Pelvic organ prolapse (POP) is a common condition where pelvic organs descend from their normal position. Risk factors include parity, age, and obesity. POP is evaluated using the POP-Q system and staged from 0-4. Nonsurgical treatments include pelvic floor exercises and pessaries. Surgical treatments aim to restore anatomy and symptoms, and include vaginal, abdominal, and laparoscopic approaches. Vaginal repairs are most common but abdominal sacrocolpopexy has higher success rates, especially for advanced prolapse. Complications of surgery include recurrence, mesh erosion, and pain.

1. Dr Abel H (R1)
Moderator ; Dr Tatek
obstetrician&Gynecologist
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Dr Abel H Oby & Gayni R1 1

2.  INTRODUCTION
 EPIDEMIOLOGY
 RISK FACTORS
 DESCRIPTION AND CLASSIFICATION
 PATHOPHYSIOLOGY
 PATIENT EVALUATION
 NONSURGICAL TREATMENT
 SURGICAL TREATMENT .
 REFERENCES

3.  Pelvic organ prolapse (POP) is a common condition that can
lead to urogenital tract dysfunction and diminished quality of
life
 Signs include descent of one or more of the following:
 the anterior vaginal wall,
posterior vaginal wall,
 uterus and cervix, vaginal apex
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4.  Exact prevalence - is difficult to ascertain
 In USA it is the third most frequent indication for
hysterectomy, and in women older than 70 years,
 Ethiopia Community-based study in rural Ethiopia (2016) •
prevalence of symptomatic POP (100:100,000
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5.  is provided by an interaction between the muscles of the
pelvic floor and connective tissue attachments to the bony
pelvis
 Levels of pelvic organ support
 Level 1
 Level 2
 Level 3
 The innervation of the pelvic region derives from the S2, S3,
and S4 segments of the spinal cord,
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6.  Parity
 advancing age,
 obesity
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7.  Classification of Risk Factors –
I. Obstetrical / Nonobstetrical
II. Modifiable / Nonmodifiable •
 Nonmodifiable: Age, connective tissue disorders, Racial
differences • Hysterectomy
 Modifiable: COPD, Constipation, Obesity
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8.  Elective cesarean delivery to prevent pelvic floor disorders
such as POP & urinary incontinence is controversial.
Theoretically, if all women underwent cesarean delivery, fewer
women would have pelvic floor disorders.
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9. 4/12/2022
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10.  most strongly correlate with POP
 Is 10 complaint
 successful replacement (± surgery) will usually provide
adequate symptom relief
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11.  SUI: ? involuntary leakage
 → Splinting is helpful
 Irritative bladder symptoms: frequency, urgency
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12.  Feeling of incomplete emptying,
 Hard straining to defecate
 Splinting, incontinence of flatus, liquid, or solid stool
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13.  Prolapse does not appear to be associated with decreased
sexual desire or with dyspareunia
 avoid sexual activity because of fear of discomfort or
embarrassment associated with POP
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14.  Baden-Walker halfway system • not as informative as the
POP-Q • Five grades
0 –Normal position
– 1 –Descent halfway to hymen
– 2 –Descent to the hymen
– 3 –Descent halfway past the hymen
– 4 –Maximum possible descent
• Disadvantage – Not compartmental specific
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16.  In 1996, the International Continence Society defined a
system of Pelvic Organ Prolapse Quantification (POP-Q
◦ It describes the location and severity of the prolapse
◦ Prolapse in each segment is measured relative to hymen
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18.  Point Aa: Is 3 cm proximal to the external urethral meatus. By definition, the range relative to the hymen, is −3 to +3 cm.
 Point Ba: Represents from vaginal cuff or anterior vaginal fornix to point Aa. Point Ba is at -3cm in the absence of prolapse. Points
range is -3 (in absence of prolapse) to +TVL (-3 to +8). In absence of prolapse Aa & Ba are almost same point i.e. (-3).
 Point C: Represents either the most distal edge of the cervix or the leading edge of the vaginal cuff after hysterectomy.
 Point D: level of uterosacral ligament attachment to the posterior cervix (no cervix = no d point, range -8 to -10).
 Point Bp: Represents from the vaginal cuff or posterior vaginal fornix to point Ap. By definition, Point range is -3 (in the absence of
prolapse) to + TVL (-3 to +8).
 Point Ap: Is 3 cm proximal to the hymen. By definition, the range of position of point Ap, relative to the hymen, is −3 to +3 cm.
 Genital hiatus: is measured from middle of the external urethral meatus to the posterior midline of the hymen. (range 2 – 4 cm).
 Perineal body: is measured from the posterior margin of the genital hiatus to the midanal opening (approx. 3 cm).
 Total vaginal length: greatest depth of the vagina in cm without straining (normal range is 8 – 12 cm).

