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Pelvic organ prolapse
1.
2. Pelvic organ prolapse is a common
condition that can lead to genital tract
dysfunction and diminished quality of life
Signs: descent of one or more of the
following
the anterior vaginal wall, posterior
vaginal wall, uterus and cervix, vaginal
apex, or the perineum
4. For pelvic organ prolapse to be considered a
disease state in a given individual, symptoms
should be attributable to pelvic organ descent
such that surgical or nonsurgical reduction relieves
the symptoms, restores function, and improves
quality of life.
6. Currently, two obstetric interventions-
elective forceps delivery to shorten second-
stage labor and elective episiotomy are not
advocated
Elective cesarean delivery to prevent pelvic
floor disorders such as POP and urinary
incontinence is controversial
7. DESCRIPTION AND
CLASSIFICATION
The terms cystocele, cystourethrocele, uterine prolapse, uterine
procidentia, rectocele, and enterocele have traditionally been
used to describe the structures behind the vaginal wall
thought to be prolapsed
However, these terms are imprecise and misleading
b/c they focus on what is presumed to be prolapsed rather than what is objectively
noted to be prolapsed.
it is more clinically useful to describe prolapse in terms of what
one actually sees:
anterior vaginal wall prolapse, apical prolapse, cervical
prolapse, posterior vaginal wall prolapse, rectal prolapse, or
perineal descent.
8. Pelvic Organ Prolapse
Quantification POP Q
This system allows clinicians and researchers to
report findings in a standardized, easily
reproducible fashion
Six points are located with reference to the plane
of the hymen:
All POP-Q points, except TVL, are measured
during patient Valsalva and should reflect
maximum protrusion.
9. Anterior vaginal wall
Point Aa : is 3 cm proximal to the external urethral meatus
In relation to the hymen, this point’s position ranges from –3
(normal support) to + 3 cm (maximum prolapse of point Aa)
Point Ba : represents the most distal position of any part o
the upper anterior vaginal wall
It is –3 cm in the absence of prolapse
Point C defines a point that is at either the most distal edge of the
cervix or the leading edge of the vaginal cuff after total
hysterectomy.
Point D defines a point that represents the location of the posterior
fornix in a woman who still has a cervix , It is omitted in the absence
of a cervix
10. In a woman with total vaginal eversion
post-hysterectomy, Ba / Bp would have
a positive value equal to the position of
the cuff from the hymen
11. Posterior Vaginal Wall
Points
Point Ap :defines a point in the midline of the posterior
vaginal wall that lies 3 cm proximal to the hymen
this point’s range of position is by definition –3 (normal
support) to + 3 cm (maximum prolapse of point Ap)
Point Bp represents the most distal position of any part of the upper
posterior vaginal wall , –3 cm in the absence o prolapse
12. Genital Hiatus and Perineal
Body
Gh : is measured from the middle of the
external urethral meatus to the midline
of the posterior hymenal ring
Pb :is measured from the posterior
margin of the genital hiatus to the
midanal opening
13.
14.
15.
16.
17. Baden Walker halfway
System
Although not as informative as the POP-Q, it is adequate for clinical
use if each compartment (anterior, apical, and posterior) is
evaluated
18. PATh OPh YSIOLOGY
Pelvic organ support : by complex
interaction of
Pelvic floor muscle
Pelvic floor connective tissue
Vaginal wall
19. Levator Ani muscle : consist of 3
muscle,ilococcygus,pubococcygus,puborectalis
Connective tissue cover superior and inferior surface
Resting contraction elevates pelvic floor and compress
vagina, urtethra and rectum towards pubic bone ; this narrow
the Gh and Prevents POP
Upper Vaginal wall
Lies nearly horizontal in standing female
Increased Intraabdominal pressure put tension on the levator
ani loos of support of vagina which become semi vertical
Which widen GH and lead to prolpase
20.
