Prolapse management

1. MANAGEMENT OF
PELVIC ORGAN PROLAPSE
Dr Ketki

2. WHEN TO TREAT ?
• Should be treated only when it is symptomatic
(Be certain symptoms are due to Prolapse )
• Interferes with the normal activity of the
woman
• The patient seeks treatment

3. MANAGEMENT OF PROLAPSE
-Preventive
-Conservative
-Surgical

4. PREVENTION

5. Genital prolapse is a preventable disease
1)Prevention and limiting injury to pelvic support during
childbirth by :
– Avoiding of: prolonged labour , bearing down before full
cervical dilatation and difficult instrumental delivery
– Encouragment of postnatal pelvic floor exercises .
– Family planning and smaller family size .
2) Avoiding and treating factors which increase the intra-
abdominal pressure such as obesity , smoking, chronic cough
and chronic constipation
3) Prevention of postmenopausal atrophy of pelvic support by
balanced diet, exercise, calcium & by the increased use of HRT.

7. CONSERVATIVE MANAGEMENT

8. • Indications of conservative management
Asymptomatic women
Old women not willing
for surgery
Mild degree prolapse
POP in early pregnancy

9. Conservative
Behavioral
management
Mechanical device
use

10. CONSERVATIVE MANAGEMENT
limited role…
» BEHAVIORAL MANAGEMENT BY PELVIC FLOOR
REHABILITATION (pelvic muscle exercises, galvanic
stimulation, physiotherapy, rest in the puerperium).
» MECHANICAL DEVICE USE (use of pessaries )

11. Pelvic floor muscle training
Progressive resistive exercises for the pelvic floor that are
often titled Kegel exercises.

13. Pelvic floor muscle training (PMFT)is advised in mild
to moderate prolapse.
Goals are-
1.Prevent worsening of prolapse
2.Decrease severity of symptoms
3.Increase strength , endurance and support of pelvic
floor musculature
4.Avoid or delay surgical intervention

14. Pessaries
Indications :
Patient unfit for surgery .
Patient refuses surgery .
During pregnancy and after delivery .
During waiting time for surgery.
As a therapeutic test to confirm that
surgery may help .

15. Support
filling
• Ring pessaries
with diaphragm
• For stage I and
II
Space
filling
• Gelhorn pessary
• For stage III and IV

16. Different types of pessaries to treat various
degrees of prolapse
• A-Hodge with knob (silicone)
• B-Risser(silicone)
• C-smith
• D-hodge with support
• E-Hodge
• F-Tandem cube
• G-Cube
• H-Hodge with support
• I-Regula
• J-Gehrung
• K-Gehrung with knob
• L-Gelhorn 95% Rigid (Acrylic)
• M-Gelhorn Flexible
• N-Gelhorn Rigid
• O-Ring with support
• P-Ring with knob
• Q-Ring with support and knob
• R-Shaatz
• S-Incontinence dish with support
• T-Ring incontinence
• U-ring
• V-Incontinence Dish
• W-Inflatoball (latex)
• X-Donut

17. Different types of pessaries to treat various
degrees of prolapse
Uterine Prolapse
Cystocele and /or
Rectocole
J-Gehrung
I-Regula
Cystocoele+SUI K-Gehrung with Knob
1st and 2nd degree 3rd degree
O-Ring with support
U-Ring without support
R-Shaatz
I-Regula
X-Donut
L,M,N-Gelhorns
W-Inflatoball
G-Cube
F-Tandem-Cube

18. Fitting of pessary
Patient is examined in lithotomy position after
emptying bladder .
Size of pessary is estimated after digital examination
and ring forceps id used to reduce the prolapse or
bladder neck
Insertion of pessary is done by usinga water –soluble
lubricant .
Pessary should be folded and collapsed to reduce its size
for insertion
Pessary is inserted in vagina and pushed high to an area
behind the symphysis pubis

19. Pessary is inserted more posteriorly to
avoid urethra
Now patient is asked to stand ,perform
valsalva and cough to ensure that
pessary is retained
Proper size is ensured by ability to sweep
the index finger between pessay and
vaginal wall.

