Genital prolapse causes and management

1. Definition of prolapse
Descent of one or more of vaginal segments
(ANT., POST., APEX)
ICS 2002
Leading edge of any vaginal segment
≥ -1cm above hymenal remnant
NIH 2001

2. Lifetime risk for surgery for prolapse /
urinary incontinence
11%
(ACOG 2007)
>30% require repeat surgery
(Progress 2007)

3. Possible risk factors
Genetic predisp.
Vaginal birth
Parity
Menopause
Advancing age
Prior pelvic surgery
Connective tissue dis.
↑ IA pressure
Obesity
Chronic constipation
↑ Straining
ACOG 2007

4. Established risk factors
Vaginal delivery (levator ms injury/
endopelv.fascia )
Advancing age
Obesity
Lancet 2007

5. Baden & Walker (1972)
Prolapse not due to stretching but rather
breaks in the fascia which could & should be
repaired individually.

6.  3
Delancey’s three levels of pelvic support.

7. The vagina can be divided into three levels.
Reprinted from DeLancey (1992, AJOG)
Ischial spine & sacrospinous
ligament
Levator ani
Pubocervical fascia
Rectovaginal fascia

8. Copyright ©2007 BMJ Publishing Group Ltd.
Doshani, A. et al. BMJ 2007;335:819-823
Delancey's three levels of pelvic support. Reprinted from Barber,8 with permission from
the Cleveland Clinic Foundation

9.  Level 1: The cardinal-uterosacral ligament complex
provides apical attachment of the uterus and vaginal
vault to the bony sacrum. Uterine prolapse occurs
when the cardinal-uterosacral ligament complex
breaks or is attenuated.
 Level 2: The arcus tendineous fascia pelvis and the
fascia overlying the levator ani muscles provide
support to the middle part of the vagina.
 Level 3: The urogenital diaphragm and the perineal
body provide support to the lower part of the vagina.

10.  LEVEL I SUPPORT
 This level consists of the cardinal and
uterosacral ligaments attachment to the
cervix and upper vagina

11. LEVEL II SUPPORT
 This support consists of the paravaginal
attachments that are contiguous with the
cardinal/uterosacral complex at the ischial spine.
 These are the connective tissue attachments of
the lateral vagina anteriorly to the arcus
tendineus fascia pelvis and posteriorly to the
arcus tendineus rectovaginalis.
 Detachment of this connective tissue from the
arcus tendineus fascia pelvis leads to lateral or
paravaginal anterior vaginal wall prolapse.

12. Level II
 POP at this level can be described as a central
hernia
 through the pubocervical fascia—i.e. a
cystocoele and/or an
 enterocoele or
 rectocoele—when herniation is occurring
through the rectovaginal fascia in the upper or
middle part

13. LEVEL III SUPPORT
 The perineal body, superficial and deep perineal
muscles, and fibromuscular connective tissue
comprise level III.
 Collectively, these support the distal one-third of
the vagina and introitus. The perineal body is
essential for distal vaginal support as well as
proper function of the anal canal.
 Damage to level III support contributes to
anterior and posterior vaginal wall prolapse,
gaping introitus, and perineal descent.

14. Weakening of / Dysfunction
↓
↓ ↓
Lev.ani Endopelvic fascia
Direct injury & its condensn.
Denervation Congenital
Age related
Child birth injury

15. Potential risk factors
(cont..)
Shape / orientation bony pelvis
Family H/O
Race / Ethnicity
Occup. Heavy weight lifting
Constipation
Connective tissue disorder
H/O hysterectomy (esp.for prolapse)
SERM
Lancet 2007

16. Potential risk factors
OBSTETRICS
Preg. irrespective of mode of delivery
Forceps
Young age at 1st delivery
Prolonged 2nd stage
Large baby
Lancet 2007

17. R. Shaw
S. Stanton
Ant. Vag. wall prolapse 51%
Post. Vag. wall prolapse 27%
Uterine / Vault prolapse 20%

18. Midline or distension cystocele. Note the
characteristic loss of vaginal wall rugae

19. a lateral cystocele, also termed paravaginal or
displacement cystocele. Rugae are present, which
indicates that loss of support is lateral rather than central

