 

preganglionic neurons. 

Efficient bladder emptying relies on the ability of brain pathways 

to turn off urethral sphincter guarding reflexes. SNS may act by 

switching off excitatory outflow to the urethral sphincter, thereby 

promoting bladder emptying in patients with urinary retention. 

Clinical Indications for SNS: 

In the United States, SNS has FDA approval for urge incontinence, 

urge-frequency syndrome and voiding difficulty. The cost of SNS 

is around $AUS13,000 and surgical revisions are required in about 

30% of cases. SNS is therefore reserved for refractory lower 

urinary tract dysfunction. 

Thorough clinical assessment, including neurological evaluation, 

is mandatory prior to considering SNS. Appropriate investigations 

are also required prior to SNS to establish a precise diagnosis and 

exclude neurological disorders (e.g. multiple sclerosis). Often 

urodynamic studies, cystoscopy and various imaging techniques 

(MRI; MRI scanning is contraindicated once SNS has been 

implanted) are performed prior to SNS. Psychiatric assessment is 

appropriate in some cases. 

SNS should be considered as an alternative to major urology 

procedures such as augmentation cystoplasty and urinary diversion. 

Results of SNS: 

Recent studies by Schmidt et al (J Urol 1999), Hassouna et al (J 

Urol 2000) and Jonus et al (J Urol2001) reported the results of SNS 

for refractory lower urinary tract disorders. These studies 

demonstrated SNS to be effective, safe and reversible therapy for 

the treatment urge incontinence, urgency-frequency syndrome 

and voiding difficulty. 

Surgical revision is reported in 6% to 50% of cases. The largest 

RCT evaluating SNS is the MDT-103 study. This study involved 633 

patients: 210 with urge incontinence; 229 with urgency-frequency 

syndrome; and 194 with urinary retention. Repositioning of the 

electrode or extension lead was required in 24.4% of patients. A 

further 21.1% of patients required repositioning or replacement of 

the implanted pulse generator. 

Recent lead modifications and the trend towards a two staged 

implantation procedure with a minimal assess surgical approach 

are likely to improve the outcomes for patients undergoing SNS.



Conclusion: 

SNS is effective therapy for refractory over active bladder 

syndromes and idiopathic urinary retention. Emerging indications 

include interstitial cystitis, perineal pain syndromes, and 

neuropathic faecal incontinence. Currently, the high cost of SNS 

and its restriction to refractory lower urinary tract disorders limits 

the use of SNS to specialist tertiary centers. 

Author address: Marcus P. Carey, Royal Women’s Hospital, Melbourne 

Anatomy of urinary continence 

Saturday 18 / Session 8 / 1405 – 1420 

DeLancey J 

There is a great deal of research which has been carried out 

during the last 50 years concerning the cause of stress urinary 

incontinence. Because of the empirical success of urethral 

suspension, most theories have suggested that it is urethral 

support which is the most important determinant of stress urinary 

incontinence. From a scientific standpoint, however, this turns out 

not to be true. Recent analyses in case control studies in our unit 

have shown that the maximum urethral closure pressure is a far 

more important parameter in establishing whether an individual is 

stress incontinent or not than is urethral support. This is not to say 

that urethral support plays no role in urinary continence but it 

does establish that urethral function is a more important 

parameter than we have previously anticipated. 

Urethral support is determined by both connective tissue and 

muscle. The connective tissues involve attachments of the fiber 

muscular layer of the anterior vaginal wall usually referred to as 

endopelvic fascia to the arcus tendineus fascia pelvis. These 

tissues are also laterally attached to the levator ani muscles. This 

attachment allows for normal mobility in the upper third of the 

urethra. It is a plausible paradigm that increases in intraabdominal 

pressure force the urethra against these underlying 

tissues to compress them closed. There is also a cough 

associated contraction of both the urethra and the levator ani 

muscles which stabilize the tissues in this region. 

The urethra itself is composed of a number of muscle layers. The 

striated urogenital sphincter muscle acts to constrict and 

compress the urethra. Our recent research has shown that there 

is a substantial loss of striated muscle with increasing age which 

roughly parallels the changes in decrease in maximum urethral 

closure pressure. Ongoing work is needed to understand all 

factors associated with urethral function but certainly the 

occurrence of low maximum urethral closure pressure in some 

nulliparous women early in life means that there may be a genetic 

predisposition to urinary incontinence in women born with a 

relatively poorly functioning urethra. 

Although there has been considerable effort in understanding 

the success rate of different surgical procedures for stress 

urinary incontinence, there is a substantial opportunity to 

develop new forms of treatment now that we recognize that 

urethral closure pressure is also a critical determinant of stress 

urinary incontinence. 

References: 

DeLancey JO. Correlative study of paraurethral anatomy. Obstet 


Chou Q, DeLancey JO. A structured system to evaluate urethral 

support anatomy in magnetic resonance images. Am J Obstet 


Miller JM, Umek WH, Delancey JO, Ashton-Miller JA. Can women 

without visible pubococcygeal muscle in MR images still increase 

urethral closure pressures Am J Obstet Gynecol. 2004 Jul;191(1):171- 

5. PMID: 15295360 

Perucchini D, DeLancey JO, Ashton-Miller JA, Galecki A, Schaer GN. 

Age effects on urethral striated muscle. II. Anatomic location of 

muscle loss. Am J Obstet Gynecol. 2002 Mar;186(3):356-60. PMID: 

11904591 

Perucchini D, DeLancey JO, Ashton-Miller JA, Peschers U, Kataria T. 

Age effects on urethral striated muscle. I. Changes in number and 

diameter of striated muscle fibers in the ventral urethra. Am J Obstet 

Gynecol. 2002 Mar;186(3):351-5. PMID: 11904590 

Umek WH, Kearney R, Morgan DM, Ashton-Miller JA, DeLancey JO. 

