UTERINE SUSPENSION

Symptomatic retrodisplaced uterus:
better treated by surgery or psychology?

Health-care providers for women are well aware of the prevalence of chronic pelvic pain in reproductive-aged patients. Among the more common causes for this condition are pelvic endometriosis, uterine fibroids, pelvic adhesive disease, and psychological trauma resulting from a history of physical or mental abuse. For another category of conditions that has a more controversial role in chronic pelvic pain, however, there are a paucity of data directly linking these problems to pelvic pain. Included in this category are Allen-Masters syndrome, pelvic congestion syndrome, and symptomatic uterine retrodisplacement.

In addition to chronic pelvic pain, symptomatic retrodisplacement of the uterus has been linked to infertility, dysmenorrhea, and dyspareunia. In this technology issue of Contemporary OB/GYN, we are fortunate to have diverse opinions on the importance and management of symptomatic uterine displacement from two well-known experts in the field of pelvic pain: Dr. John Petrozza from the Massachusetts General Hospital and Harvard Medical School and Dr. Barbara Levy from University of Washington School of Medicine, Seattle, Wash. Both clinicians share their interpretation of the research as well as their own clinical experience in managing this controversial condition.

—Keith Isaacson, MD, Issue Editor

Uterine suspension:
more than just a fad

By John C. Petrozza, MD

Uterine suspension has become an infrequent procedure, rarely taught in ob/gyn residencies and—with the exception of articles on pelvic pain—hardly mentioned in current gynecologic texts. This is a surgical technique that appears to be looking for an indication. One factor discouraging greater use of this procedure has been the difficulty in measuring its end points. Also, descriptive studies that haphazardly use this technique in patients with generalized chronic pelvic pain will more often document failure. That's not surprising considering the various causes for chronic pelvic pain. The recommendation to avoid the indiscriminate use of uterine suspension is supported by a recent consensus statement by an expert panel on chronic pelvic pain.¹ However, a review of the available literature does support the effectiveness of uterine suspension in a few situations. Thus, I want to focus on the clinical situations for which this technique will work, rather than on those that have been dispelled over time.

Historical perspective of uterine suspension

Since the first uterine suspension in 1882, many variations have been introduced, most of them involving shortening of the round ligaments and possibly attaching these ligaments to a stable structure such as the anterior rectus sheath.² Initially, the indications were broad enough to include dysmenorrhea, pelvic pain, infertility, backache, and cystic degeneration of the ovary. But keep in mind that this was during the late 19th century, when a retroverted uterus was considered pathologic, especially if it was nonmobile. Because one in five females was reported to have a retroverted uterus, physicians felt that something had to be done to anatomically correct the position of the uterus.³

Traditional surgical approach

All uterine suspensions during the late 1800s and early-mid 1900s were done through a Pfannenstiel or paramedial incision. Simple round ligament fixation was done by running an in-and-out suture along the length of the round ligaments and securing them to the uterine cornua or to the anterior rectus sheath. The Baldy-Webster technique brought the round ligaments through the posterior leaf of the broad ligaments and attached them to the back of the uterus. The Coffey suspension attached the round ligaments to the anterior uterus, which often frustrated obstetricians during a subsequent cesarean section. The Olshausen technique suspended the round ligaments through the peritoneum and rectus muscle to the anterior rectus sheath. Gilliam's procedure involved plicating the round ligaments, bringing them up through a small incision near the internal inguinal ring, beyond the lateral margin of the rectus muscle, and onto the anterior rectus sheath. (Several modifications to the Gilliam's procedure have been reported.) Finally, uterosacral plication either alone or in combination with one of the other procedures has been documented.^4,5

The goal of the uterine suspension is to elevate the uterus out of the cul-de-sac, ensure that the procedure will hold up to the stress of a pregnant uterus and not interfere with the delivery process, and avoid creating loops of tissue where bowel might become trapped and incarcerated. Unfortunately, many of the procedures did not fulfill these requirements.

Laparoscopic approach

Ever since the initial description of a technique for laparoscopic ventrosuspension in 1967, the ability to perform uterine suspension laparoscopically has rekindled interest in its use, especially among gynecologists who deal with pelvic pain.^6-8 Many of the laparoscopic approaches mimicked techniques previously done by laparotomy.^9-12 Others, such as the Falope ring technique, used technology taken from other laparoscopic procedures.¹³ Unfortunately, if the procedure relied on the fortitude of the round ligament alone, and no attempt was made to secure the ligament to the anterior rectus sheath, failure was imminent.

