2. Definition
• Pelvic organ prolapse is a buldge of pelvic organs and their associated
vaginal segment into or through the vagina.
• Normally, external OS lies at the level of ischial spine & internal os at the
upper border of pubic symphysis. So any descent of uterus from these
levels is a case of prolapse.
3. Support of uterus
• Primary supports:
• Muscular/Active support:
1. Pelvic diaphragm- Levator ani(Pubococcygeus, Iliococcygeus, Puborectalis) &
Ischiococcygeus
2. Urogenital diaphragm- Superior & Inferior fascia of Urogenital diaphragm, Deep
transverse perinei muscle & sphincter urethrae muscle.
3. Perineal body:
4 sets of paired muscles 2 unpaired muscles
Superficial transverse perinei. External anal sphincter
Deep transverse perinei Longitudinal muscle fold of rectum & anal canal.
Bulbocavernosus.
Fibre of Pubococcygeus.
5. Levels of vaginal support
Level I: Cardinal &
Uterosacral ligament
attachment to the
cervix & upper vagina
1
Level II: Paravaginal
attachment of lateral
vagina & endopelvic
fascia to the Arcus
tendinous.
2
Level III: Perineal body
, Superficial & Deep
perineal muscles &
fibromuscular
connective tissue.
3
6. Risk factors
associated with
Pelvic Organ
Prolapse(POP)
Vaginal birth:
• Risk of POP is increased 1-2 times
with each vaginal delivery.
Pregnancy:
• High progesterone level causing
laxity of pelvic tissue.
Age:
• In women aged 20—59 years , the
incidence of POP roughly doubled
with each decade.
Menopause:
• Hyperestrogenism.
7. Risk factors
associated with
Pelvic Organ
Prolapse(POP)
Connective tissue disease:
•Marfan syndrome,
•Ehlers- Danlos syndrome.
•(Ratio of collagen I to Collagen III & IV is decreased)
Race: Hispaniacs & white women have high
incidence.
Chronically increased intra abdominal
pressure:
•COPD
•Chronic constipation
•Obesity
•Repeated heavy lifting
Pelvic floor trauma:
•Forceps/Vacuum Delivery
•Episiotomy
11. Anterior Wall
Anterior Wall
Cystocele:
• The cystocele is formed by laxity and descent of the upper two-thirds of the anterior vaginal
wall.
• As the bladder base is closely related to this area, there is herniation of the bladder through
the lax anterior wall.
Urethrocele:
• When there is laxity of the lower-third of the anterior vaginal wall, the urethra herniates
through it.
• This may appear independently or usually along with cystocele and is called cystourethrocele.
12. Posterior Wall
Relaxed perineum:
• Torn perineal body produces gaping introitus with bulge of the lower part of the
posterior vaginal wall.
Rectocele:
• There is laxity of the middle-third of the posterior vaginal wall and the adjacent
rectovaginal septum.
• As a result, there is herniation of the rectum through the lax area.
13. Vault Prolapse
Enterocele:
• Laxity of the upper-third of the posterior vaginal wall results in herniation of the
pouch of Douglas.
• It may contain omentum or even loop of small bowel and hence, called enterocele.
• Traction enterocele is secondary to uterovaginal prolapse.
• Pulsion enterocele is secondary to chronically raised intra-abdominal pressure.
14. Vault Prolapse
Secondary vault prolapse:
• This may occur following either vaginal or abdominal hysterectomy.
• Undetected enterocele during initial operation or inadequate primary repair usually
results in secondary vault prolapse.
16. Uterovaginal prolapse
• Prolapse of the uterus, cervix, and
upper vagina.
• This is the most common type.
Cystocele occurs first followed by
traction effect on the cervix
causing retroversion of the
uterus. Intra-abdominal pressure
has got piston like action on the
uterus thereby pushing it down
into the vagina.
Congenital prolapse
• There is usually no cystocele.
