COMPARISON OF POST TOTAL VAGINAL HYSTERECTOMY

OUTCOME WITH OR WITHOUT FIXATION OF SACROSPINOUS

LIGAMENT IN PALEMBANG-INDONESIA IN 2016

By
AMIR FAUZI

THESIS

Submitted to the School of Graduate Studies in Fulfillment of the

Requirements for the Award of the Degree of Doctor of Philosophy
in Management/Business

MANAGEMENT AND SCIENCE UNIVERSITY

SHAH ALAM, MALAYSIA

2016
 ABSTRACT

There are many factors correlated with Pelvic Organ Prolapse (POP),
such as age, BMI, birth weight, number of pregnancies, history of pelvic
surgery, delivery procedure, and family history of POP. Surgical management
of POP can be performed with or without sacrospinous ligament fixation .
There are many surgical outcomes with this treatment, including vaginal
stump prolapse, rectocele, cystocele, complication of urinary symptoms and
defecation, buttock pain & reduction in the quality of life. This study aims to
compare urinary symptoms, defecation symptoms, buttock pain & quality of
life of between POP patients who underwent sacrospinous ligament fixation
and POP patients who did not undergo fixation post total vaginal
hysterectomy (TVH). The methodology of this study was a single blind
randomized clinical trial. To fulfill the design requirement, this research used
an observation and survey methodology. The sample size was 32 with 16
control and 16 for treatment. This study was conducted from January to
December 2016 at the Dr. Mohamed Hoesin Hospital Palembang. The results
of this study are expected to have practical and theoretical importance, as
described elsewhere here in. The limitations of research are in terms of cost,
time, knowledge and labor. This study was limited on the effort to reveal the
results of a comparison of urinary and defecation symptoms, buttock pain and
quality of life of POP patients post-TVH who underwent fixation and patients
who did not undergo fixation of the sacrospinous ligament at the M.Hoe sin
Hospital Palembang. In conclusion, there were no significant differences in
urinary symptoms, symptoms of defecation, and patients’ perception of
quality of life between patients who underwent sacrospinous ligament fixation
and patients who did not experience sacrospinous ligament fixation. There
were significant differences in buttock pain between patients who underwent
sacrospinous ligament fixation and patients who did not experience
sacrospinous ligament fixation.

Keywords: sacrospinous ligament fixation, pelvic organ prolapse, total

vaginal hysterectomy

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 MANAGEMENT & SCIENCE UNIVERSITY

___________________

SCHOOL OF GRADUATES STUDIES

2017

WE HEREBY RECOMMEND THAT THE THESIS

BY
AMIR FAUZI

ENTITLED: COMPARISON OF POST TOTAL VAGINAL

HYSTERECTOMY OUTCOME WITH OR WITHOUT FIXATION OF
SACROSPINOUS LIGAMENT IN PALEMBANG-INDONESIA IN 2016 BE
ACCEPTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE
OF DOCOTR OF PHILOSOPHY IN MANAGEMENT

Dr. Zulhabri
Supervisor

Prof. Dr. Ali Khatibi

Co- Supervisor

Prof. Dr. Ali Khatibi

Dean,
School of Graduate Studies (SGS)

The Internal and External Examiners are as follows:

Internal Examiner External Examiner External

Examiner

iii
 STATEMENT OF THE ORIGINAL AUTHORSHIP

_____________________

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any higher education institution. To the

best of my knowledge and belief, the thesis contains no material previously or

written by other person except where due reference is made.

SEPTEMBER 2017

AMIR FAUZI

012014111682

iv
 ACKNOWLEDGEMENT

This thesis becomes a reality with the kind support and help of many
individuals. I would like to extend my sincere thanks to all of them.

Foremost, I want to offer this endeavor to Allah SWT for the wisdom he
bestowed upon me, the strength, peace of my mind and good health in order
to finish this research.