I have used two techniques that seem to provide adequate and prolonged ventrosuspension: the modified Olshausen procedure and a more recent innovation called the UPLIFT (uterine suspension positioning by ligament fixation and truncation) procedure (Metra PS kit, Inlet Medical, Inc., Eden Prairie, Minn.).^14,15 (See "The modified Olshausen and UPLIFT techniques".)

Surgical complications

Reported complications to uterine suspension include avulsion of the round ligament, intermittent urinary retention,¹⁶ pain at the site of attachment of the round ligament to the anterior rectus sheath,¹⁷ damage to the inferior epigastric artery or vein, intestinal obstruction through a loop of suture or tissue created by the suspension,¹⁸ damage to the fallopian tube, infection, excessive suspension of the uterus leading to chronic pelvic pain, the theoretical risk of increased enterocele formation, and difficulty performing hysteroscopic procedures, endometrial biopsies, or IUD insertions if the uterus is suspended too high (Personal experience).

Indications for uterine suspension

There are now only four indications for uterine suspension: collisional dyspareunia, prevention of pelvic adhesions and infertility in selected cases, dysmenorrhea, and uterine prolapse. More than 600 patients who have undergone this procedure have been evaluated in the literature. All except two have reported positive results.

Collisional dyspareunia

The primary indication for uterine suspension is collisional dyspareunia. This diagnosis requires taking a thorough history, and performing a physical exam and laparoscopy to eliminate any other source for a patient's pain. These women typically do not have chronic, indolent pain, nor do they have significant dysmenorrhea. Their one complaint is pain with deep penetration at intercourse. Certainly it's important to pay particular attention to the position of the uterus and signs of cul-de-sac pathology. But unfortunately, it's difficult to determine which is the source of their pain: the retroverted uterus or minimal endometriosis in the cul-de-sac.

On physical exam, these patients have a retroverted, retroflexed uterus and pain at the uterine-cervical junction or uterine fundus. While some clinicians recommend a trial of a pessary to confirm the diagnosis, others question its usefulness.^19,20 Typically, a Smith-Hodge pessary is used for 4 to 6 weeks. These women will notice a dramatic improvement in their pain; however, their male partner may experience discomfort during vaginal intercourse. Once the pessary is removed, their dyspareunia will resume.

The literature appears to support the benefit of uterine suspension for this indication. Unfortunately, the studies have failed to separate women who have only collisional dyspareunia from those with chronic pelvic pain, of which collisional dyspareunia was a component. What is clear is that despite this concern, these patients improved.

In a series of 75 women with a symptomatic retroverted uterus who underwent laparoscopic uterine suspension, Carter found that 84% (n=63) reported their dyspareunia resolved at up to 2 years follow-up.¹⁵ Every patient was evaluated by clinical exam and ultrasound as to the degree of uterine retroversion, as well as to eliminate any ovarian or uterine abnormalities. In addition, every case of collisional dyspareunia was confirmed by palpating the retroverted uterus. Of the remaining women, another 7% (n=5) reported mild pain and 4% (n=3) moderate pain. Remarkably, in all these women, dyspareunia declined from 8.1 to 1.5 on a 10-point scale (0 = no pain and 10 = the worst pain the patient had ever experienced).

In a prospective randomized trial at Howard University College of Medicine, Ostrzenski performed laparoscopic uterine suspension on 32 women with dyspareunia.²¹ Thirty-one women were in the control group (diagnostic laparoscopy). In the treatment group, 87.5% of the women reported complete resolution of their pain, even at 2-year follow-up, which differed significantly from results in the control group (P<0.0001).

In 2000, Batioglu reported on 30 women who underwent uterine suspension surgery for chronic pelvic pain or dyspareunia. No causes other than a retroverted uterus were identified for their pain.²² At 2 years, 19 of the 20 women who returned for follow-up had complete resolution of their dyspareunia. The one patient who continued to have dyspareunia was noted to have had a retroverted uterus. Gargiulo and colleagues showed the beneficial effects of laparoscopic uterine suspension in a prospective study of 50 women with dyspareunia due to uterine retroversion.¹⁷ At 1 year, 33 of the remaining 40 women had complete absence of dyspareunia.

