This document provides information on pelvic organ prolapse. It defines prolapse as the descent of genital organs through the pelvic floor. It describes the three levels of pelvic support and the types of prolapse that can occur at each level. Symptoms, signs, grading systems, etiology related to childbirth, and risk factors are outlined. Both conservative treatments like pelvic floor exercises and pessaries as well as various surgical repair options to correct prolapse in the anterior, posterior, and apical compartments are summarized.

1. PELVIC ORGAN
PROLAPSE
Dr.Deepeka.T.S.M.S(OBG)., MRCOG(U.K).,Fellow in Reproductive Medicine
Senior Resident, Department of Obstetrics and Gynecology,
SNIMS.

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4. Definition
Genital prolapse is the descent of one or more of the genital
organ (urethra, bladder, uterus, rectum or Douglas pouch or
rectouterine pouch”) through the fasciomuscular pelvic floor
below their normal level.
Vaginal prolapse can occur without uterine prolapse but the
uterus cannot descent without carrying the vagina with it.

6. Supports of PELVIS-De Lancey
Level 1(proximal suspension)
 (cervix and upper vagina):
 Suspensory axis
 Uterosacrals and Cardinal ligaments
 Defect apical prolapse (UV Prolapse , enterocele, and
vault prolapse )

7. Level II(lateral attachements)
 (mid vaginal support)
 Attachment axis
 Anterior-pubocervical fascia
 Posteriorly :rectovaginal fascia
main supports-arcus tendinus fascia pelvis & arcus
tendinus recto vaginalis
 Defects paravaginal & pararectal defects

8. Level III(distal fusion)
• Lower vaginal supports –fusion axis
• Urogenital diaphragm and the perineal body
• Endopelvic fascia
• Defects—posteriorlyRectocele & perineal descent
anteriorly urinary incontinence

9. ETIOLOGY
Vaginal delivery
Prolonged second stage
Rapid successive vaginal delivery
Delivery of macrosomic baby
Instrumental delivery
Premature straining before
complete cervical dilatation

10.  Menopause
 Age & hormone related
 Congenital
 Spina bifida
 Bladder exstrophy
 Connective tissue disorders –Ehlers-danlos & Marfans
syndrome

11. Other risk factors
 Climateric -Increasing age
 Child birth -Multiparity
 Chronic cough
 Chronic costipation
 Obesity
 Previous hysterectomy
 Severe physical stress
 Intraabdominal tumours
 Surgery– Abdominoperineal resection , Radical
vulvectomy

12. Baden-Walker System
 The system has five degrees/grades
 0 – No prolapse
 1 – Leading edge of prolapsed structure descends
halfway to vaginal introitus (hymen)
 2 – Leading edge of prolapsed structure descends to the
vaginal introitus
 3 – Leading edge of prolapsed structure(s) protrudes up
to halfway outside the vagina
 4 – Leading edge of prolapsed structure(s) protrudes
more than halfway outside the vagina

14. Degrees of uterine prolapse
 1st degree-2nd degree-3rd degree 4th degree

15. POP Q

20. Types of prolapse:
1)Vaginal Prolapse:
1) Anterior vaginal wall prolapse:
a. cystocele
b. urethrocele.
c) cysto-urethrocele.

21. 2) Posterior vaginal wall prolapse:
a) enterocele
b)rectocele
c) Perineal descent

24. 3) Vault prolapse:
(descent of the vaginal vault, where the top of the
vagina descends )or inversion of the vagina) after
hysterectomy.
* Vault prolapse is more likely to occur after subtotal than
after total hysterectomy.

26. Symptoms of prolapse:
1. sensation of weakness in the perineum.
2. a mass which appears on straining. and
disappears when she lies down.
3.Discharge ( if ulcer)

27. 3.Urinary symptoms
 Urgency and frequency
 Stress incontinence.
 Inability to micturate unless the anterior vaginal
wall is pushed upwards by the patient's fingers.
4.Rectal symptoms-
 incontinence,
 incomplete emptying,
 straining during defecation,
 urgency,
 digital pushing

28. 5. Backache,.
6. Leucorrhoea is caused by the congestion and
associated by chronic cervicitis.
7.Sexual dysfunction-dyspareunia,decreased
lubrication

29. Signs
ASSESSMENT OF PROLAPSE
 Examined in the lithotomy position- empty bladder
 Stress incontinence must be looked for on a full bladder
 3 compartment- assessed seperately
 Anterior compartment—sims speculum(retracting the
posterior vaginal wall
 Middle compartment—by noting the descent of uterus
 Posterior compartment-sims speculum (retracting the
anterior vaginal wall)

30.  Cystocele and urethrocele looked for by retracting
posterior vaginal wall
 Enterocele
 Retract the posterior vaginal wall with sims.
 Hold the posterior lip of cervix with vulsellum or allis
 Cervix is kept reduce at the level ischial spine
 Speculum is then slowly withdrawn as the patient is asked to
cough-- bulge appears from above downwards
 Rectal examination—ask the patient to strain
 Impulse on tip of finger—enterocele
 Pulp of finger-rectocele