22. Subtotal hysterectomy not protective
Prophylactic culdoplasty protective

23. Demonstarting uterine descent
Single tooth valsellum to cervix
Gentle traction

24. SYMPTOMS
VAG. URINARY BOWEL SEXUAL
ACOG RECOMMENDATIONS (Level A):
The only symptom specific to prolapse is the awareness
of a vaginal bulge or protrusion. For all other pelvic
symptoms, resolution with prolapse treatment cannot be
assumed

25. VAGINAL SYMPTOMS
Bulge / Protrusion
Pressure
Heaviness
Discharge (if ulcer)

26. URINARY SYMPTOMS
Frequency
Urgency
Incontinence
Weak / Prolonged stream
Hesitancy
Manual reduction- void
Position change to start or complete voiding
Retention (rare)

27. Urinary Frequency
Most women void 8 times per day or less.
Without a history that reflects increased fluid
intake, increased voiding may indicate
 urge incontinence,
 urinary tract infection,
 calculi, or urethral pathology, and
 should prompt additional evaluation.
 In women with IC, the number of voids may
commonly exceed 20 per day.
Williams Gynecology

28. Urinary Retention
 It is important to determine if the patient
adequately empties her bladder. Often
incomplete emptying can result in
incontinence associated with either stress
or urgency.
 The term overflow incontinence is no
longer used.
Williams Gynecology

29. Williams Gynecology
The volume of urine lost with each episode
may also provide diagnostic clues.
 Large volumes are typically lost following the
spontaneous detrusor contractions associated
with urge urinary incontinence and may often
involve loss of the entire bladder volume.
 In contrast, women with SUI usually describe
smaller volumes lost.

30. Postvoid dribbling is classically
associated with urethral diverticulum,
which may often be mistaken for urinary
incontinence

31. BOWEL SYMPTOMS
Incontinence (because of common risk
factors)
Feeling of incomplete emptying
Straining during defecation
Urgency
Splinting / Digital pushing

32. OTHERS
? Back pain (Advanced prolapse- ↓ back
pain)
? Dysparenunia

33. Lancet 07
Although patients with pelvic organ
prolapse sometimes attribute back and
pelvic pain to their prolapse, very little
evidence is available to show that the
disorder causes pain. The complaint of
pain in a woman with prolapse should
prompt clinicians to search for other
sources of the pain before attributing it to
the disorder.

34. Examination
Resting Straining Retract post
wall to see
Dorsal / Squatting / Lt. lateral / ant wall
Lithotomy / standing prolapse &
Sims speculum vice versa.
Bivalve speculum
P/V P/R R/V

35.  The extent of prolapse of the anterior
vaginal wall can be assessed by placing a
Sim’s speculum in the vagina to retract the
posterior vaginal wall
 The blade is then placed to retract the
anterior vaginal wall and she strains again
to reveal any posterior prolapse.

36. Lancet -07
A bivalve speculum is inserted and the cervix or—in
women who have had a hysterectomy—vaginal cuff
is identified to assess apical vaginal support. While
the patient strains the speculum is slowly withdrawn
and the descent of the vaginal apex is noted
A rectovaginal examination can be useful to identify
presence of a rectocoele and establish the integrity of
the perineal body
A bimanual and rectal examination is undertaken to
rule out coexistent gynaecological or rectal
pathological fi ndings.

37. Bivalve speculum to assess apical vaginal
support (cervix / vaginal cuff)
Patient strains --speculum gradually
withdrawn

38.  The Marshall test, otherwise known as the Marshall-
Bonney test, is performed by placing an index finger and
the second finger on either side of the bladder neck.
With the bladder relatively full, the patient is instructed to
perform Valsalva or cough. The 2 fingers at the bladder
neck serve to support the proximal urethra during
Valsalva maneuver. The absence of leakage with
bladder neck elevation and the presence of leakage with
loss of bladder neck support confirms stress urinary
incontinence due to urethral hypermobility. However, the
Marshall test is neither sensitive nor specific enough to
diagnose stress urinary incontinence by today's
standards. Thus, the Marshall test is not widely practiced
today.