20. Effective and
satisfactory
outcome have
been reported
for stage II and
greater prolapse
using the
Gelhorn and
Ring diaphragm
pessary.

22. Complications of pessaries
Complications Treatment Remark /pictures
1. Vaginal Discahrge and
Odour
Periodic douching or
Trimo-San gel.
2. Mucosal erosion and
abrasion
Discontinuation of
therapy
Common in women untreated
for vaginal atrophy and those
who do not remove & reinsert .
3. Infections , fistula ,
transmigration of pessary
into the bladder.
Discontinuation of
therapy
Very rare complications
4. Herniation and
incarceration of cervix
and even small bowel
Discontinuation of
therapy
Very very rare
5. Vaginal cancer Discontinuation of
therapy
Very very rare. Rubber
pessaries may be related to it .

23. • Precautions - to minimize side effects:
– Use silicon pessary and rubber pessary use
should be avoided.
– Change the pessary yearly - or earlier if infection
or ulceration occurred .
– Use of vaginal oestrogen cream in menopausal
patients .

24. Follow up after fitting
• On follow up visit – proper placement and
support of prolapse as well as continence
efficacy should be ensured .
• Pessary intergrity should be checked and
tissue should be evaluated for irritation ,
pressure , sores , ulceration and lubrication.

25. After initial fitting should return in 1-2
weeks
After this , followed at 4-6 weeks
depending on patient proficiency in
placement and removal of pessary
Later she should continue follow up at 6
– 12 months interval

26. SURGICAL MANAGEMENT

27. Choice of surgical method - depends on the followings:
 Age
 Parity and wish for further pregnancy.
 Type of Prolapse
 Degree of Prolapse
 Any prior surgery for prolapse
 Associated Factors(urinary/Fecal incontinence , PID)
 Any associated comorbid condition (cardiac condition )
 wish of the paitent .

28. IS
Type of surgical
procedure
Restorative
Correcting her own
support tissue
Compensatory
(attempt to replace
deficient support with
permanent graft )
Extirpative
(Removing uterus
and correcting the
suupport tissue)
Obliterative
(Closing the vagina )
COLPOCLESIS

29. Surgical procedure
Conservative
Abdominal
Shirodkars
posterior sling
Soonawala `s
unilateral
posterior
Purandares`s
Cervicopexy
Joshi`s
Sling
Virkud Sling
Khannas
Sling
vaginal
For very old
patients
Le Forts
Operation
Dani `s Stitch
For Young
patient
Fothergills
Operation
Non
Conservtive
Abdominal
Vaginal
Laproscopic

30. RECONSTRUCTIVE SURGERY is invariably needed
and has to be a COMBINATION OF
PROCEDURES to correct the multiple defects
MOST COMMONLY PERFORMED
VAGINAL HYSTERECTOMY WITH
PELVIC FLOOR REPAIR

31. Route of surgery is mostly vaginal ….
also tried are abdominal & laproscopic
Surgical repair may be directed to
1. Anterior compatment
2. Middle or apical
3. Posterior compartment

33. ANTERIOR COMPARTMENT (extends from pubic
symphysis anteriorly to posterior aspect of cervix )
- Anterior compatment separates bladder from lumen
of vagina.
-Defects in vaginal wall
Central defects – Displacement cystocoele
(older term)
lateral defects – Distention Cystocoele(older
term )

34. Defects-
urethrocele,
cystocele (main
support being
pubovesical-
cervical fascia)

36. USUALLY CYSTOCELES
• usual defect is a midline/central defect or
anterior cystocoele ( defect in the
fibromuscular layer of the vagina – ANTERIOR
COLPORRHAPHY
• Lateral cystocele or paravaginal defect due to
vagina detaching from the arcus tendinous
fascia – PARAVAGINAL REPAIR