• The uterus herniates down along
with inverted upper vagina.
• This is often met in nulliparous
women and hence called
nulliparous prolapse.
• The cause is congenital weakness
of the supporting structures
holding the uterus in position.
17. Complex prolapse
Is one when prolapse is associated with some other specific defects.
It includes the following:
• Prolapse with urinary or fecal incontinence,
• Nulliparous prolapse,
• Recurrent prolapse,
• Vaginal and rectal prolapse or prolapse in a frail woman.
18. Clinical
Features
• Symptoms:
• Buldge symptoms:
• Sensation of vaginal buldging or protrusion.
• Seeing or feeling a vaginal or perineal buldge
• Pelvic or vaginal pressure.
• Heaviness in pelvis or organ
• Urinary symptoms:
• Incontinence
• Frequency
• Urgency
• Weak or prolonged urinary stream.
• Hesitancy
• Feeling of incomplete emptying
• Manual reduction of prolapse to start or complete voiding
• Position change to start or complete voiding.
19. Clinical Features
Bowel symptoms:
• Incontinence of flatus or liquid/ solid stoll.
• Feeling of incomplete emptying.
• Hard straining to defecate.
• Urgency to defecate.
• Digital evacuation to complete defecation.
• Splinting vagina or perineum to start or complete defecation.
• Feeling of blockade or obstruction during defecation.
Sexual symptoms:
• Dyspareunia.
• Decreased lubrication.
• Decreased sensation.
• Decreased arousal or orgasm.
21. CLINICAL
EXAMINATION
AND
DIAGNOSIS OF
POP
1. Composite examination
• Inspection and palpation: Vaginal, rectal,
rectovaginal or even under anesthesia
may be required to arrive at a correct
diagnosis.
2. General examination
• Details, including body mass index (BMI),
signs of myopathy or neuropathy,
features of chronic airway disease
(COPD) or any abdominal mass should
be done.
22. CLINICAL
EXAMINATION
AND
DIAGNOSIS OF
POP
3. Pelvic examination
• Bladder should be emptied.
• Position is Lithotomy.
• In both dorsal and standing positions. The
patient is asked to strain as to perform a Valsalva
maneuver during examination.
• This often helps to demonstrate a prolapse
which may not be seen at rest.
• Levator ani muscle tone is assessed by placing
examining fingers (index and middle) inside the
vagina and thumb outside. The muscle
(pubovaginalis) is palpated in the lower third of
vagina. Patient is asked to squeeze the anus and
the muscle tone is felt.
23. CLINICAL
EXAMINATION
AND
DIAGNOSIS OF
POP
4. Bowel function evaluation
5. Bladder function evaluation:
Clean catch / catharized urine sample for infection.
Post void residual volume (≤ 100ml is acceptable)
6. Rectal examination helps to detect deficient perineum.
7. Imaging:
Fluoroscopic evaluation of bladder function
USG pelvis
Defecography for patient in whom intussuption or rectal
mucosal prolapse is suspected.
MRI: evaluation of pelvic pathology such as Mullerian
anomalies, pelvic pain.
8. Urethral mobility measurement( resting urethral angle ≤ 30°
or maximal strain angle >30°)
24. Pelvic organ
prolpase
quantification
(POP-Q)
• Recommended by the International Continence Society as it
standardizes terminology and is most objective, site specific
and anatomical.
• Prolapse in each segment is measured relative to the hymen.
• Six points are located with reference to the plane of the
hymen:
• Two on the anterior vaginal wall (points Aa and Ba),
• Two at the apical vagina (points C and D), and
• Two on the posterior vaginal wall (points Ap and Bp) .
• Genital hiatus (Gh), perineal body (Pb), and total vaginal
length (TVL) are also measured.
• All POP-Q points, except TVL, are measured during
patient Valsalva and should reflect maximum protrusion.