31.  BIMANUAL EXAMINATION
 To rule out pelvic mass
 ASSESSMENT OF PELVIC FLOOR MUSCLES
 Pubococcygeus assessed at 4 and 8 ‘0 clock position
 PR Examination – to assess the tone of anal sphincter
 PUDENDAL NERVE SENSATION

32. DECUBITUS ULCER
 Seen in long standing prolapse
 on most dependent part
 Cause—venous stasis
 Healing is rapid
 Non healing ulcer—malignancy should be excluded

33. INVESTIGATIONS:
 USG-to rule out pelvic mass and hydronephrosis
 renal function test—long standing prolapse
 Urodynamic investigations—in case of associated
incontinence

34. DIFFERENTAIL DIAGNOSIS
 Gartners cyst- retention cyst – remnants of wolffian duct
 Urethral diverticulum
 Large fibroid polyps
 Chronic inversion
 Elongation of cervix

35. Prevention
Proper intra-natal care (during delivery):
Avoid aetiological factors as straining during the first stage(before
full cervical dilatation)
Avoid the application of forceps before full cervical dilatation;
Episiotomy should be done when indicated to avoid hidden perineal
lacerations
Avoid fundal pressure to deliver the placenta.

36. Proper post-natal care (after delivery):
 Accurate repair of perineal tears or
episiotomies
Avoidance of occurrence of R.V.F.
Correction of retroversion during the
puerperium
Encourage pelvic floor exercises and other
postnatal ex‘s
prevent puerperal constipation
Care of general health to prevent debility and
bad general health.
GENERAL MEASURES ;treatment of chronic cough
& constipation , correction of obesity

37. MANAGEMENT
 CONSERVATIVE MX
 Pelvic floor muscle training
 PESSARIES—indications
 High risk for surgery
 Not willing for surgery
 Pregnancy
 lactation

38. Pessaries
 2 types
 SUPPORT –Ring pessary
 SPACE FILLING-Gelhorn and cube pessary
 Ask the patient to cough—to ensure pessary is in place
 Ensure that she is able to void urine before leaving clinic
 FOLLOW UP
 initial—at 2 weeks
 First year- 3monthly
 afterwards-- 6 monthly

40. SURGICAL MANAGEMENT
ANTERIOR COMPARTMENT
 Anterior colporrhaphy
 Paravaginal repair

41. Anterior colporrhaphy
Indication-
cystocele and cystourethrocele
Midline plication of pubocervical
fascia infront of the bladder

42. POSTERIOR COMPARTMENT
Posterior colporrhaphy,
colpoperineorrhaphy
 Indication
 Rectocele , relaxed perineum
 Midline plication of vaginal tissue and
pararectal fascia
 Midline plication of levator ani and
resconstruction of perineal body

43. MIDDLE / APICAL COMPARTMENT
 Apical defects-3 types
 Uterine prolapse
 Enterocele
 Vault prolapse following hysterectomy

44. 1)WARD- MAYO REPAIR
 Vaginal hysterectomy with PFR
 Performed where childbearing is complete
 Combined with
Enterocele(Mc Call culdoplasty)
Cystocele (anterior colporrhaphy)
Rectocele(colpoperineorrhaphy) correction

45. Mc Call culdoplasty
Approximation of uterosacral
ligaments in the midline so as to
oblieterate the peritoneum of
the posterior cul-de-sac as high
as possible
fixation of uterosacrals to the
vault

46.  2)SACROSPINOUS COLPOPEXY
 In case of procidentia
 3) ABDOMINOSACROCOLPOPEXY
 Abdominal method of apical suspension
 4) LE FORT OPERATION/COLPOCLEISIS
 Elderly women with medical problems
 Total obliteration of vagina –suturing anterior posterior
denuded vagina

47.  MANCHESTER /FOTHERGILL’S OPERATION
 Women who completed family
 Who wishes to retain the uterus
 Procedure –anterior colporrhaphyligation of cardinal
ligaments amputation of cervix suturing the cardinal
ligaments to the front of cervix( Fothergills
stitch)reforming the lips of cervix using the vagina
(sturmdorf suture)
 Preserves menstrual and reproductive function

49.  SHIRODKAR EXTENDED MANCHESTER OR VAGINAL SLING
OPERATION
 Modification of Fothergills procedure
 Cervical amputation is avoided
 Best for women with strong uterosacrals

50. SPECIAL SITUATIONS
 ENTEROCELE
 Vaginal correction—McCalls culdoplasty
 Abdominal correction– Halban and Moscowitz Procedure
 VAULT PROLAPSE
 Vaginal- Sacrospinous colpopexy
 Abdominal--Sacrocolpopexy

52. NULLIPAROUS PROLAPSE
 Causes—spina bifida or connective tissue disorder
 Usually combination of uterine and vaginal prolapse
 ABDOMINAL SACROHYSTEROPEXY-
 Mesh is attached to junction of uterus & cervix & anterior
longitudinal ligament at sacral promontory
 PURANDARE SLING OPERATION(CERVICOPEXY)
 SHIRODKAR SLING OPERATION
 Strengthening of uterosacral ligaments
 KHANNA POSTERIOR SLING OPERATION

54. THANK U….