37. • The site – specific correction depends on access to
normal support structure .
• Operative Goals of anterior vaginal reconstruction
Defect Operative Goal
Central Defect (Distension
cystocoele)
Reconstrution of pubocervical septum / repair of distention
cystocoele.
Proximal Defect / Transverse
defect
Reattach proximal pubocervical septum to the suspensory
support of the paracolpium . Rebuild the pericervical ring
and compensate for the defect left by absence of the
cervix. (De Lancey Level I)
Lateral Defect
(displacement cystocoele)
Paravaginal Repair or To reattach the pubocervical septum
to the ATFP(De Lancey Level II)
Distal Defect Urethropexy (De Lancey Level III)

38. Anterior
colporrhaphy
Repairing the hernia of the
wall in between the
bladder and vagina.

39. Anterior colporrhaphy
Complications
General complications
1.Anaesthetic complication
2.Bleeding
3.Post operative
complications
4.Bladder infections
Specific complications
1.Damage to Bladder and
ureter
2.Constipation
3.Dypareunia
4.incontinence

40. PARAVAGINAL
DEFECT AND REPAIR
Lateral defect i.e
defect where
pubocervical attaches
to ATFP which occurs
in one of the
Following ways .
1.Fascia breaking away
from White line
2.White line detaches
from sidewall
3.Split in white line

41. PARAVAGINAL REPAIR
• Method to correct a lateral defect or lateral
cystocele.
• Surgical repair through an
1.Open Retropubic Incision
2.Vaginal Retropubic incision
3. Laproscopically
• Goal- to reattach pubocervical fascia to ATFP
and fascia overlying Obturator internus

42. Burch
Colposuspension -
It is a well established
abdominal operation
to treat female stress
urinary incontinence.
The aim of the surgery
is to lift the bladder
neck to the strong
ligaments on the
pelvic bones using
suture.

43. Posterior compartment
• The posterior vaginal compartemnt
encompasses the dorsal wall of the vagina
and its supporting structures .
• Extends from uterosacral and cardinal
ligament attachments of the vaginal the
pericervical connective tissue ring to the
perineal body.

44. Posterior compartment defects
Defect Point to be noted
1.Posterior Detachment of rectovaginal
septum
uterosacral /pericervical connective tisse
ring
2.Central or lateral defect in mid vaginal
portion of rectovaginal septum
Central- break in septum
Lateral-detachtment from levator fascia
3. Detachtment of rectovaginal septum
from perineal body
-
4.Disruption of perineal body Normal felt as substantial pyramidal body
2-4cm between vagina and external anal
sphincter
5.Disruption or attenuated external anal
sphicter
-

45. • Surgical approach for posterior compartment
repair
1.Posterior colporrhaphy
2.Site specific repair
3. levator myorraphy
4.Post anal repair

46. Posterior compartment
POSTERIOR COLPORRAPHY &
COLPOPERINEORRHAPHY
• Done to correct a rectocele and repair a
deficient perineum
• Lax vagina over the rectocele is excised, and
rectovaginal fascia repaired after reducing the
rectocele
• Approximate the medial fibres of levator ani
• Usually combined with a perineorraphy if
there is defective perineal body.

47. Posterior
Colpoperineorapp
hy

49. • Site specific defect repair-
• The vaginal epithelium is opened at the perineal body. The
posterior vaginal epithelium is incised in the midline to a level
proximal to the rectocele bulge and dissected away from the
underlying fibromuscularis.
• The dissection is extended laterally to the endopelvic fascial
attachment of the posterior vaginal wall to the arcus
tendineus fasciae pelvis and arcus tendineus fasciae
rectovaginalis.
• The fibromuscularis is carefully inspected to identify breaks.