25. Points Description Range
Aa Anterior wall 3cm from hymen -3cm to +3cm
Ba Most dependent portion of rest of anterior vaginal wall -3cm to +TVL
C Cervix or vaginal cuff ±TVL
D Posterior fornix(if no prior hysterectomy) ±TVL OR omited
Ap Posterior wall 3cm from hymen -3cm to +3cm
Bp Most dependent portion of rest of posterior vaginal wall -3cm to +TVL
TVL Greatest depth of vagina when its apex is at normal position 11cm
Gh Middle of external urethral meatus to posterior midline hymen 4cm
Pb Posterior margin of genital hiatus to mid anal opening 3cm
26. • After collection of site
specific measurement ,
these are arranged in
grid system of charting
and stages are assigned
according to the most
dependent portion of
prolapse.
27. POP-Q Staging
System
• Stage 0: No prolapse is
demonstrated. Points Aa, Ap,
Ba, and Bp are all at − 3 cm
and either point C or D is
between − TVL (total vaginal
length) cm and − (TVL − 2) cm
(i.e., the quantitation value
for point C or D is ≤ − [TVL −
2] cm).
28. POP-Q Staging
System
• Stage I: The criteria for stage 0 are not met, but the
most distal portion of the prolapse is > 1 cm above
the level of the hymen (i.e., its quantitation value is <
− 1 cm).
• Stage II: The most distal portion of the prolapse is ≤ 1
cm proximal to or distal to the plane of the hymen
(i.e., its quantitation value is ≥ − 1 cm but ≤ + 1 cm).
• Stage III: The most distal portion of the prolapse is >
1 cm below the plane of the hymen but protrudes no
further than 2 cm less than the total vaginal length in
centimeters (i.e., its quantitation value is > + 1 cm
but < + [TVL − 2] cm).
29. Stage IV: Essentially,
complete eversion of
the total length of the
lower genital tract is
demonstrated. The
distal portion of the
prolapse protrudes to
at least (TVL − 2) cm
(i.e., its quantitation
value is ≥ + [TVL − 2]
cm). In most instances,
the leading edge of
stage IV prolapse will
be the cervix or vaginal
cuff scar.
30. Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse on Physical Examination
Grade
Grade 0 Normal position for each respective site
Grade 1 Descent halfway to the hymen
Grade 2 Descent to the hymen
Grade 3 Descent halfway past the hymen
Garde 4 Maximum possible descent for each site
31. DEGREES OF UTERINE
PROSLAPSE (CLINICAL)
• Normal: External os lies at the
level of ischeal spines. No
prolapse.
• First degree: The uterus descends
down from its normal anatomical
position but the external os still
remains above the introitus.
• Second degree: The external os
protrudes outside the vaginal
introitus but the uterine body still
remains inside the vagina.
• Third degree : The uterine cervix
and body and the fundus
descends to lie outside the
introitus.
• Procidentia involves prolapse of
the uterus with eversion of the
entire vagina.
33. Preventive
Adequate antenatal and intranatal care.
• To encourage early ambulance.
• To encourage pelvic floor exercises by squeezing the
pelvic floor muscles in the puerperium.
Adequate postnatal care:
• To avoid strenuous activities, chronic cough,
constipation and heavy weight lifting.
• To avoid future pregnancy too soon and too many
by contraceptive practice.
General measures
34. Conservative
• Asymptomatic women.
• Old woman not willing for surgery.
• Mild degree prolapse.
• POP in early pregnancy.
Indications of conservative management:
• Improvement of general measures .
• Estrogen replacement therapy may improve minor degree
prolapse in postmenopausal women.
• Pelvic floor exercises in an attempt to strengthen the muscles
(Kegel exercises).
• Pessary treatment.
Meanwhile, following measures may be taken:
35. Pessary Treatment
• Indications of use are:
• Early pregnancy — the pessary should
be placed inside up to 18 weeks when
the uterus becomes sufficiently
enlarged to sit on the brim of the
pelvis.
• Puerperium — to facilitate involution.