Results of several other studies are similar, with up to 89% to 100% of women having complete or partial relief of dyspareunia at up to 40.5 months follow-up (Table 1).^23-25

TABLE 1
Laparoscopic uterine suspension—reported success rates

Prevention of pelvic adhesions

The second indication for uterine suspension surgery are selected cases of endometriosis or chronic pelvic inflammatory disease involving the cul-de-sac, where we are concerned about the reformation of adhesion. Clearly, prevention is of special concern for reproductive-aged women who want to conceive naturally or for women who may have pelvic pain because of adhesions. Many studies evaluating laparoscopic surgery for endometriosis find a high rate of adhesion recurrence (80% to 90%) and de novo adhesion formation in 0% to 21% of patients during second-look laparoscopy.^27-30

The theoretical benefits of elevating the uterus out of the cul-de-sac seem intriguing. It is clear that preventing surgically denuded areas from reapproximation will reduce formation or recurrence of adhesions. Since most adhesions form within days, even a temporary elevation should be beneficial. Researchers have not directly compared whether adhesion barriers are just as effective as uterine suspension over the long term. However, each technique has been studied separately.

A recent multicenter evaluation of a 0.5% ferric hyaluronate gel in women undergoing a laparotomy followed by a second-look laparoscopy suggests that it's about as effective in reducing adhesions as other adhesion barriers currently on the market.³¹ A literature review revealed no studies evaluating the recurrence of adhesions after a uterine suspension. However, Abuzeid and colleagues performed ovarian suspension in 20 infertile women who had stage 3 and 4 endometriosis.³² A retrospective evaluation revealed that 15 women failed to conceive, of whom five underwent a second-look laparoscopy. Four of these women had no adhesions and one had minimal adhesions. The limitations of this study are obvious, yet considering it is the only review looking at a suspension procedure for the prevention of adhesions, it is encouraging that some of these women had no recurrence of adhesive disease.

Ivey performed laparoscopic uterine suspension as an adjunct procedure to help reduce adhesion formation on 225 women with cul-de-sac or uterosacral ligament endometriosis.³³ Using a CO₂ laser to vaporize adhesions and endometriosis, pelvic pain declined in 94% of women. Life-table analysis revealed monthly fecundities of 15.58%, 6.29%, 17.86%, and 7.89% in patients with minimal, mild, moderate, and severe stages of endometriosis, respectively. These rates were higher than what had been published in the literature at that time, especially for minimal disease and suggested that adhesion reformation had been reduced or eliminated.

Dysmenorrhea

From a pathophysiologic standpoint, it's hard to understand how a retroverted uterus can cause dysmenorrhea. Perhaps an increased flexion at the cervical-uterine junction creates greater uterine pressure during menstrual flow; or perhaps uterine retroversion is a marker for adenomyosis. Nevertheless, 20% to 30% of women with a retroverted uterus experience pelvic pain, which usually includes dysmenorrhea.¹⁴ Some investigators have suggested empirically performing a uterine suspension if no other source for the dysmenorrhea or pelvic pain is found.

Carter reports that laparoscopic uterine suspension reduced dysmenorrhea in a series of 75 women.¹⁵ Pain with menses fell at 2-year follow-up from 8.4 to 1.7 on a 10-point scale, again with 10 being the worst pain. In Serour's study of 150 women with symptomatic uterine retroversion, 66 patients reported dysmenorrhea, of which 68% (n=45) had significant improvement at up to 30-month follow-up.²⁴ Patterson evaluated 100 women who underwent a laparoscopic uterine suspension, 16 of whom had dysmenorrhea as their primary indication for the surgery.²⁵ After an average of 40.5 months, 82% (n=14) reported complete or partial relief.

Uterine prolapse

A retroverted uterus is subject to prolapse, due to the alignment of the uterine corpus with the vaginal axis. Increasing abdominal pressure exerts an enormous force on the uterus, forcing it into the vagina, and ultimately weakening or tearing its support mechanisms. In most patients with uterine prolapse, vaginal hysterectomy and support of the vagina are performed. However, for young women who have not completed childbearing, or women who do not want a hysterectomy, a uterine suspension seems to be a viable option.

