Pelvic organ prolapse

 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

Symptoms
 vaginal bulging,
 pelvic pressure, and
 splinting or digitation

 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.

 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

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.

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.

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

 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

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

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

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

PATh OPh YSIOLOGY
Pelvic organ support : by complex
interaction of
 Pelvic floor muscle
 Pelvic floor connective tissue
 Vaginal wall

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

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

 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

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

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

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

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)

 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.

 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

 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

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

 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.

 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

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

 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?

 If the full extent of prolapse cannot be
demonstrated, a woman should be
examined in a standing position
and during Valsalva maneuver

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

For significant prolpase or bothersome sx :
option of mgt
 Surgical
 Non surgical

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.

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

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

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

 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

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

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

 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.

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

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.


 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

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


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.

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

 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

Vaginal Apex
 can be resuspended with several
procedures which include
 abdominal sacrocolpopexy
 sacrospinous ligament fixation,
 uterosacral ligament vaginal vault
suspension

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.

 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.

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

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

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