19. STAGE 0: No prolapse is demonstrated during maximal straining.
STAGE I: The most distal portion of the prolapse is >1 cm above
hymen (< -1 cm).
STAGE II
 The most distal portion of prolapse is ≤1 cm proximal to or
extends 1 cm through the plane of hymen (≥ -1 cm, but ≤ +1
cm).
STAGE III
 The most distal portion of the prolapse is > 1cm below hymen
but no further than 2 cm less than the TVL (there is not
complete vaginal eversion) => ( > +1 cm, but < + [TVL-2] cm).
STAGE IV
 Complete eversion of the vagina (≥ + [TVL-2] cm). In most, the
leading edge of stage IV prolapse is the cervix or vaginal cuff
scar.

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21.  Expectant
Mild descent, Asymptomatic
 Conservative
Mildly symptomatic women Unwilling/unfit for surgery POP in early
pregnancy
 Surgical Management
Failed or declined conservative mgt POP is bothersome
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22.  Pessaries are usually made of silicone or inert plastic, and
they are safe and simple to manage
 Traditionally, pessaries have been reserved for women either
unfit or unwilling to undergo surgery.
 However, urogynecologists, used pessaries as a first-line
therapy before recommending surgery
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23.  Vaginal bleeding
 Pessary ulcers or abrasions
 Prolapse ulcers
 Pelvic pain
 erosion
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24.  to strengthen pelvic floor & provide supportive “backboard”
against which the urethra may close.
 Pelvic floor exercise has minimal risk and low cost
Two hypotheses describe the benefits of pelvic floor muscle exercises for prolapse prevention and
treatment.
Women learn to consciously contract ms before and during increases in abdominal pressure. This
prevents organ descent.
Regular muscle strength training builds permanent muscle volume and structural support.
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25.  to strengthen pelvic floor & provide supportive “backboard”
against which the urethra may close
 has minimal risk and low cost
 Two hypotheses describe the benefits of pelvic floor muscle
exercises
◦ Women learn to consciously contract muscle before and during
increases in abdominal pressure
◦ Regular muscle strength training builds permanent muscle volume and
structural support.
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26.  aim to help patients achieve a sustained pelvic floor
contraction of 10 seconds.
 Hold the pelvic muscle contraction for ≥3 seconds (8-10
seconds) & then relax for 1-2x this duration
 This squeeze and release is repeated 10-15x exercises
3x/day throughout the day for a total of 45 contractions
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27.  candidate for surgical treatment are POP women who have
symptomatic prolapse who have failed or decline conservative
management
 The two categories of prolapse surgery are
i. obliterative and
ii. reconstructive
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28.  Primary aims of surgery
◦ Restore Anatomy
◦ improve specific symptom
 Maximizing bladder, bowel, and coital function
◦ Improve QOL
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29.  attempt to restore normal pelvic anatomy
 Approach
◦ Vaginal,
◦ Abdominal,
◦ Laparoscopic and
◦ Robotic
 Procedure route selection is individualized, and compelling
evidence does not support one approach as superior to
another
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30.  Factors determining route
o Location of defect & symptom severity
o Patient’s general health • age, comorbidities, state of tissues,
sexual activity
o Patient preference
o Surgeon’s experience
 Routes of surgery – Vaginal (80-90%); Abdominal (1020%);
Laparoscopic
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31.  Vaginal apex resuspension is a vital component of POP repair
and an important focus in surgery planning
 The vaginal apex can be resuspended with several procedures
that include:
◦ abdominal sacrocolpopexy;
◦ sacrospinous ligament fixation or
◦ uterosacral ligament vaginal vault suspension
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32.  Suspension of the vagina to the sacral promontory or into the
longitudinal ligament of the sacrum
 It restores the vaginal apex close to normal anatomic position
 Advantages: procedure’s durability over time and
conservation of normal vaginal anatomy
 Compared with other vault suspension procedures, it offers
greater vaginal apex mobility and avoids vaginal shortening
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33.  When hysterectomy is performed in conjunction with
sacrocolpopexy, supracervical rather than TAH should be
considered
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34.  Many surgeons use it as their primary surgery for all cases of
post hysterectomy vault prolapse
 typically recommend it for
◦ Patients with stage III support
◦ Advanced prolapse
◦ Previously failed a vaginal approach
◦ Foreshortened vagina or
◦ Coexisting conditions that predispose to subsequent failure.
 long-term success rates approximate 90%.
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35.  one of the most popular procedures for apical suspension
 vaginal apex is suspended to sacrospinous ligament
unilaterally or bilaterally using a vaginal extraperitoneal
approach.
 Dyspareunia may be more likely after SSLF than other apical
suspensions may be due to narrowing of the vagina, shorter
vx
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36.  Obtaining adequate exposure is critical,
 vascular complications, when encountered, may be life
threatening.
 Complications are buttock pain from nerve involvement with
supporting ligatures in 3% of pts & vascular injury in 1%.
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37.  The sacrospinous ligament extends from the ischial spine to
the sacrum. The ligament is wider medially and narrows as
it inserts on the ischial spine. The ligament lies within the
coccygeus muscle (not shown).
 The right CSSL complex and ischial spine (IS) are shown
with respect to course & relationships of: Internal pudendal
artery; Inferior gluteal artery (IGA); Lumbosacral trunk (LST)
and Sacral nerves (S1-S5).