39. BJOG Bonney's test—fact or
fiction?
 Bonney test produced significant increases in
the urethral closure pressure and transmission
of impulse from the abdomen to the urethra
which indicated occlusion of the urethra rather
than elevation of the bladder neck. The Bonney
test does not differentiate between patients with
sphincter weakness and those with bladder
instability and therefore should be discarded.
 Received 5 December 1985, Accepted 10 May
1986

40. Q-tip test: This test is performed by inserting a
sterile lubricated cotton swab (Q-tip) into the
female urethra. The cotton swab is gently
passed into the bladder and then slowly pulled
back until the neck of the cotton swab is fit
snugly against the bladder neck. The patient
then is instructed to perform a Valsalva
maneuver or to contract the abdominal muscles.
Excessive motion of the urethra and bladder
neck (hypermobility) with straining is an
important finding for type II stress incontinence.
A Q-tip excursion angle greater than 35°
indicates urethral hypermobility

41. NICE UI
The Q-tip, Bonney, Marshall, and Fluid-Bridge
tests are not recommended in the assessment of
women with UI.
A urine dipstick test should be undertaken in all
women presenting with UI to detect the
presence of blood, glucose, protein, leucocytes
and nitrites in the urine.

42. R / V
Rectocoele / Enterocoele
Integrity of perineal body

43. Williams Gynecology
 Enterocele can only definitively be diagnosed by
observing small bowel peristalsis behind the vaginal wall
In general, bulges at the apical segment of the posterior
vaginal wall should implicate enteroceles, whereas
bulges in the distal posterior wall are presumed to be
rectoceles.
 Further distinction may be found during standing
rectovaginal examination. A clinician's index finger is
placed in the rectum and thumb on the posterior vaginal
wall. Small bowel may be palpated between the rectum
and vagina, confirming enterocele.

44. Danforth
 Detection of an enterocele is performed
best in the awake, straining patient by
noting a mass of small intestine between
the rectum and vagina; it may not be
suspected in a supine individual at rest.

45. Valsalva / Cough stress testing with full
bladder with reduced prolapse

46. Danforth
In instances in which the uterus is not
necessarily going to be removed, uterine
support should be tested before it is
assumed that the uterus is well supported.
This can be done by grasping the cervix
with a tenaculum or ring forceps and
applying traction until it stops descending.
Occult prolapse, in which the cervix comes
below the hymenal ring, can be detected
in this way

47. The five stages of prolapse
Stage 0: No prolapse
Stage I: The most distal portion of the prolapse is >1 cm
above the level of the hymen
Stage II: The most distal portion of the prolapse is ≤1cm
proximal or distal to the hymen
Stage III: The most distal portion of the prolapse is >1 cm
below the hymen but protrudes no further than 2 cm
less than the total length of the vagina
Stage IV: Complete eversion of the vagina

48. The staging system is not as sensitive as
the POPQ for description and follow-up of
individual patients.

49. Pelvic muscle function assessment
Palpate pelvic muscles a few cms. inside
hymen : 4 & 8 o’clock
Baseline tone / Increase with contraction

50. May identify women who benefit from pelvic
muscles exercise
Women taught

51.  For women with positive prolapse
reduction stress test results who are
planning vaginal prolapse repair, tension-
free vaginal tape (TVT) midurethral sling
(rather than suburethral fascial plication)
appears to offer better prevention from
postoperative stress incontinence

52. Need for ancillary testing beyond a
comprehensive history and physical examination
depends largely on the
 patient’s presenting symptoms. Most
women will need little additional testing.
 Those with pelvic organ prolapse who
complain of lower urinary-tract symptoms
should undergo urinalysis and post-void
residual volume testing with a urethral
catheter or bladder ultrasound.
Lancet 07

53. Lancet 07
Urodynamic assessment :
 with substantial urinary incontinence,
 irritative voiding symptoms, or
 voiding dysfunction.
Although urodynamics are currently being used
to predict postoperative urinary incontinence,
findings of a randomised trial have disputed the
usefulness of this test as a predictor of altering
surgical management

54. Prevention of VAULT PROLAPSE following
VAGINAL HYSTERECTOMY
McCALL culdoplasty
Approximating the uterosacral ligaments
using continuous sutures so as to
obliterate the peritoneum of posterior cul-
de-sac as high as possilble.
After midline approximation the uterosacrals
fixed to the vault.