• Patients absolutely unfit for surgery
specially with short life expectancy.
• Patient’s unwillingness for operation.
• While waiting for operation.
• Additional benefits: Improvement of
urinary symptoms (voiding problems,
urgency).
36. SURGICAL
MANAGEMENT
• Surgery is the treatment of symptomatic prolapse where
conservative management has failed or is not indicated.
• Surgical procedures may be:
A. Restorative —
I. correcting her own support tissues or
II. compensatory — using permanent graft
material .
B. Extirpative—
Removing the uterus and correcting the support
tissues.
C. Obliterative—
Closing the vagina.
37. Factors
determining
the choice of
surgery are:
• Patient’s age
• Parity
• Degree of prolapse
• Type of prolapse (cystocele, enterocele)
• Any prior surgery for prolapse
• Associated factors (urinary/fecal incontinence, PID)
• Any associated comorbid condition
38. TYPE OF PROLAPSE AND THE COMMON SURGICAL REPAIR PROCEDURES
Organ descent Clinical condition Type of operation
VAGINAL WALL
Anterior (Upper 2/3) or whole Cystocele/cystourethrocele
Paravaginal defect
• Anterior colporrhaphy
• Paravaginal defect repair
Posterior (Lower 2/3) Rectocele • Colpoperineorrhaphy
Posterior (Upper 1/3) Enterocele • Vaginal repair of enterocele with
PFR
• McCall culdoplasty
• Moskowitz procedure
Combined anterior and posterior Cystocele and rectocele • PFR (combined procedure)
39. Organ descent Clinical condition Type of operation
VAGINAL WALL FOLLOWING
HYSTERECTOMY (Vaginal or
abdominal)
Vault prolapse (secondary) Vaginal:
Repair of vaginal vault along with
PFR
Sacrospinous colpopexy
Colpocleisis (Le Fort)
Abdominal: Sacral colpopexy
UTEROVAGINAL Uterus along with
vaginal walls
Uterovaginal prolapse • Vaginal hysterectomy with PFR
(Elderly woman, family
completed)
• Fothergill’s operation
(preservation of uterus)
40. Organ descent Clinical condition Type of operation
Uterus (Without vaginal
walls)
Congenital or
nulliparous prolapse
(Young women)
Cervicopexy or Sling
(Purandare’s) operation
Pelvic organ prolapse
(POP)
POP with stress in
continence
• Vaginal: TOT
operation
• Abdominal: Burch
operation
41. Management
of
Uterine
prolapse
In young Nulliparous females or any female who desire future
pregnancy/ congenital prolapse: Sling surgery (
Cervicopexy/Purandare sling, Shirodkar sling, Composite/Virkud).
Females < 40 years who doesnot desire future pregnancy but
wants to retain menstrual functions: Manchester
operation(Fothergills operation).
Females ≥ 40 years and doesnot desire future pregnancy and does
not want to retain menstrual function: Ward Mayo’s vaginal
hysterectomy.
Females who refuse surgery or has contraindication to surgery:
Young females- Ring pessary, old females :Le fort repair/Dani’s
repair.
Prolapse during pregnancy /puerperium or young females with
contraindication to surgery: Ring pessary.
42. Pessary
2 basic varieties:
•Supportive variety: Ring Pessary.
•Space occupying variety: Gellhorn pessary.
Indications:
Prolapse during pregnancy.
In puerperium – to facilitate involution.
Patient unfit or unwilling for surgery.
Women who have undergone atleasst one previous attempt at surgical
intervention without relief.
Diagnostic: it may be placed diagnostically to identify which women are at
risk for urinary incontinence after prolapse correction.
43. Problems
associated
with
pessary:
It is never curative and is only palliative.
Can cause vaginitis.
Has to be changed every 3 months.
Forgotten pessary can cause vaginal ulcerations, erosions ,
and fistula formation.
May cause dyspareunia.
It does not cure stress incontinence.