Few reports exist that evaluate the effectiveness of laparoscopic uterine suspension in women with uterovaginal prolapse. One study by Rimailho in 1993 revealed an 87% success rate in 92 women with uterine prolapse.³⁴ Mean follow-up was 5 years. The principle behind most surgical procedures, especially those in urogynecology, is to restore normal anatomy. Although it's beneficial to support the uterus with a suspension and further support the bottom of the uterus and top of the vagina with an uterosacral ligament plication, in many patients there's still the issue of lateral vaginal support. Many women with prolapse require support in this area for durability of the entire procedure.

Conclusions

Results of many prospective and observational studies confirm the benefits of uterine suspension, especially when there is a specific indication. These studies even suggest improvement in women with chronic pelvic pain, which is often multifactorial. However, I'm aware of only one randomized controlled trial that suggests the effectiveness of uterine suspension.²¹ Unfortunately, this is the case with many gynecologic procedures. Does this mean we should forgo the procedure until we get conclusive evidence from larger studies? No. What it does mean is that we should be prudent in selecting patients who will actually benefit from this procedure, acquiring the skills to perform the suspension laparoscopically, and tracking these patients to determine their long-term benefits. Ideally, further randomized control studies will help settle the debate.

REFERENCES

1. Gambone JC, Mittman BS, Munro MG, et al. Consensus statement for the management of chronic pelvic pain and endometriosis: proceedings of an expert-panel consensus process. Fertil Steril. 2002;78:961-972.

2. Fluhmann CF. The rise and fall of suspension operations for uterine retrodisplacement. Bull John Hopkins Hosp. 1955;96:59.

3. Kelly HA. History of retrodisplacement of the uterus. Surg Gynecol Obstet. 1915;20:598.

4. Donaldson JK, Sanderlin JH, Harrell WB. A method of suspending the uterus without open abdominal incision. Am J Surg. 1942;15:537.

5. Gleeson NC, Gaffney GM. Ventrosuspension—five years of practice at the Rotunda Hospital reviewed. J Obstet Gynecol. 1990;10:415.

6. Steptoe PC. Laparoscopy in Gynecology. Edinburgh: Livingston; 1967:78.

7. Howard FM. Laparoscopic evaluation and treatment of women with chronic pelvic pain. J Am Assoc Gynecol Laparosc. 1994;1:325-331.

8. Carter JE. Laparoscopic treatment of chronic pelvic pain in 100 adult women. J Am Assoc Gynecol Laparosc. 1995;2:255-262.

9. Servy EJ, Aksu MF, Tzingounis VA. Laparoscopic hysteropexy and the position of the fallopian tubes. In: Phillips JM, ed. Endoscopy in Gynecology: the proceedings of the third International Congress on Gynecologic Endoscopy in San Francisco, California. Downey, Calif: American Association of Gynecologic Laparoscopists, Department of Publications; 1978:87.

10. Yen CF, Wang CJ, Lin SL, et al. Combined laparoscopic uterosacral and round ligament procedures for treatment of symptomatic uterine retroversion and mild uterine decensus. J Am Assoc Gynecol Laparosc. 2002;9:359-366.

11. Ou CS, Liu YH, Joki JA, et al. Laparoscopic uterine suspension by round ligament plication. J Reprod Med. 2002:47:211-216.

12. Candy JW. Modified Gilliam uterine suspension using laparoscopic visualization. Obstet Gynecol. 1976; 47:242-243.

13. Massouda D, Ling FW, Muram D, et al. Laparoscopic uterine suspension with Falope rings. A report of three cases. J Reprod Med. 1987;32:859-861.

14. Olshausen R. Uber ventrale operation bei prolapsus und retroversio uteri. Zentralbl Gynakol. 1886;10:698.

15. Carter JE. Carter-Thomason uterine suspension and positioning by ligament investment, fixation and truncation. J Reprod Med. 1999;44:417-422.

16. Lose G, Lindholm P. Impaired voiding efficiency and urinary retention after laparoscopic ventrosuspension ad modum steptoe. Acta Obstet Gynecol Scand. 1984;63:371-372.

17. Gargiulo T, Leo L, Gomel V. Laparoscopic uterine suspension using three-stitch technique. J Am Assoc Gynecol Laparosc. 2000;7:233-236.