50. • Defects are individually isolated and repaired
with a delayed-absorbable 0 or 2-0 suture.
• Repair of perineal body defects are also
addressed with interrupted suture.

51. Middle or apical compartment
The apical defects can be of three types:
• Uterine prolapse
• Enterocele
• Vault prolapse following hysterectomy
Vaginal route is usually preferred.

52. VAGINAL HYSTERECTOMY WITH PELVIC FLOOR
REPAIR( WARD-MAYO REPAIR )
• Commonest operation performed in cases of
uterovaginal prolapse in cases where
childbearing is complete
• usually combinedd with repair of an
associated cystocele, enterocele and rectocele

53. -Initial steps are same as in anterior
colporrhaphy .
-uterovesical peritoneum is cut open
-posterior Vaginal wall along with
cervicovaginal junction is cut
-vaginal wall is dissected down till pouch of
douglas
-peritoneum is cut opened

54. - First clamp is placed which includes
uterosacral ligament , mackendrodts ligament,
and descending cervical artery . Tissue are cut
as close to cervix and suturer with vicryl
-Second clamp includes uterine artery and
base of broad ligament .
- Fundus is brought out through anterior pouch
-third clamp includes round ligament, fallopian
tube , mesosalpinx and ligament of ovary

55. -Correction of enterocoele is done .
-Peritoneum is closed by purse string suture.
- sutures on either side of uppermost pedicle are
tied.
-Sutures of US ligamnet and Mackendrodts ligament
are passed through the vault crosswise and are to
be held temporarily .
-Pubocervical fascia is approximated and fixed to the
uppermost tied broad ligament pedicles

56. - Vaginal flaps are excisied and margins are
approximated.
-sutures of lowermost pedicle are tied , fixing
the ligament with vaginal cuff.
- Perineorahaphy is done.
- -Vaginal packing is done

57. SACROSPINOUS COLPOPEXY
• In cases of procidentia with complete vaginal
eversion and in cases of vault prolapse
• Vault of vagina is attached to the sacrospinous
ligament
Access via the retrovaginal space upto the
ischialspine

58. Mc Call
Culdoplasty
Method of supporting
the vaginal cuff during
a vaginal hysterectom
by attaching the utero
sacral and cardinal
ligaments to the perito
neal surface with sutu
re material such that,
when tied, it draws to
ward the midline, help
ing to close off the cul-
de-sac.

59. • Halban Culdoplasty –
- Abdominal method of obliterating
enterocoele sac.
- In this , each uterosacral ligament are
shortened and then vertical purse string
sutures are interposed between uterosacral
ligamnets

60. • MOSCHCOWTICHZ CULDOPLASTY :
- Another abdominal method of repair of enterocoele .
- In this, purse string suture are used to obliterate the
sac by placing the sutures at the base of sac
encircling the cul de sac and serosa of the rectum.
- Bites are taken through the uterosacral ligamnets
and back of cervix . All sutures are then tied

61. Fothergills/ manchester
operation

62. Steps of fothergills operation

63. • Fothergills stitch

64. LEFORT’S REPAIR OR COLPOCLEISIS
• Obliterative procedure
• Very rarely employed
• Only in elderly women with medical problems
making them unfit for repair operation
Vaginal epithelium is removed followed by
suturing of the anterior and posterior walls of
vagina therby obliterating the vagina.

65. • DANI`S STITCH :
-easier and simpler than Le- Forts
-inceased risk of SUI after this stitch can be
minimized by sub urethral placement of the
stitch to lift the urethra.
-Occurrence of stitch cutting through can be
minimized by use of polyglycolic acid material
and going sufficiently deep in tissue around
the introitus

66. SHIRODHKAR’S EXTENDED MANCHESTER OR
VAGINAL SLING OPERATION
• Modification of fothergill’s
• Cervical amputation is avoided
• Here uterosacral ligaments are isolated to
form slings which are crossed and stitched
together in in front of the cervix.

