Table 2.
Indicator | Validity* Rating |
Feasibility* Rating |
---|---|---|
Screening/Diagnosis: Initial Evaluation | ||
A. A woman over age 65 who is seen for a routine annual examination should be examined for pelvic organ prolapse (POP). |
2.5, D, 2-5 | 5.0, I, 2-7 |
1. IF a woman complains of a new or worsening vaginal bulge or protrusion, THEN she should have a pelvic examination BECAUSE these symptoms are strongly associated with POP and treatments are available. |
8.0, A, 7-9 | 8.0, A, 5-9 |
Treatment/Management with Pessary | ||
2. IF a woman has symptoms of prolapse, THEN she should be offered a pessary BECAUSE pessaries are an effective, low-risk, non-surgical means to improve symptoms. |
7.0, A, 6-8 | 7.0, A, 7-8 |
3. IF a pessary is fitted THEN a patient should undergo a pelvic exam every 6 months BECAUSE pessaries lost to follow-up can cause serious complications. |
6.5, I, 3-8 | 7.0, A, 1-8 |
Surgical Management | ||
4. IF a woman has asymptomatic POP of stage 1 or less, THEN she should not be offered surgical intervention stage I prolapse BECAUSE there is no proven benefit of surgery for asymptomatic prolapse. |
7.5, A, 7-9 | 7.5, A, 3-9 |
5. IF surgical intervention is performed, THEN the prolapse should be staged by pre-operative pelvic examination and specific prolapse components (anterior, posterior, apical) should be documented BECAUSE surgery should be tailored to the specific defects present. |
7.0, A, 5-9 | 7.0, A, 6-9 |
6. IF a woman with symptomatic apical prolapse undergoes surgery and is a candidate for vaginal and abdominal surgery, THEN she should be counseled about the risks and benefits of both approaches BECAUSE each has unique risks and benefits. |
7.0, A, 2-9 | 6.5, I, 1-8 |
7. IF prolapse surgery that includes the use of mesh is performed, THEN pre-operative counseling should be given about the specific risks associated with synthetic mesh BECAUSE risks of mesh include urinary tract erosion, fistula, infection, vaginal mesh extrusion, chronic pain, and injury to adjacent organs. |
7.0, A, 4-9 | 6.5, I, 1-9 |
8. IF a hysterectomy for POP is performed, THEN a concomitant vault suspension procedure should be completed BECAUSE hysterectomy alone for prolapse results in high recurrence rates. |
8.0, A, 5-9 | 8.0, A, 7-9 |
9. IF surgical repair of anterior/apical POP is performed, THEN the patient should be counseled about the risk of post-operative stress urinary incontinence (SUI) BECAUSE level I evidence exists that SUI can be prevented with a concomitant incontinence procedure. |
7.0, A, 6-8 | 7.0, I, 6-8 |
B. A stress continent woman with anterior POP who undergoes surgical intervention should be examined for SUI after prolapse reduction. |
3.5, I, 1-6 | 6.0, I, 1-8 |
C. A woman with positive stress testing with POP reduction who chooses to undergo a vaginal POP repair should be offered a midurethral synthetic sling. |
6.0, D, 4-8 | 7.0, A, 5-8 |
D. A woman who undergoes an abdominal sacrocolpopexy (either open, laparoscopic, or robotic) should have synthetic mesh instead of biologic graft material. |
5.0, I, 3-7 | 7.0, I, 4-8 |
10. IF a woman elects to undergo an abdominal sacrocolpopexy (either open, laparoscopic, or robotic), regardless of the results of pre-operative stress testing with prolapse reduction, THEN she should be offered a concomitant continence procedure BECAUSE of the increased risk of stress urinary incontinence after surgery for high stage prolapse. |
7.0, A, 5-8 | 7.0, A, 4-8 |
11. IF a woman over age 65 with advanced POP (stage 3 or greater) plans to undergo surgical treatment of prolapse and no longer wishes to engage in sexual activity, THEN she should be offered a colpocleisis BECAUSE this operation has low morbidity and high efficacy. |
6.5, I, 4-9 | 6.0, I, 2-9 |
12. IF a patient undergoes surgery for anterior and/or apical vaginal prolapse, THEN intra-operative cystoscopy to evaluate for bladder and ureteral integrity should be performed BECAUSE missed urinary tract injuries result in serious complications. |
7.5, A, 5-9 | 7.5, A, 7-9 |
E. A woman who undergoes a rectocele repair with perineorrhaphy should be counseled pre-operatively about possible long-term complications of surgery, including dyspareunia resulting from the repair, as well as persistent defecatory dysfunction. |
5.0, I, 3-7 | 6.0, I, 3-8 |
F. A woman who undergoes a rectocele repair with perineorrhaphy should undergo posterior colporrhaphy by a vaginal approach. |
5.5, I, 1-7 | 7.0, I, 1-8 |
G. A woman greater than age 65 with an intact uterus who elects to undergo a partial colpocleisis should have her endometrium evaluated. |
3.0, I, 1-5 | 4.0, D, 1-7 |
13. IF a woman undergoes prolapse surgery, THEN she should be re- evaluated with a pelvic examination within three months of surgery BECAUSE prolapse surgery can result in treatable adverse events, including pelvic pain and mesh-related complications. |
7.7, A, 6-8 | 8.1, A, 8-9 |
14. IF a woman undergoes prolapse surgery with mesh, THEN she should be re-evaluated with a pelvic examination one year after surgery BECAUSE mesh can result in delayed complications. |
7.4, A, 5-9 | 7.7, A, 5-9 |
median score, level of agreement, range of second round rankings (scale of 1-9)
Level of agreement:
A=agreement with first round rankings
D=disagreement with first round rankings
I=indeterminate
Shaded areas indicate quality indicators that were rejected by the panel.