18. Mann WJ, Stenger VG. Uterine suspension through the laparoscope. Obstet Gynecol. 1978:51:563-566.

19. Smith DB, Kelsey JF, Sherman RL, et al. Laparoscopic uterine suspension. J Reprod Med. 1977;18:98-102.

20. Yoong AF. Laparoscopic ventrosuspensions. A review of 72 cases. Am J Obstet Gynecol. 1990;163:1151-1153.

21. Ostrzenski A. Laparoscopic retroperitoneal hysteropexy. A randomized trial. J Reprod Med. 1998;43:361-366.

22. Batioglu S, Zeyneloglu HB. Laparoscopic plication and suspension of the round ligament for chronic pelvic pain and dyspareunia. J Am Assoc Gynecol Laparosc. 2000;7:547-551.

23. Koh LW, Tang FC, Huang MH. Preliminary experience in pelviscopic uterine suspension using Webster-Baldy and Franke's method. Acta Obstet Gynecol Scand. 1996;75:575-578.

24. Serour GI, Hefnawi FI, Kandil O, et al. Laparoscopic ventrosuspension: a new technique. Int J Gynaecol Obstet. 1982;20:129-131.

25. Paterson ME, Jordon JA, Logan-Edwards R. A survey of 100 patients who had laparoscopic ventrosuspensions. Br J Obstet Gynaecol. 1978; 85:468-471.

26. Gordon SF. Laparoscopic uterine suspension. J Reprod Med. 1992;37:615-616.

27. Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Operative Laparoscopy Study Group. Fertil Steril. 1991;55:700-704.

28. Gurgan T, Urman B, Yarali H. Adhesion formation and reformation after laparoscopic removal of ovarian endometriomas. J Am Assoc Gynecol Laparosc. 1996;3:389-392.

29. Chapron C, Guibert J, Fauconnier A, et al. Adhesion formation after laparoscopic resection of uterosacral ligaments in women with endometriosis. J Am Assoc Gynecol Laparosc. 2001;8:368-373.

30. Canis M, Mage G, Wattiez A, et al. Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril. 1992;58:617-619.

31. Johns DB, Keyport GM, Hoehler F, et al. Reduction of postsurgical adhesions with Intergel adhesion prevention solution: a multicenter study of safety and efficacy after conservative gynecologic surgery. Fertil Steril. 2001;76:595-604.

32. Abuzeid MI, Ashraf M, Shamma FN. Temporary ovarian suspension at laparoscopy for prevention of adhesions. J Am Assoc Gynecol Laparosc. 2002;9:98-102.

33. Ivey JL. Laparoscopic uterine suspension as an adjunctive procedure at the time of laser laparoscopy for the treatment of endometriosis. J Reprod Med. 1992;37:759-765.

34. Rimailho J, Talbot C, Bernard JD, et al. [Anterolateral hysteropexy via abdominal approach. Results and indications. Apropos of a series of 92 patients.] [Article in French.] Ann Chir. 1993;47:244-249.

Dr. Petrozza is Chief, Vincent Reproductive Medicine and IVF Service, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.

Uterine suspension:
not supported by the evidence

By Barbara Levy, MD

Dysmenorrhea, dyspareunia, and pelvic pain are among the most common complaints women bring to us as gynecologists. As caring physicians who want to do everything possible to help alleviate patients' pain and suffering, we frequently explore and adopt techniques and procedures designed to correct anatomic abnormalities or "diseases" believed to contribute to their symptoms. It is imperative, however, that we recall our duty to "first do no harm." We must ask ourselves what the level of evidence is to support these procedures and what potential harm we may inflict upon our patients when recommending and performing them.

Let's explore uterine suspension from an evidence-based standpoint and see what science can tell us about the indications for this procedure. A normal anatomic variant, uterine retroversion has been implicated variously as a cause of primary infertility, dysmenorrhea, and dyspareunia.

Infertility

The myth that a retroverted uterus causes infertility by some unknown mechanism has been debunked. Pelvic adhesions that fix the uterus in a retroverted position may certainly contribute to primary tubal infertility. However, excluding adhesions or endometriosis, a retroflexed, retroverted uterus in and of itself is not in any way related to infertility. There is absolutely no evidence to support uterine suspension for the treatment of infertility.

Some pelvic surgeons do perform suspension subsequent to extensive resection of cul-de-sac endometriosis or adhesions in our belief that raising the uterus up and out of the cul-de-sac will prevent adhesions from reforming. But no evidence supports the effectiveness of this endeavor. Certainly primary uterine suspension without the additional procedures to excise endometriosis and lyse adhesions cannot be expected to improve pregnancy rates.