55. A similar procedure described for abdominal
hysterectomy.
Uterosacrals identified prior to dividing them
from the uterus
(Progress 2007)

56. SACROSPINOUS FIXATION at the time of
vaginal hysterectomy is recommended for
MARKED UTEROVAGINAL PROLAPSE
WHEN the VAULT DESCENDS to
INTROITUS DURING CLOSURE
(at the end of ant. vag. wall closure)
(RCOG 2007 oct)

57. Incidence of vault prolapse after
hysterectomy
↓
↓ ↓
After vag. After abd.
(for prolapse) (non prolapse)
12% 2%
(J Reprod Med 1999)

58. Urodynamic studies
No urinary stmptoms – not justified
Do only if significant urinary symptoms

59. Urodynamic studies(cont..)
↓ ↓ ↓
Obstructed Atonic Overactive
voiding bladder ↓
↓ ↓ surgery will
good prog. less not improve
after cystocoele favourable symptoms
repair

60. R / V examination
Anterior displacement of rectal finger
towards vagina --- rectocoele
Pt. asked to strain
Non rugated vag. epithelium proximal to
examining finger --- enterocoele

61. McCall culdoplasty
Uterosacral ligament SUSPENSION for
VAGINAL APEX
Upto 3 sutures placed in each uterosacral
ligament & incorporated into the ant & post
vaginal
(fibromuscular layers + vag epith.)
Some surgeons approximate
The uterosacral lights in midline
Done if esp.redundant cul-de-sac

62. McCALL Culdoplasty (cont..)
↓ ↓
Excessive redundant Otherwise
cul-de-sac suspend the rt & lt
Approximate the 2 vag. apex to ipsilateral
uterosacrals in uterosacral ligament
midline
↓ Less post op bowel
vaginally done by dysfunction
McCALL

63. Post. Colporrhaphy
Midline plication of subepithelial vaginal
tissue
Traditionally MEDIAL PORTION of
LEVATOR ANI PLICATED
Largely abandoned because of dyspareunia
ACOG 2007

64. Reconstruction of perineal body
= Perineorrhaphy

65. Mesh use in ANT / POST
COLPORRHAPHY
 WHO (2005) Mesh transvaginally only in
TRIALS
 May have place in recurrent cases

66. Sacrohysteropexy
Junction of cervix &
uterus is attached by a
mesh,which is
peritonised,to the ant.
longitudnal ligament
over S1 or S2.

67. Pessaries
TRADITIONALLY
Pregnancy
Med contraindic. to surgery
Debilitated patients
CURRENTLY
Can be fitted in most women regardless of
prolapse stage or site of predominant
prolapse
ACOG 2007

68. Pessaries (cont..)
Clinicians should discuss option with ALL
WOMEN WHO have SYMPTOMATIC
PROLAPSE
Should be considered before surgery
ACOG 2007
Women who fail / decline pessary are
candidates for surgery
LANCET 2007

69. Surgery
compartment
Ant colporrhaphy Posterior
Site sp.repairs Uterine Vault colporraphy
VH+repair Sacrocolpopexy
Sacrohysteropexy Sacrospinous fixation
Sling Operations
ANT.
MIDDLE POST.