21. The Defect Theory of Pelvic
Organ Prolapse
attenuation of the vaginal wall without loss of fascial
attachments is called a distention cystocele or rectocele
With distention-type prolapse, the vaginal wall appears
smooth and without rugae, due to abdominal contents
pressed against the vagina from within
In contrast, anterior and posterior wall defects due to loss o
the connective tissue attachment of the lateral vaginal wall to
the pelvic sidewall are described as displacement
(paravaginal) cystocele or rectocele
22. With displacement-type prolapse, vaginal rugae are visible.
Both defect types could result from the stretching or tearing
of support tissues during second-stage labor
23. Levels of Vaginal Support
Level 1 support :
suspends the upper or proximal vagina
consists of the cardinal and uterosacral ligaments
attachment to the cervix and upper vagina
The cardinal ligaments fan out laterally and attach to the parietal fascia of the obturator internus and piri ormis
muscles, the anterior border o the greater sciatic oramen, and the ischial spines.
The e uterosacral ligaments are posterior bers that attach to the presacral region at the level o S2 through S4
maintains vaginal length and horizontal axis.
Defects in this support complex may lead to apical
prolapse
This is frequently associated with small bowel
herniation into the vaginal wall, that is, enterocele
25. Level II 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
26. Level III support
is composed of the perineal body, super- fcial and deep
perineal muscles, and fibromuscular connective tissue
these support the distal one third of the vagina and introitus
The perineal body is essential for distal vaginal support and
proper function of the anal canal.
Damage to level III support contributes to anterior and
posterior vaginal wall prolapse, gaping introitus, and perineal
descent
27.
28. PATIENT EVALUATION
symptom
Commonly assted with GI,GU and MS
system
Assess carefully the symptom if they r
caused by prolapse
Symptom asst can be done using
questionner : Pelvic Floor Distress Inventory (PFDI) / the Pelvic
Floor Impact Questionnaire (PFIQ)
29. If bulge symptoms are the primary complaint, successful
replacement of the prolapse with nonsurgical or surgical
therapy will usually provide adequate symptom relief .
Urinary symptoms often accompany POP and may include
stress urinary incontinence (SUI), urgency urinary incontinence,
requency, urgency, urinary retention, recurrent urinary tract in ection, or
voiding dys unction
Although these symptoms may be caused or exacerbated by POP, it
should not be assumed that surgical or nonsurgical correction of
prolapse will be curative.
30. In contrast, urinary retention has been found to improve with
prolapse treatment if the symptom is due to an obstructed urethra
Constipation
often present in women with POP, although
it is generally not caused by POP
surgical repair or treatment with a pessary will not usually cure
constipation and may actually worsen it
Therefore, if a patient’s primary symptom is constipation, treatment
of prolapse may not be indicated.
Constipation should be viewed as a problem distinct from prolapse
and evaluated separately
31. Digital decompression of the posterior vaginal wall, the
perineal body, or the distal rectum to evacuate the rectum is
the most common defecatory symptom associated with
posterior vaginal wall prolapse
Surgical approaches to this problem provide variable
success, and symptom resolution rates range from 36 to 70
percent
32. Female sexual dysfunction
some prolapse procedures such as
posterior repair with levator plication and
vaginal placement of mesh may contribute
to postoperative dyspareunia.
Therefore, care is taken in planning
appropriate surgical procedures for women
with concomitant sexual dysfgtunction
33. Pelvic and back pain is another complaint
in women with POP, but little evidence
supports a direct association.
POP is associated with varied complaints,
symptoms and their severity do not
always correlate well with advancing
stages of prolapse.
34. Thus, when planning surgical or nonsurgical therapy,
realistic expectations should be set with regard to
symptom relief
A patient is informed that symptoms directly related
to prolapse such as vaginal bulge and pelvic
pressure are likely to improve with a successful
anatomic repair.