Pelvic pain and dysmenorrhea

Since diagnostic laparoscopy became popular for the evaluation of pelvic pain in the mid 1970s, gynecologists have struggled to find surgical solutions to this challenging problem. We must, however, examine the assumptions on which we base our interventions.

Adhesions, endometriosis, and pain. I find it both confusing and disturbing that some women with extensive pelvic adhesions havelittle or no discomfort, while others with minimal anatomic distortion suffer constantly. Similarly, many women with severe pelvic endometriosis are entirely asymptomatic while others with Stage 1 disease have excruciating pain and dysmenorrhea. How can a scientist make sense out of these discrepancies? If, indeed, adhesions cause pain, why don't all women with adhesions experience it? If endometriosis is a disease that causes severe and incapacitating dysmenorrhea, pelvic pain, and infertility, what is the mechanism? Most importantly for this article, if adhesions or endometriosis are associated with uterine retroversion,will creating an anteflexed position of the uterus improve patients' symptoms?

Dysmenorrhea: a physiologic condition. Uterine suspension has been combined with presacral neurectomy in the management of dysmenorrhea. We know that the innervation of the uterus is complex and anastomotic among multiple spinal segments, and reasonably strong evidence supports the contention that central pain will improve with disruption of thepresacral nerves. No evidence exists, however, that the addition of uterine suspension improves outcomes in patients with pelvic pain or dysmenorrhea.

Indeed, the mechanism of dysmenorrhea has come to light over the past several decades. What used to be considered a psychologic maladaptation to menarche and the advent of "womanhood" is now recognized as a physiologic condition related to excess prostaglandin production, smooth muscle contraction, tissue hypoxia, and the release of pain-generating substances within the tissue. Appropriate treatment of dysmenorrhea, therefore, is medical, not surgical. There is nothing about repositioning the uterus that would alter prostaglandin secretion within the endometrium; therefore, uterine suspension is unlikely to have any benefit whatsoever in treating dysmenorrhea.

Short-term relief for chronic pelvic pain. With respect to chronic pelvic pain, we must understand that any intervention is likely to create a transient effect. The placebo effect of surgical intervention is quite powerful. In addition, the depolarization of the nerve supply to the muscles and organs of the pelvis created during general anesthesia in and of it-self may contribute to temporary release of muscle spasm and improvement in pelvic floor tension myalgia.

Women who suffer from chronic pelvic pain are vulnerable. They are desperate for a "quick fix" to their problem and anxious to pursue any intervention promoted by Internet sites, support groups, or their physicians. It's our job to carefully analyze the data and offer surgical intervention only when the evidence supports a long-lasting improvement in symptoms. Any surgical intervention is likely to relieve symptoms only in the short-term, whether due to the effect of general anesthesia, time away from normal activities, washing out toxic substances from the peritoneal cavity, or a patient's strong belief in her surgeon and the procedure.

We mustn't give in to the temptation we all feel to do something. Patients frequently arrive in our offices ready for an operation. They'll tell us that they suffer from adhesions or endometriosis and that they had tremendous improvement after their first operation. Unfortunately, over time, the patients' symptoms return. Their interpretation of the pain—and ours as well—is that the "disease" has returned. Obviously the solution, then, is to operate again—or is it? How many operations should we perform? How many operations are enough?

Perhaps we need to rethink our strategy in approaching these patients. Often as surgeons, we think we may be able to offer the patient some additional procedure that will more permanently improve her symptoms. Uterine suspension is often undertaken in this context. We think to ourselves, "maybe if I reposition the uterus in an anterior position, I can reduce the risk of adhesion reformation." Unfortunately, many patients with recurring pelvic symptoms and chronic pelvic pain have a complicated biopsychosocial problem that is unlikely to respond to any one-dimensional intervention. Indeed, surgical interventions, which by their nature cause tissue injury, are more likely to cause harm than good in the long term. Each surgical incision has the potential to create abdominal wall nerve entrapment, and certainly tethering the uterus in an unnatural position—pulled forward by the round ligament—is not a solution to chronic pelvic pain.

