Deszensus und Prolaps

 

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Zusammenfassung

Deszensus und Prolaps des weiblichen Genitale sind häufige Erkrankungen, deren Inzidenz mit dem Lebensalter steigt. Die klassischen Termini zur Beschreibung der Senkungszustände wie z. B. Zystozele, Rektozele und Enterozele sollen nach den Vorstellungen der Standardisierungskommission der ICS ersetzt werden durch definierte Fixpunkte. Dazu wurde die „Pelvic Organ Prolaps Quantification” (POPQ) entwickelt mit einer Einteilung in 5 Stadien. Für die wissenschaftliche Dokumentation ist das System ein Fortschritt, in der klinischen Praxis allerdings aufwendig und gewöhnungsbedürftig. In Bezug auf die Ätiologie haben vaginale Geburten die engste statistische Korrelation zum Prolaps, gefolgt von klimakterischer Involution, konstitutionellen Faktoren, körperlicher Belastung, chronischer Bronchitis und Übergewicht. Die Diagnostik ist überwiegend klinisch orientiert. Mit der dynamischen Kernspintomographie lassen sich Defekte supportiver Strukturen sehr differenziert objektivieren. Ob sich diese bildgebende Diagnostik im Hinblick auf die hohen Kosten zur Routinemethode entwickelt, bleibt abzuwarten. Konservative Behandlung wie Beckenbodentraining bzw. Elektrotherapie empfiehlt sich bei jüngeren Patientinnen mit mäßigem Deszensus und geringem Beschwerdebild. Moderne Pessare sind indiziert als erster Behandlungsversuch oder wenn die Patientin sich nicht zur Operation entschließen kann. Die Anwendung sollte in der Perimenopause stets unter lokaler Gabe von Estrogenen erfolgen. In der Chirurgie der Senkungszustände etablieren sich neben den klassischen Methoden seit knapp 10 Jahren zunehmend laparoskopische Techniken. Diese verfolgen dabei prinzipiell keine neue Operationsstrategie, sondern realisieren taktische Schritte bekannter Rekonstruktionsmethoden auf minimal-invasivem Weg. Die laparoskopischen Fixationsoperationen eignen sich besonders für junge Frauen mit dem Wunsch nach Uteruserhalt.

Pelvic organ prolapse

Summary

Pelvic organ prolapse of the female is a common disease with age dependent increase in incidence. The committee for standardisation of the International Continence Society recently suggested to avoid classical terms such as cystocele, rectocele or enterocele for the description of prolapse and to replace them by defined landmarks. The „Pelvic Organ Prolapse Quantification” (POPQ) was developed and five different grades of prolapse were defined. This is a true gain for scientific documentation but needs some effort to be implemented in routine practical work. Previous normal vaginal delivery is statistically highly correlated with prolapse, followed by climacteric involution, constitutional factors, physical work, chronic bronchitis, and overweight respectively. The diagnosis is confirmed by clinical examination. Defects of the supportive structures can be precisely assessed with dynamic magnetic resonance imaging. Time will show whether this costly method will become part of routine diagnostic procedures. A patient with moderate prolapse or few complaints may be treated conservatively with pelvic floor training or electrotherapy. Modern pessaries are tried as first line therapy or for patients unwilling to undergo surgery. Local estrogen application should routinely be prescribed for perimenopausal patients. In the last decade laparoscopic techniques have been established in addition to standard methods of pelvic floor reconstruction. These techniques do not follow a new surgical strategy but realise the minimal invasive approach to established methods of pelvic floor reconstruction. Of note, laparoscopic fixation is very convenient for young women who want to preserve their uterus. Long time follow up is not available for most techniques.

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Univ. Prof. Dr. Hans Dietrich Methfessel

Klinik und Poliklinik für Gynäkologie des Klinikums der Medizinischen Fakultät der Martin-Luther-Universität Halle-Wittenberg

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