70. Shirodkar`s sling is closed loop and
posterior sling surgery
-Tape is fixed to the back of cervix and
then to sacral promontory
.(Artificial uterosacral ligament)
ADV-Provides static bony support
-No tendency to enterocoele
formation .
DISADV-Difficult, more in left side as
sling has to pass under psoas loop
and then sigmoid mesentry.
- Injury tosigmoidcolon,ureter,major
vessels , gentiofemoral nerve .
- Chances of bowel obstruction .

73. Purandare`s abdominal cervicopexy
is a dynamic ,closed loop and
anterior sling operation .
- In this sling are formed from rectus
sheath and fixed on the anterior
surface of the uterus near isthumus.
-

74. Procedure of Purandare`s Abdominal
cervicopexy.
Abdomen opened by pfannestial incision.
Uterus is held with shirodkars uterus holding forceps
.Uterovesical fold of peritoneum is opened and
bladder is pushed down.
Mersilene Tape is fixed to front of cervix by sutures of linen
Bonneys round ligament holding forceps is passed lateral
to the rectus abdominis , posterior rectus sheath is pierced
and then it is passed into the broad ligament of same side
to come into uterovesicall space.
Tip of tape is caught with forceps and tape is drawn out.

75. Procedure is repeated on the other side
UV fold of peritoneum is then closed .Two ends
of the tape is pulled so that the top of the
uterus lies in flush with top of symphysis pubis
Tape is sutured to the rectus sheath on the
both sides.
Round ligament plication is then done

76. • In Joshi`s sling , mersilene tape
is anchored to anterior surface
above the level of internal os
and attached laterally to
pectineal ligament.
• Imp points-
• -weight of uterus is shared by
two strong ligamentous
anchoring points.
• -minimal dissection away from
structures
• -most patient deliver vaginally
and CS can be done without
cutting tape

77. • Technique-Abdomen opened by pfannestial incision
uterus is held with shirodkars uterus holding forceps
.Uterovesical fold of peritoneum is opened and bladder
is pushed down.
Mersilene tape is anchored to the anterior surface of
the uterus just above the level of internal os
A long artery forceos is passed subperitoneally
from the retropubic space, just below the lateral
end of the round ligament,toward the lateral edge
of peritoneal incision over uterus .
Lateral end of tape is grasped and drawn to the
retropubic space . Procedure is repeated on other side

78. Lateral end of the tape is threaded into curved
cutting mayo needle and is passed through
adequate thickness of pectineal ligament on each
side .
Two ends of tape are now drawn taut to elevate
the uterus adequately and are anchored to the
pectineal ligaments using 3-4 knots
Knots are fixed to prevent loosening and the
excess portion of the tape is cut-off.

79. • Virkud`s sling operation is open ,static
and dynamic sling operaion .
• Tape is attached posteriorly on
uterocervical junction .
R- It is passed retroperitoneally and fixed
to sacral promontory
L- Carried between the two layers of
broad ligament upto the lateral border
of left rectus abdominis muscle
• Combination of shirodkar`s posterior
sling on right and purandare`s sling on
left.
• ADV-Easy to perform
- no risk of bowel obstruction

81. • KHANNA`S SLING
- Static open and neutral sling surgery .
- Tape is fixed to the isthumus posteriorly and then
edge of tape is fixed to anterior superior illiac spine .
• SOONAWAALA`S SLING
-Mersilene tape is attached to the uterosacral
posteriorly .Ends are carried from the right side and
are fixed to the anterior longitudinal ligament in
front of sacral promontory.

82. • WILLIAM –RICHARDSON`S OPERATION –
In this external oblique aponeurosis is
dissected free, brought inside the abdominal
cavity extraperitoneally and fixed to the
lateral fornices of vagina with the linen or silk
sutures so as to elevate the vault of vagina .

83. • RECENT INNOVATION
IN
MANAGEMENT
OF
POP .