I would like to express my gratitude toward my family for the encouragement

which helped me in completion of this thesis. My beloved and supportive
wife, Dr. Hj. Devi Azri Wahyuni, SpM who is always by my side when times
I needed her most and helped me a lot in making this study, and my lovable
children, Sonia Prima Arisa Putri, Utari Mudhia Arisa Putri, Muthia Azzahrah
Arisa Putri, Amira Azra Arisa Putri who served as my inspiration to pursue
this undertaking.

I am highly indebted to School of Graduate Studies (SGS) for their guidance

and constant supervision as well as for providing necessary information
regarding this research and also for their support in completing this thesis.

I would like to express my special gratitude and thanks to Dean of SGS and
my supervisor for imparting their knowledge and expertise this study.

My thanks and appreciation also go to my colleague and people who have

willingly helped me out with their abilities in completing this thesis

Alhamdulillah.

AMIR FAUZI
SEPTEMBER 2017

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 TABLE OF CONTENT

PREFACE

PAGE

TITLE PAGE ................................................................................... i

ABSTRACT ..................................................................................... ii

RECOMMENDATION .................................................................... iii

STATEMENT OF THE ORIGINAL AUTHORSHIP ...................... iv

ACKNOWLEDGEMENT ................................................................ v

TABLE OF CONTENT .................................................................... vi

CHAPTER I INTRODUCTION

1.1 Background ............................................................................... 1

1.2 Problem Identification ............................................................... 5

1.3 Research Objectives ................................................................ 5

1.3.1 General Objectives ........................................................ 5

1.3.2 Specific Objectives ....................................................... 5

1.4 Research Question ..................................................................... 6

1.5 Significance of the Study .......................................................... 7

1.6 Problem Limitation .................................................................. 7

1.7 Hypothesis ............................................................................... 8

1.8 Research Benefit ....................................................................... 8

1.8.1 Academic Benefit ............................................................. 8

1.8.2 Clinical Benefit ................................................................ 9

1.8.3 Benefit for the Society ..................................................... 9

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CHAPTER II LITERATURE REVIEW

2.1 Pelvic Anatomy and Basic Function .............................................. 10

2.1.1 Pelvic .......................................................................... 10

2.1.2 The Pelvic Floor Muscles ...................................................... 13

2.1.3 Supportive connective tissues................................................ 15

2.1.4 Perineal membrane (Urogenital Diaphgram) ......................... 16

2.1.5 Perineal Body .................................................................. 16

2.1.6 Nerves .................................................................. 16

2.2 Obstetric Factors That Cause Pelvic Base Muscles Weakness

And Damage .................................................................. 17

2.2.1 Pathophysiology of Pelvic Base Muscles Weakness and

Damage .................................................................. 17

2.2.2 Obstetric Factors That Are Risk Factors For Pelvic Floor

Dysfunction ............................................................ 21

2.3 Pelvic Organ Prolapse .............................................................. 23

2.3.1 Definition .............................................................. 25

2.3.2 Prevalence of Pelvic organ prolapse ...................................... 25

2.3.3 Symptoms and signs ............................................................. 26

2.3.4 Physical examination of pelvic organ prolapsed ..................... 27

2.3.5 Staging of prolapse .............................................................. 30

2.3.6 Imaging .............................................................. 31

2.3.7 Differential Diagnosis ........................................................... 31

2.3.8 Management .............................................................. 31

2.3.9 Recurrence of Pelvic Organ Prolapse ..................................... 34

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2.4 Fixation Of Sacrospinous Ligament .......................................................... 35