70. Cystourethrocoele with USI
↓
↓ ↓
Ant.colporrhaphy Burch
+ Colposuspension
TVT

71. STRESS INCONTINENCE
 Improves as prolapse extends beyond
hymen possibly from urethral obstruction
 Latent stress incontinence in
symptomatically continent – also called
OCCULT / MASKED

72. ACOG RECOMMENDATIONS
(Level A):
Stress-continent women with positive stress
test results (prolapse reduced) are at higher
risk for developing postoperative stress
incontinence after prolapse repair alone
compared with women with negative stress
test results (prolapse reduced)

73. ACOG RECOMMENDATIONS
(Level A):
For stress-continent women planning
abdominal sacral colpopexy, regardless of
the results of preoperative stress testing,
the addition of the Burch procedure
substantially reduces the likelihood of
postoperative stress incontinence without
increasing urgency symptoms or
obstructed voiding.

74. Uterine descent +
Uterine preservation
 Manchester operation
 Shirodkar operation
 Purandare’s operation
 Sacrohysteropexy
 Sacrospinous fixation

75. The following recommendations and conclusions
are based on limited or inconsistent scientific
evidence (Level B): ACOG 2007
Compared with vaginal sacrospinous
ligament fixation, abdominal sacral
colpopexy has less apical failure and less
postoperative dyspareunia and stress
incontinence, but is also associated with
more complications.

76. Women Considering Pregnancy
Ideally, childbearing should be complete
before considering surgery for prolapse to
avoid the theoretical but plausible risk of
recurrent prolapse after subsequent
pregnancy and delivery. For women who
become pregnant after prolapse repair,
decisions regarding mode of delivery
should be made on a case-by-case basis;
evidence to guide such decisions is
lacking.

77. Complications were more frequent in
women aged 80 years and older and in
women who had reconstructive rather than
obliterative surgery.

78. Stress urinary incontinence Green 04
complaint of involuntary leakage during effort or exertion, occurs
at least weekly in one third of adult women.
basic evaluation of women with stress urinary incontinence
includes a history, physical examination, cough stress test,
voiding diary, postvoid residual urine volume, and urinalysis.
Formal urodynamics testing may help guide clinical care, but
whether urodynamics improves or predicts the outcome of
incontinence treatment is not yet clear.
The distinction between urodynamic stress incontinence
associated with hypermobility and urodynamic stress
incontinence associated with intrinsic sphincter deficiency
should be viewed as a continuum, rather than a dichotomy, of
urethral function.

79. Q-Tip Test
 If urethra is poorly supported, it may display hypermobility
during increases in intra-abdominal pressures.
 To assess mobility, a clinician places the soft end of a cotton
swab into the urethra to the urethrovesical junction. Failure to
insert the swab to this depth typically leads to errors in
assessment of urethrovesical junction support. Termed the Q-
tip test, this evaluation may be uncomfortable and application
of intraurethral analgesia may prove helpful. Commonly, 1
percent lidocaine jelly is placed on the cotton swab prior to
insertion. Following placement, Valsalva maneuver is
prompted, and the swab angle excursion at rest and with
Valsalva maneuver is measured with a goniometer or
standard protractor (Fig. 23-8).
 An angle excursion at rest or with Valsalva maneuver greater
than 30 degrees above the horizontal indicates urethral
hypermobility, and may help direct planning of surgical
treatment for stress incontinence

80. post void residual volume
 of less than 50 mL is regarded as normal
 greater than 150–200 mL are regarded as
abnormal.
 In older women, up to 100 mL may be regarded
as normal, depending on the circumstances
 NOVAK:provided the patient has voided 150 mL
or more, a PVR less than or equal to 100 mL is
acceptable

81. Overactive bladder syndrome
(OAB)
Urgency that occurs with or without urge UI and
usually with frequency and nocturia.
OAB that occurs with urge UI is known as ‘OAB wet’.
OAB that occurs without urge UI is known as ‘OAB
dry’.
These combinations of symptoms are suggestive of
the urodynamic finding of detrusor overactivity, but
can be the result of other forms of urethrovesical
dysfunction.

82.  Expert opinion concludes that
symptomatic categorisation of UI based on
reports from the woman and history taking
is sufficiently reliable to inform initial, non-
invasive treatment decisions.