The axial location of structural regions in the urethra: a magnetic 

resonance study in nulliparous women. Obstet Gynecol. 2003 

Nov;102(5 Pt 1):1039-45. PMID: 14672484 

Miller JM, Perucchini D, Carchidi LT, DeLancey JO, Ashton-Miller J. 

Pelvic floor muscle contraction during a cough and decreased 

vesical neck mobility. Obstet Gynecol. 2001 Feb;97(2):255-60. 

PMID: 11165591 

Howard D, Delancey JO, Tunn R, Ashton-Miller JA. Racial differences 

in the structure and function of the stress urinary continence 

mechanism. Obstet Gynecol. 2000 May;95(5):713-7. PMID: 10775735 

Howard D, Miller JM, Delancey JO, Ashton-Miller JA. Differential 

effects of cough, valsalva, and continence status on vesical neck 

movement. Obstet Gynecol. 2000 Apr;95(4):535-40. PMID: 10725485 







23






24 

Evidence for continence surgery 


Haylen BT, Chetty N 

Evidence is defined (Oxford Concise English Dictionary, 1995) as 

‘available facts, circumstances etc, supporting or otherwise a 

belief, proposition, etc, or indicating whether or not a thing is true 

or valid’. 

Clinical evidence for continence surgery should be as a minimum 

the presence of the symptom and sign of stress incontinence. 

There is little evidence for whether urodynamics made a 

difference to the chance of incontinence after subsequent 

treatment. The value of urodynamics is, however, the ability to 

separate the group for whom surgery is effective from those 

where it is not effective or contra-indicated or where 

management needs to be altered. Women undergoing 

urodynamics are more likely to receive drug or surgical treatment. 

There is no evidence that physiotherapy provides an effective 

curative alternative to surgical treatment for stress incontinence. 

Many continence surgeries have been subject to Cochrane 

studies. Summary statements can be made on most of these. 

Anterior Vaginal Repair: Less effective than open 

retropubic suspension. 

Bladder Neck Suspensions: Similar performance to anterior 

vaginal repair. 

Open Retropubic Colposuspension: Effective continence 

procedure, more invasive than midurethral slings. 

Laparoscopic colposuspension: As effective as open 

colposuspension (short-term) with less perioperative morbidity / 

hospitalization though more costly. 

Traditional Suburethral Sling: Too little data to allow 

comparative studies 

Periurethral Injection Therapy: Very little randomized data. 

The most popular continence procedure, the midurethral sling 

(tape) procedure has been subject to non-Cochrane studies. Cure 

rates of 81% - 93% for most studies; 63% vs 51% (open colpo) in 

randomized controlled trial at 2 years. Similar efficacy retropubic 

vs trans-obturator approach except severely incontinent women 

where retropubic approach may be more effective. 

Author address: Bernard T. Haylen, Naven Chetty. St Vincent’s Clinic & 

Hospital, Sydney. Australia 

Laparoscopic colposuspension: dead 

and buried 


Carey M 

The open Burch colposuspension (OBC) appears to be an effective 

and durable anti-incontinent procedure. The laparoscopic Burch 

colposuspension (LBC), first described in the early 1990’s, has the 

proposed advantages of no laparotomy incision, less postoperative 

pain, shorter time in hospital and a quicker return to 

normal activities. LBC has been performed for over a decade with 

a relatively small number of reported prospective randomised trials 

(Moehrer B, Carey M, Wilson D. Laparoscopic colposuspension: a 

systematic review. Br J Obstet Gynaecol 2003; 110:230-235). Most 

of the trials comparing surgical outcomes have been complicated 

by different surgical techniques for the open and laparoscopic 

approaches, such as different number or type of sutures. 

In our unit, we performed an RCT of 200 women with urodynamic 

stress incontinence randomly allocated to either LBC or OBC 

(Carey MP, Goh J et al. Laparoscopic versus open Burch 

colposuspension: a randomised controlled trial. BJOG 2006 Sep; 

113(9): 999-1006). We attempted to treat both groups in an identical 

fashion, with the only difference being the laparoscopic or low 

transverse incisions for surgical approach. Our data showed no 

difference in short and long term cure rates assessed by 

symptoms, self-completed questionnaires and urodynamics. 

We demonstrated that LBC has several advantages over OBC: less 

blood loss, less pain and earlier return to activities of normal daily 

living. The role of LBC in the treatment of urinary stress 

incontinence has changed with the introduction of the tension-free 

vaginal tape (TVT) procedure and other mid-urethral tapes. From 

our data, rates of cure for stress incontinence at 6-month postoperative 

urodynamics were 78% for OBC and 72% for LBC. These 

were comparable to rates of cure for stress incontinence at 6- 

month post-operative urodynamics for a multicentre randomised 

controlled trial comparing OBC (67%) and TVT (81%) in greater than 

300 subjects (Ward K, Hilton P. Prospective multicentre randomised 

trial of tension-free vaginal tape and colposuspension as primary 

treatment for stress incontinence. BMJ 2002; 325 (7355): 67-70). 

Presently, there are only a few small, randomised controlled trials 

comparing LBC and TVT with relatively small numbers and short 

follow-up times. TVT is also a minimally invasive procedure that is 

relatively quick to perform, requiring little equipment, and having a 

shorter learning curve than LBC. As more evidence is accumulated 

about the long-term success rates of TVT, it has become the first 

line choice for stress incontinence surgery in many centres. 

In my practice, LBC is now usually performed on women 

presenting with failed mid-urethral tape procedures. 

Author address: Marcus Carey. Royal Women’s Hospital, Melbourne

NOTES 




29

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