However, other associated symptoms such as
constipation, back pain, and urinary urgency and
frequency may or may not improve
35. Physical Examination
Perineal Examination
Put her on lithotomy position
vulva and perineum are examined
for signs of vulvar or vaginal atrophy or other abnormalities
Do sacral reflexes
bulbocavernosus reflex is elicited by tapping or stroking lateral to the clitoris
and observing contraction of the bulbocavernosus muscle bilaterally
stroking lateral to the anus and observing a reflexive contraction o the anus,
known as the anal wink reflex
Intact reflexes suggest normal sacral pathways. However, they can be absent in
women who
are neurologically intact
36. POP examination begins by asking a woman to attempt
Valsalva maneuver prior to placing a speculum in the vagina
Patients who are unable to adequately complete
a Valsalva maneuver are asked to cough. T is “hands-off ”
approach more accurately displays true anatomy
Importantly, this assessment helps
answer three questions:
(1) Does the protrusion come beyond
the hymen?
(2) What is the presenting part of the prolapse
(anterior, posterior, or apical)?
(3) Does the genital hiatus signi cantly widen with increased
intraabdominal pressure?
37. If the full extent of prolapse cannot be
demonstrated, a woman should be
examined in a standing position
and during Valsalva maneuver
38. APPROACh TO TREATMENT
Expectant Management
For women who are asymptomatic or mildly symptomatic
NB: It is difficult to predict if prolapse will worsen or if
symptoms will develop
In this situation, benefits of treatment are balanced
against risks
Pelvic floor muscle rehabilitation may be offered to a
patient seeking to prevent prolapse progression
However, no data support the effectiveness of this
practice
40. Choice depends on
the type and severity of symptoms,
age and medical comorbidities,
desire for future sexual function and/or
fertility, and
Risk factors for recurrence.
41. Non surgical treatment
Pessary
usually made of silicone or inert plastic, and they are
safe and simple to manage.
Indication
most common indication for vaginal pessary is POP
Other indication POP associated urinary
incontinence
Diagnostically i.e whether the sx is related to POP
Traditionally pessary was for those unfit or unwilling
to go for surgery
42. Pessary type: can be
Support (e.g ring)
Space filing (e.g Cube)
Of all pessaries, the two most commonly
used and studied devices are
the ring and the Gellhorn pessaries
43. Pessary placement
Vaginal atoprhy should be treated first if there is
Ideally, a pessary is removed nightly to weekly,
washed in soap and water, and replaced the next
morning
After initial placement, a return visit may follow in 1
to 2 weeks.
For patients comfortable with their pessary
management, return visits may be semiannual
44. For those unable or unwilling to remove and
replace a device themselves
pessary may be removed and the patient’s
vagina inspected at
the provider’s of ce every 2 or 3 months
Delaying visits longer than this may lead to
problematic discharge and odor
45. Pessary complication
Pessary Ulcer
are treated by changing the pessary type or size to alleviate pressure points or by
removing the pessary completely until healed. T
treatment of vaginal atrophy with local estrogen is commonly required. Alternatively,
wate rbased lubricants applied to the pessary may help prevent these complications
Prolapse ulcers :
have the same appearance as pessary ulcers,
result from the prolapsed bulge rubbing against patient clothing.
T ese are treated by replacing
the prolapse either with a pessary or by surgery
Pelvic pain with pessary use is not normal. T is usually indicates that the size is too large, and a smaller pessary would be
more suitable.
Abnormal odor : managed by encouraging more requent nighttime
device removal, washing, and reinsertion the next day
46. Pelvic floor muscle exercise
also known as Kegel exercises
suggested as a therapy that might
limit progression and alleviate prolapse
symptoms
Unfortunately, high-quality scientific
evidence supporting pelvic exercise for
prevention and treatment of prolapse is
lacking
47. Exercise sets are performed numerous
times during the day, with some reporting
up to 50 or 60 times each day
However, specific details in performance of
these exercises a subject to provider pref
erence and clinical setting.
48. SURGICAL TREATMENT
Thus, the surgeon and the patient must agree on the desired
results
surgical success be defined as absence of bulge symptoms in
addition to anatomic criteria.
