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Increasing Anteroposterior Genital Hiatus Widening Does Not Limit Apical Descent for Prolapse Staging During Valsalva's Maneuver

Effect on Symptom Severity and Surgical Decision Making

Guanzon, Anna, MD*; Heit, Michael, MD, PhD; Khoder, Waseem, MD

Female Pelvic Medicine & Reconstructive Surgery: November/December 2018 - Volume 24 - Issue 6 - p 412–418
doi: 10.1097/SPV.0000000000000474
Original Articles

Objective Determine if anteroposterior genital hiatus (GH) widening obscures rather than facilitates signs and symptoms, inadvertently altering management decisions for women with pelvic organ prolapse (POP) during Valsalva's Maneuver, at a given total vaginal length (TVL).

Methods We performed a retrospective cohort with nested cross-sectional study of patients who underwent POP surgery. Data from obstetric and gynecologic history, preoperative and postoperative physical examinations, and 20-item Pelvic Floor Distress Inventory (PFDI-20) and 7-item Pelvic Floor Impact Questionnaire (PFIQ-7) scores were extracted. Study participants were compared in 2 groups: anteroposterior widened (>3 cm) and not widened (≤3 cm) GH, for baseline leading edge and POP stage, while controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were evaluated within GH groups. Delta GH, PFDI-20, and PFIQ-7 scores after apical suspension with and without posterior colporrhaphy were compared to assess the clinical value of the procedure.

Results Study participants with anteroposterior GH widening during Valsalva maneuver had greater baseline leading edge descent and higher POP stage compared with those without anteroposterior GH widening after controlling for TVL. Baseline PFDI-20 and PFIQ-7 scores were similar within both GH categories controlling for prolapse severity. Adding posterior colporrhaphy to apical suspension resulted in a greater anteroposterior GH reduction without improving delta PFDI-20 or PFIQ-7 scores.

Conclusions Facilitation through herniation rather than obscuration from anteroposterior GH widening explains why patients will not be undertreated based on signs and symptoms of disease. Adding posterior colporrhaphy to apical suspension more effectively reduces anteroposterior GH widening without differential improvement in symptoms rendering the operation to no more than a cosmetic procedure.

From the *Department of Obstetrics and Gynecology and

Division of Female Pelvic Medicine and Reconstructive Surgery, Indiana University, Indianapolis, IN.

Correspondence: Michael Heit MD, PhD, 1633 North Capitol Ave, Ste 436, Indianapolis, IN 46202. E-mail:

No funding has been received for this study.

The authors have declared they have no conflicts of interest.

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