2.4.1 Definition ........................................................................................ 35

2.4.2 Objectives ........................................................................................ 36

2.4.3 Indication .......................................................................................... 36

2.4.4 Contraindications ............................................................................ 37

2.4.5 Procedure .......................................................................................... 38

2.4.6 Monitoring and follow up ............................................................... 43

2.4.7 Complications................................................................................... 43

2.4.8 Recovery........................................................................................... 46

2.5 Theoritical Framework .............................................................................. 48

CHAPTER III RESEARCH METHODOLOGY

3.1 Design and method ................................................................................... 49

3.2 Time and Place .......................................................................................... 49

3.3 Operational Definition .............................................................................. 50

3.4 Population and Sample ............................................................................. 51

3.5 Sample Selection Criteria .......................................................................... 52

3.5.1 Inclusion Criteria .............................................................................. 52

3.5.2 Exclusion Criteria ............................................................................. 52

3.6 Sample Size ............................................................................................... 52

3.7 Data Collection Techniques ...................................................................... 53

3.8 Data analysis Method ............................................................................... 58

3.9 Principle of Ethics .................................................................................... 58

3.10 Conceptual Framewordk ........................................................................... 61

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CHAPTER IV RESULTS AND DISCUSSION

4.1 Respondents Characteristic ..................................................................... 62

4.1.1 Age................................................................................................. 62

4.1.2 Occupation ..................................................................................... 65

4.1.3 Number of Children ...................................................................... 65

4.1.4 Body Weight and Body Height...................................................... 66

4.1.5 Length of Surgery ......................................................................... 66

4.2 Output Characteristic .............................................................................. 67

4.2.1 Urinary Symptoms ........................................................................ 67

4.2.2 Defecation Symptoms .................................................................... 69

4.2.3 Buttock Pain................................................................................... 70

4.2.4 Quality of life ................................................................................. 72

4.3 Comparison of Vaginal Result between Fixation and non-Fixation of

Sacrospinous. ....................................................................................... 75

4.4 Comparison of Bleeding Complications between Sacrospinosus

Fixation and Non Fixation Sacrospinosus. ............................... 77

CHAPTER V CONCLUSION AND SUGGESTIONS

5.1 Conclusion ............................................................................................. 79

5.2 Suggestion .............................................................................................. 80

REFERENCE ................................................................................................. 81

APPENDIX ..................................................................................................... 92

LIST OF TABLE ........................................................................................... xii

LIST OF FIGURES ....................................................................................... xiii

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 LIST OF TABLE

NO TITLE PAGE

Table 2.1 3x3 table for Recording Measurement Result of POP-Q ............. 30

Table 3.1 Operational Definition ................................................... 50

Table 3.2 Validity and Reliability Test Result of Variable Urinary

Disorders ............................................................................. 54

Table 3.3 Validity and Reliability Test Result of Variable Defecation

Disorders ............................................................................. 55

Table 3.4 Test Result Validity and Reliability of Variable Buttock Pain 56

Table 3.5 Test Results Validity and Reliability of Variable Quality of Life 57

Table 3.6 Bivariate Analysis of Characteristics of Respondents Variable . 59

Table 4.1 Respondents Characteristic ............................................. 63

Table 4.2 Urinary Symptom Characteristic ..................................... 68

Table 4.3 Defecation Symptoms Characteristic ............................... 70

Table 4.4 Buttock Pain Characteristic ............................................ 71

Table 4.5 Quality of Life Characteristics ........................................ 73

Table 4.6 Comparison of Vaginal Results between Fixation and non

Fixation of Sacrospinous ............................................... 74

Table 4.7 Comparison of Bleeding Complications .......................... 77

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 LIST OF FIGURE

NO TITLE PAGE

Figure 1 Pelvic Bone And Ligament On The Sagittal Pieces (Netter, 2014) .... 12

Figure 2 Pelvic floor (Corton, 2009) .................................................................. 13

Figure 3 Levator ani muscle (Anderson, 2007) ................................................. 14

Figure 4 Pelvic floor (Corton, 2009) .................................................................. 16

Figure 5 Reference Point that is used in POP-Q Measurements

(Bump, 1996) ....................................................................................... 31

Figure 6 Sacrospinosus Fixation Technique (quoted from Vasavada

et al, 2005) .......................................................................................... 44

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