2. Definition
• Slipping or downward falling of the uterus and its’ dependent walls and/or
along with other adjacent organs, i.e. the bladder, rectum and bowel with
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3. Epidimiology of POP
Incidence
• 9 to 11% of women present with symptoms of the POP
• Lifetime risk of POP surgery 11% to 19%
• Age: doubling in the risk after each decade of life
• Pregnancy: 50% in parous and 2% in nulliparous
• Ethnicity: highest in Hispanic American and lowest amongst African American
• Obesity and Certain occupations i.e. manual and house work, shown to have
significantly increased risk for POP.
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4. Cont.Epid.
• Other risk factors includes, COPD, Chronic Constipation, Estrogen deficiency,
family history and genetic risk, and connective tissue disease
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5. Anatomy
Levels of support
• There are diverse structures that take part in supporting the female genital
tract and preventing pelvic organ prolapse were captured by (1992), who
described three levels of support:
• Level I (suspension) – cardinal and uterosacral ligaments.
• Level II (attachment) – arcus tendinous fascia and fascia over the
pubococcygeus and iliococcygeus muscles.
• Level III (fusion) – urogenital diaphragm and perineal body.
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6. Anatomy
Pelvic Floor musculature
• The pelvic floor is predominantly made of Pelvic floor muscle and fascia
• the The levator ani muscles are broad U shaped sheet of muscles that stretch backwards and
inwards from either side of the pelvis to meet in the middle line, encircling the urethra, vagina
and the rectum and reaching the coccyx.
• The urethra and the vagina traverse the U shaped gap in the anterior part of the pelvic floor.
• The levator ani orginate from the back of the body of the pubic bone, the white line over the
obturator interus muscle and the medial aspect of the ischeal spines.
• The levator ani muscles can be described in three parts; puboccocygeus, iliococcygeus and
ischeococcygeus. The puboccocygeus can be described in two parts, pubovaginalis and
puborectalis.
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8. Anatomy
Urogenital Diaphragm
• The urgental diaphragm (perineal membrane) is a triangular sheet of dense fibrous tissue spanning the anterior half of the pelvic outlet, and is pierced by the vagina and urethra
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9. Anatomy
the perineal membrane and Vaginal support
The perineal body lies between the vagina and the rectum and provides a point
of insertion for the levator ani muscles. It has a central position in the pelvic
floor.
The vagina is composed of epithelium, smooth muscle muscularis and adventia
and is supported by its attachment to endopelvic fascia, perineal body, levator
ani muscles as well as perineal muscles.
Tears developing in the endopelvic fascia as a result of vaginal delivery, leading
to central defect, which manifests as central prolapse.
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10. Classification
Anterior, Apical and Post. compartment
• This is commonly described as a cystocele, urethrocele or cystourethrocele,
depending on the underlying structure.
• The apical compartment or vaginal apex, the uterus may prolapse (called
uterine or occasionally utero-vaginal prolapse). The apex may prolapse in
women who have had a hysterectomy, producing post-hysterectomy vaginal
vault prolapse, or prolapse of the vaginal cuff.
• The rectum may prolapse into the posterior part of the vagina to produce a
rectocele. A per rectal examination may differentiate a rectocele from an
enterocele.
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11. Grading
• There are a number of systems used to describe the severity of vaginal prolapse.
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12. Grading
Baden-walker halfway
• Grade 1 prolapse extends halfway down the vagina
• Grade 2 prolapse to the hymenal ring
• Grade 3 prolapse beyond the hymenal ring but not maximal descent
• Grade 4 prolapse equates to maximal descent.