"Bump" dyspareunia

Finally, let's address the most common indication for uterine suspension: "bump" dyspareunia. Most research into sexuality in women emphasizes sexual dysfunction rather than normal function. There is a mechanical view of female sexual function based on studies of male erectile dysfunction. In order to understand the foolishness of surgical intervention for most cases of sexual pain disorder in women, we must review the physiology of human female sexual response. The linear model of the human sexual response cycle may not be completely applicable to women, but for the purposes of describing the physiologic alterations that occur with sexual behavior, they will suffice. This model basically states that the phases are excitement, plateau, orgasm, and resolution. In response to a desire for physical closeness or intimacy, there are specific genital changes that occur with normal female sexual response:

EXCITEMENT PHASE–There is transudation across the vaginal epithelium, creating lubrication, vasocongestion, separation of the labia, lengthening of the vagina, and early uterine elevation.

PLATEAU PHASE–The upper one third of the vagina expands in diameter, the clitoris engorges and elevates, there is maximal vaginal transudation and lubrication, and the uterine fundus elevates completely up and away from the vaginal apex. The outer third of the vagina tenses.

ORGASM PHASE–uterine contractions, vaginal contractions with tenting of the vagina

RESOLUTION PHASE–all changes go in reverse.

It is clear then, based on scientific research performed in the 1960s by Masters and Johnson, that normal female sexual response generates a physiological uterine suspension. Vasocongestion of the vagina and uterus during sexual excitement causes an increase in vaginal length of approximately 30%. In addition, the cervix and uterus are lifted out of their usual orientation and into a high anteverted position. Even when the uterus is fixed posteriorly with dense pelvic adhesions or endometriosis, the increase in vaginal length and caliber will occur with normal physiological arousal. "Bump" dyspareunia therefore is a disorder of sexual arousal and not an anatomic abnormality requiring surgical correction!

As physicians and surgeons we are misinterpreting our patients' complaints. We're not trained as sexual therapists, and therefore most of us misconstrue this disorder of female sexual arousal as a sexual pain disorder. The medical approach to female sexual complaints has been historically based on a typically male-oriented analysis of anatomic function. Penetration and intercourse are not possible when there is a male arousal disorder. We call this erectile dysfunction, or ED, now extensively researched and popularized bythe pharmaceutical industry. Unfortunately, intercourse and penetration are possible despite a lack of female arousal. Although lubricants do facilitate penile penetration into an unaroused vagina, they do not correct the lack of vascular congestion. Without physiologic arousal, the vagina does not expand, and the uterus will notelevate.

Surgical intervention for "bump" dyspareunia will permit less painful penetration and sexual intercourse when the woman is unaroused. It is the anatomic correction of a physiological disorder. The analogy in male sexual dysfunction is the placement of a penile prosthesis for erectile dysfunction. While this may be required in some circumstances, it is—and should be—the option of last resort. Only when psychologic, pharmaceutical, and mechanical interventions fail should surgery for sexual dysfunction be considered.

Studies supporting uterine suspension in treating dyspareunia are relatively small, nonrandomized, noncontrolled series. While short-term improvements in dyspareunia are reported—and indeed are not surprising—as advocates for the women we treat, we must be circumspect in analyzing these results. Even though placement of a penile prosthesis will correct male erectile dysfunction and permit penetration, it is NOT the appropriate intervention for most men who suffer from psychologic, drug-induced, or early neurovascular abnormalities. We should be carefully evaluating our patients for the source of their arousal disorder, not subjecting them to surgery for the "quick fix." While tethering the uterus in an elevated location may appeal to both patients and surgeons in that it's rapid and doesn't require the time and energy necessary to elucidate and correct the source of arousal dysfunction, it is not the evidence-based appropriate intervention.

Gynecologic surgeons must learn to recognize, evaluate, and manage our patients' functional and physiologic disorders. Just as we do not overreact by treating migraine headaches with neurosurgery, we should not treat neurovascular and pain complaints in the pelvis with surgery. Just because we're able to identify structural variants, we mustn't assume that they're in any way related to our patients' complaints.

Conclusions

A careful search of the literature fails to provide any support for the use of uterine suspension in modern management of infertility or pelvic pain. (I'm reminded of a quotation from Mark Twain: "There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment of fact.")