Can be
OBLITERATIVE PREOCDURES
_ Include Lefort colpocleisis and complete colpocleisis
RECONSTRUCTIVE PROCEDURES
- Procedures include sacrocolpopexy, paravaginal repair, and vaginal
vault suspension to Uterosacral ligament
49. Obliterative Procedures
include Lefort colpocleisis and complete colpocleisis
These procedures involve removing vaginal epithelium, suturing anterior
and posterior vaginal walls together, obliterating the vaginal vault, and
effectively
closing the vagina
are only appropriate for elderly or medically compromised patients who
have no desire for future coital activity
are technically easier, require less operative time, and offer
superior success rates compared withreconstructive
procedures.
50. Success rates : range from 91 to 100 percent
after colpocleisis, fewer than 10 percent of patients
express regret, often due to loss of coital activity
If ther is uterus prior to procedure, hystrectomy can be
done before colpocleisis or
If uterus retention is planned , neoplasia excluded
preoperatively
51. Reconstructive Procedures
More commonly performed
Has vaginal, abdominal,laparascopic and robotic approach
Procedures include sacrocolpopexy, paravaginal repair, and vaginal
vault suspension to uterosacral ligament
Abdominal :
preffered for those with recurrent prolpase
Those believed to be @ high risk for recurrence
Vaginal
typically offers shorter operative time and a quicker return to
daily activities
52. Surgical treatment
In preparing for prolapse correcting surgery
Each pt should understand anticpated result
Surgeon should factor
A pt’s goals and expectations
Symptoms and quality of issues
best estimates of goal attainment based
on scientific evidence and the surgeon's
personal experience
the surgeon and the patient must agree on
desired endpoints.
53. Anterior Compartment
anterior colporrhaphy
has been the most common operation,
yet long-term anatomic success rates are poor
symptom relief may be acceptable.
Mesh or biomaterial may also be used in conjunction
Mesh is used to reinforce the vaginal wall and is sutured in
place laterally.
However, the use o mesh and mesh kits or anterior vaginal wall
prolapse remains controversial
54. If its due to anterior apical segment defect : do
apical suspension procedure (sacrocolpopexy or
uterosacral ligament vaginal vault suspension) will
resuspend the anterior vaginal wall to the apex and
reduce anterior wall prolapse
Also prevent enterocele formation
if a lateral defect is suspected, paravaginal
repair can be performed
55. Vaginal Apex
can be resuspended with several
procedures which include
abdominal sacrocolpopexy
sacrospinous ligament fixation,
uterosacral ligament vaginal vault
suspension
56. Abdomnial sacrocolpopexy
suspends the vaginal vault to the sacrum
using synthetic mesh
Advantages
the procedure’s durability over time and
conservation o normal vaginal anatomy
offers greater vaginal apex mobility and
avoids vaginal shortening.
57. When hysterectomy is performed in conjunction
with sacrocolpopexy, consideration is given to performing a
supracervical rather than a total abdominal hysterectomy.
With the cervix left in situ, the risk of postoperative mesh
erosion at the vaginal apex is believed to be diminished
In this case, the mesh is not exposed to vaginal bacteria,
which occurs when the vagina is opened with total
hysterectomy
In addition, the strong connective tissue o the
cervix allows for an additional anchoring point or the permanent
mesh.
58. sacrospinous ligament fixation
(SSLF)
vaginal apex is suspended to the sacrospinous
ligament unilaterally or bilaterally using a vaginal
extraperitoneal approach
After SSLF, recurrent apical prolapse is
uncommon
anterior vaginal wall prolapse develops
postoperatively in 6 to 28 percent of patients and
is thought to develop from redirection of
abdominal forces anteriorly
59. Complications (SSLF)
buttock pain
vascular injury
Uterosacral ligament vaginal vault suspension is
another apical surgery. With this procedure, the
vaginal apex is attached to remnants o the
uterosacral ligament at the level o the ischial
spines or highe