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14. Grading
PoP quant. System (POP-Q)
• theThese points, alongside the distances, are then scored over a three-by-
three grid, as shown below.The Pelvic Organ Prolapse Quantification System:
Anterior wall – Aa Anterior wall – Ba Cervic or Cuff – C
Genital hiatus – GH Perineal body – PB Total vaginal length – TVL
Posterior wall – Ap Posterior wall – Bp Posterior fornix – D
The prolapse is then staged into:
• Stage 0 – No prolapse, points Aa, Ap, Ba and Bp are –3 and point C is between –TVL and –TVL–2
• Stage 1 – Most distal point <-1 (more than 1 cm above the hymen)
• Stage 2 – Most distal point ≥ –1 and ≤1 (between 1 cm above and 1 cm below the hymen)
• Stage 3 – Most distal point > 1 but < TVL-2 (more than 1 cm below the hymen, but at least 2 cm less than the total vaginal
length)
• Stage 4 – Most distal point > TVL –2 (complete vaginal eversion, with <2 cm of the vaginal wall still above the hymen)
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15. POP-Q
KEYS
• The pelvic organ prolapse quantification (POP-Q) exam is used to quantify,
describe and stage pelvic support.
• There are 6 points measured at the vagina with respect to the hymen.
• Points above the hymen are negative numbers; points below the hymen are
positive numbers.
• All measurements except tvl are measured at maximum valsalva
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18. CLINICAL ASSESSMENT
Aims
• The aims of patient assessment are:
• Establish the patient problem(s) and the link between these problems and clinical findings
• Identify the etiological factor(s), which may affect management line(s)
• Assess the risk for alternative management options, including anaesthetic risk as well as risk of
subsequent failure and/or recurrence
• Recognise patient features that may influce the choice of management, such as future fertility
plans
• Request investigations as appropriate to establish clinical findings and/or assess risk of
surgery.
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19. HISTORY
PERSONAL
• AGE,
• COMPLAINT AND DURATIONS: ranges from asymptomatic to disturbing
once, including urinary, bowel, and local symptoms.
• It is vital in history taking to define not only the problems associated with the
anatomical defect but to also elicit all functional problems including urinary,
bowel and sexual function.
• Some of these symptoms are embarrassing and patients may not volunteer
them, hence the need for sensitivity, empathy, privacy and tactful direct
questioning.
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20. HX CONT.
PROL. SYMPTOMS
• Bulge, something coming out from below, something falling down from pelvis, Ulcerations,
problems with urination and defecation.
• Vaginal bulge, or lump down below, is the commonest symptom. This tends to increase with
straining, long standing and towards the end of the day and get better by lying down.
• Advanced degrees of pelvic organ prolapse may remain outside the vulva even at rest.
• Bearing down sensation: this can be caused by distension of the upper vagina as well as pelvic
congestion.
• Backache may be encountered as a result of traction on the uterosacral ligaments, though it can
also be experienced by overweight patients.
• Bleeding may results from ulceration after a long standing prolapse
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21. History
urinary/bowel symptoms
• Urinary: Stress incontinence, Voiding dysfunction, Overflow incontinence,
recurrent urinary tract infections, overactive bladder symptoms
• Bowel: Anal incontinence, Obstructed defecation, rectal frequency and
urgency
• Sexual dysfunction: dyspareunia and impairment in the quality of life
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22. Hx
past hx/previous meds/obsgyne/social
• Past history of procedures affect the outcome including previous pelvis
surgeries like colposuspension, Tension free type, previous hysterectomy
• past and current medical problems should alert the anesthetic and team about
any further care.
• Number, mode of delivery, trauma associated with it, time interval since last
delivery, size of babies, any problems with babies from birth trauma,
• family hx of POP, smoking and chronic cough like COPD
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23. Physical exam
General
• General health – surgical approaches, and complex abdominal and/or
laparoscopic procedures, may not be appropriate for elderly or frail patients
• Body mass index – obesity predisposes to pelvic organ prolapse and may
increase surgical risk, eg. deep vein thrombosis
• Joint hypermobility/varicose veins – may signify weak connective tissue, which
predispose to the pelvic organ prolapse and possible recurrence after surgery.
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24. Phys. exam.