While surgical anatomical reorientation of the uterus into the position normally created during sexual excitement and arousal may improve dyspareunia, it is not the root cause. The lack of vaginal engorgement, lubrication, and lengthening—and not the retroversion of the uterus—is responsible for these complaints. Good medical practice requires an attempt to recognize and treat the underlying physiologic problems. Surgery may be an option of last resort for those patients who do not respond to appropriate medical and psychologic interventions. However, there is no reliable, quality evidence-based science to support uterine suspension as an effective treatment for pain, infertility, or sexual dysfunction. If we remember to "first do no harm," we will not offer uterine suspension as a "quick fix" for our patients suffering from these unfortunate conditions.

SUGGESTED READING

Basson R, Berman J, Burnett A, et al. Report of the International Consensus Development Conference on Female Sexual Dysfunction: definitions and classification. J Urol. 2000;163:888-893.

Batioglu S, Zeyneloglu HB. Laparoscopic plication and suspension of the round ligament for chronic pelvic pain and dyspareunia. J Am Assoc Gynecol Laparosc. 2000;7:457-451.

Carter JE. Carter-Thomason uterine suspension and positioning by ligament investment, fixation and truncation. J Repro Med. 1999;44:417-422.

Fluhmann CF. The rise and fall pf suspension operations for uterine retrodisplacement. Bull John Hopkins Hosp. 1955;96:59.

Gleeson NC, Faffney GM. Ventrosuspension—five years of practice at the Rotunda Hospital reviewed. J Obstet Gynecol. 1990;10:415.

Howard FM. Pelvic Pain Diagnosis and Management. Philadelphia, Pa: Lippincott, Williams, and Wilkins; 2000.

Masters W, Johnson V. Human Sexual Response. Boston: Little Brown and Co; 1966.

Steege JF, Metzger DA, Levy BS. Chronic Pain: An Integrated Approach. Philadelphia, Pa: W.B. Saunders; 1998.

Issue Editor's note: As practicing gynecologists and surgeons, we are often faced with clinical decisions that require us to practice the "art of medicine" when there are little clinical data to support our therapies. We desperately want to do something that will improve our patients' quality of life and yet we must "first do no harm." Drs. Petrozza and Levy have provided valuable opinions and data that offer the qualified support for surgical therapy for Dr. Petrozza's patients and a lack of support for surgery for Dr. Levy's patients. In addition, Dr. Petrozza has described his laparoscopic technique for repositioning the uterus and the UPLIFT device.

As with all medical therapies, especially surgical ones, we must conclude that the benefits outweigh the risks before subjecting patients to therapy. I thank Dr. Petrozza and Dr. Levy for providing us with valuable information that will help each clinician make that difficult decision for women diagnosed with symptomatic uterine retrodisplacement.

—Keith Isaacson, MD

The modified Olshausen and UPLIFT techniques

Both of these procedures, in skilled hands, can be done in a very short time.

The modified Olshausen procedure. This technique involves placing a synthetic, permanent suture through a lower-quadrant 5-mm port. Next the needle driver is inserted through a contralateral 5-mm port and the round ligament is plicated starting laterally and ending about 0.5 cm from the uterus. You then reverse the suture in direction and bring out the free end of the suture through a small stab incision 0.5 to 1 cm above or below the 5-mm port. Next the port is removed, the skin and subcutaneous tissue between the port site and stab incision are connected with a scalpel, and the suture is tied down over the intervening bridge.

Remember to place both sutures and position the uterus before tying the sutures down. The goal is to make the uterus axial. Release your pneumoperitoneum slightly, since the expansion of the anterior abdominal wall may convince you to tighten your sutures too much, resulting in over-suspension of the uterus.

The UPLIFT technique. This newer approach uses a custom-designed disposable suture passer that is inserted next to the lateral 5-mm ports. The passer is guided through the internal inguinal ring into the round ligament. The suture traverses the length of the round ligament to about 0.5 cm from the uterus, where it exits. The suture passer is removed, reinserted, and once again directed through the round ligament, where it exits and grabs the suture, bringing it back through the round ligament and out through the anterior rectus sheath. The suture is then tied onto this fascial layer. Once again, both sides must be done and the uterus positioned prior to tying the sutures. A special device to close the fascia is included in the manufacturer's kit.

Dr. Levy is Clinical Assistant Professor of Obstetrics and Gynecology, University of Washington School of Medicine, Seattle, Wash.

 

John Petrozza. Symptomatic retrodisplaced uterus: better treated by surgery or psychology?. Contemporary Ob/Gyn 2003;48:32-48.