84. Transvaginal Mesh
• Mesh was introduced to reduce the risk of recurrent
prolapse .
• Physiology of repair-
aim is to create new connective tissue and to
replace broken ligaments and septa instead of
trying tio tighten or to suture an altered
Suspensory apparatus.
• Recent innovations includes
- Transvaginal Mesh
-Laparoscopy and robotics for prolapse repair

85. • Transvaginal Mesh –
-Mesh has been used in open sacrocolpopexy
since more than 50 years(1958 by Hughier and
Scali).
-Use of prosthesis (previously prohibited)
recognised feasible since 1997.
-In late 1990s and 2000s FDA approved
implants as treatment of POP and SUI.

86. • Mesh is implanted in selected place where
collagen tissue is weak.
• Aim is to restore the correct axes of vagina.
Mesh provokes inflammatory reactions
Attracts macrophages, inflammatory cells and
fibroblasta
Collagen fibrosis

87. • Mesh use in prolapse surgery
- Augmented mesh repair (mesh overlay)
- Mesh replacement (needle kit )
• 1.First generation mesh kit – involves blind
needle passes.(NVC)
2.Second generation mesh- obviate the need to
use needle

88. MESH
1st generation
needle –
driven kits
Anterior
compartment
Perigee(American
medical system )
Anterior PROLOIFT
Posterior
compartment
Apogee
Posteror and Total
PROLIFT
2nd
generation
Mesh kits
Elevate
system
Pinnacle

89. • Complications
1. Mesh exposure (Erosion)
2. Contraction of mesh due to excessive tension
in arms (dyspareunia)
3. Infection
4. Abscess formation
5. Voiding dysfunction
6. Other complications like granuloma
formation , fistula formation

90. • Key Points for preventing complications
1.Optimization of modifiable risk factors
2.Selection of mesh type (Macroporous
polypropylene mesh)
3.Tension free mesh suspension
4.Prevention of mesh rolling or bunching(mesh
should be properly trimmed)

91. Laparoscpy/Robotics
• Laparoscopic Retropubic urethropexy –
introduced in 1991
• With FDA approval of robotic assistance for
gynaecological procedure , adoption of
laproscopic sacral colpopexy has increased .

92. • Laproscopic uterine suspension procedure
(uterosacral ligament uterine suspension/
sacrocervicopexy)------ Stage II and III Prolapse
(POP-Q).
• Laproscopic sacrocolpopexy is an option in
stage II and IV vault prolapse .

93. • Advantages of laproscopic
1.Improved anatomic visualisation
2.Shortened post operative hospitalization
3.Decreased post operative pain

94. • Surgical robotics is used in laparoscopy rather
than open surgical procedure.
• Developed since 1980s – to address the
limitations of laparoscopy.
• Goal-to help surgeon to improve patient care
• Surgeons with advanced laproscopic skills
performed robotic procedures , with da Vinci
Robot there has been rapid adoption of robot
assisted laproscopic procedure

95. • Advantages over conventional laproscopy
1.Superior visualizaton
2.Mechanical improvements
3.Stabilization of instruments within the surgical
field.
4.Improved ergonomics for operation for
surgeon (can perform in seated position )
5. Surgical stimulation , Telemonitoring and
Telepresence surgery.

96. • Limitations of Robotic Surgery
1.Additional surgical training
2.Instrumentation limitations
3.Lack of hepatics(tactile feedback)
4.Tip of endoscopic camera becomes hot and
must be cleaned outside peritoneal cavity.

97. • The robotic approach to sacral colpopexy
differs from the laproscopic approach on a
few parameters:
1.Trocar locations
2.Docking the robotic patient cart
3.Use of intracorporeal knot tying

98. • TVM- results and complications rates needs
to be reassessed.
• Robotic hysterectomy and sacrocolpopexy are
in armamentarium of few reference centres.
Their results have to be reproducedb and
improved

99. THANK YOU