Abdominal
• Scar(s) of previous abdominal surgery: adhesions may need to be dealt with during
abdominal or laparoscopic approach to post-hysterectomy vaginal vault prolapse, or
uterine prolapse in patients who are yet to complete their families.
• Abdominal masses/ascites: may have caused pelvic organ prolapse and may require
investigation and/or treatment prior to or at the same time as managing pelvic organ
prolapse, and may even take more priority (for example, in case of suspected ovarian
malignancy) or affect the management of pelvic organ prolapse, as in cases of ascites
due to medical disorder.
• Hernia in the umbilicus, scar area or in the groin can mark underlying connective tissue
weakness that may predispose to pelvic organ prolapse and its possible recurrence after
surgery, and may also require management at the same time.
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25. Phys. Exam
Local
• Inspect for ulcerations, atrophy and leakage of urine
• Exam with speculum, Cusco and Sim’s under valsalva’s maneuver
• Bimanual examination to asses for the size, mobility and position of the
uterus.
• Rectal examination: tone and posterior wall defects
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26. Invx
special
• Although the diagnosis of PoP is mainly clinical, these specific investigations
can be applies to delineate further about defects associated with it and similar
pathologies resulting in swelling at vulva gardners cyst, barhtolon’s gland cyst.
• Special ins include: 3/4D ultrasound either transvaginal/transperineal, MRI,
Defecography, urodynamics, and urine culture and sensitivity
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27. Management
Factors to be considered
A number of factors need to be considered when deciding on a management plan for a woman with pelvic organ prolapse. These include:
• nature of symptoms and degree of bother
• nature and extent of prolapse
• Completion of family and future pregnancy plans
• sexual activity
• age
• fitness for surgery and anaesthesia
• associated incontinence symptoms
• woman's goals
• work, physical activity and domestic circumstances
• previous management and outcome
• surgical experience and familiarity with different surgical procedures
• having realistic expectations about outcomes, in the light of history and examination.
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28. Mngt options
Discuss management options with women who have pelvic organ prolapse, including no treatment,
non-surgical treatment and surgical options, taking into account:
• the woman's preferences
• site of prolapse
• lifestyle factors
• comorbidities, including cognitive or physical impairments
• age
• desire for childbearing
• previous abdominal or pelvic floor surgery
• benefits and risks of individual procedures.
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29. Management
Non-surgical
• Lifestyle modification:losing weight, if the woman has a BMI greater than 30
kg/m2, minimising heavy lifting, preventing or treating constipation, and any
medical problems resulting in increased intra-abdominal pressure.
• Topical oestrogen: vaginal oestrogen for women with pelvic organ prolapse
and signs of vaginal atrophy; oestrogen-releasing ring for women with pelvic
organ prolapse and signs of vaginal atrophy, who have cognitive or physical
impairments that might make vaginal oestrogen pessaries or creams difficult
to use.
• Physiotherapy
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30. MDT and surgical treatments
General rules
• MDT meeting should be held before each surgical procedure for any urogyne
problem.
• Surgical options will depend on the factors mentioned previously, and will
mainly focus on area of defect, namely Anterior, posterior, apical, post-
hysterectomy vault prolapse, uterine preservation techniques, recurent
prolapse
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31. references
Basu M, Duckett J. Barriers to seeking treatment for women with persistent or recurrent symptoms in urogynaecology. BJOG 2009;116:726–
30.
Jeffery S, Fynes M, Lee F, Wang K, Williams L, Morley R. Efficacy and complications of intradetrusor injection with botulinum toxin A in patients
with refractory idiopathic detrusor overactivity. BJU Int 2007;100:1302–6.
(link is external)
Edmonds K, editor. Dewhurst's Textbook of Obstetrics and Gynaecology. 8th ed. Oxford: Wiley-Blackwell; 2012.
Royal College of Obstetricians and Gynaecologists; British Society of Urogynaecology. Post-Hysterectomy Vaginal Vault Prolapse. Green-top
Guideline 46. London: RCOG Press; 2015.
(link is external)
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