38.  With this procedure, the vaginal apex is attached to remnants
of uterosacral ligament at the level of ischial spines or higher
 Performed vaginally or abdominally, it replace vaginal apex to
a more anatomic position than SSLF
 anterior vaginal prolapse recurrences range from 1-7% and
overall recurrence rates of 4-18%.
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39.  If the apex is not prolapsed, hysterectomy need not be
incorporated into POP repair.
 rationale for hysterectomy is that resuspension of the vaginal
apex can more successfully be accomplished after the uterus
is removed
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40.  anterior colporrhaphy has been the most common operation,
yet long-term anatomic success rates are poor
 sx relief from anterior colporrhaphy may be acceptable
 Anterior vaginal wall prolapse may result from central
(midline), lateral, or apical fibro muscular defects
 Mesh or biomaterial has also been used in conjunction with
anterior colporrhaphy
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41.  Posterior vaginal wall prolapse may be due to enterocele or
rectocele
 Discontinuity of the anterior and posterior vaginal wall
fibromuscular layers allows for this herniation
Traditional posterior colporrhaphy
Site-specific posterior repair
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42.  Mesh reinforcement with allograft, xenograft or synthetic
mesh is used in conjunction with posterior colporrhaphy and
site-specific repair to help reduce prolapse recurrence
 efficacy & safety of graft augmentation in the posterior
vaginal wall has not been established.
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43.  Approximately 30% of women undergoing surgery for
prolapse will require a repeat operation for recurrence
Selective use may include:
1. The need to bridge space
2.Weak or absent connective tissue
3.Connective tissue disease
4.High risk for recurrence (obesity, chronically increased intraabdominal
pressure, and young age) and
5.Shortened vagina
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44.  Noted complications include mesh
◦ erosion,
◦ scarring,
◦ pain and dyspareunia
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45. 1 . Te Linde's Operative Gynecology, 12th Edition
2. Williams Gynecology, 4th Edition
3. Post-Hysterectomy Vaginal Vault Prolapse (Green-top
Guideline No.
4. UpToDate 2021
5. Surgical management of pelvic organ prolapse in women.
Cochrane Database Syst Rev
6 ,ACOG Practice Bulletin No. 214
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46. Thank you!!!!!