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PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.
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3. Prolapse: Latin word– procedere- to fall.
POP: The herniation of the pelvic organs to or beyond
the vaginal walls.
4. PELVIC ORGAN PROLAPSE
ANTERIOR
COMPARTMENT
PROLAPSE
Hernia of anterior
vaginal wall often
associated with
descent of the
bladder
(cystocele) .
POSTERIOR
COMPARTMENT
PROLAPSE
Hernia of the
posterior vaginal
segment often
associated with
descent of the
rectum
(rectocele) .
ENTEROCELE
Hernia of the
intestines to or
through the
vaginal wall
APICAL
COMPARTMENT
PROLAPSE
(uterine prolapse,
vaginal vault
prolapse)
PROCIDENTIA
Hernia of all
three
compartments
through the
vaginal introitus.
4
5. PREVALANCE
One of the most common gynaeological disorder
3rd most common cause of gynaecological surgery esp PM
Lifetime risk for age 80yrs >10%
11. THE PELVIC DIAPHRAGM
The pelvic diaphragm(pelvic floor) is composed of:
1. Levator ani muscle
i. Iliococcygeus
ii. Pubococcygeus
2. The coccygeus and
3. Pyriformis
This is the most important muscular support of pelvic
organs.
15. POSITIONAL SUPPORT OF VAGINA IN
NULLIPAROUS WOMAN
The lower one third of the vagina is oriented more
vertically,
whereas
the upper two thirds deviate horizontally, thereby
maintaining the vaginal axis in an almost horizontal
position.
15
16. Normal axis of uterus/vagina and the
levator plate
Levator plate 16
18. DE-LANCEY’S BIOMECHANICAL SUPPORT
De-lancey’s level of vaginal support
LEVEL I – suspends upper vagina and cervix from
pelvic sidewall via the cardinal and the uterosacral
ligaments
LEVEL II – created by vaginal attachments to arcus
tendineus and fascia of levator ani
LEVEL III – support is created by the urethropelvic
ligaments
De Lancey JOL Clin Ob Gyn 36: 897-909
20. MAIN CAUSE OF POP ARE:
Acquired
Levator muscle
weakness
Ligaments injury
Nerve injury (Pudendal
nerve)
Endopelvic fascial
weakness
Perineal body
weakness
Congenital
Inborn weakness of
support system.
20
24. POP QUANTITATIVE SCORING:
Stage Description
0 No descent of Pelvic Organs
I
Leading edge of Prolapse remaing≥1cm above the
hymenal ring
II
Leading edge of Prolapse extends from 1cm above or 1cm
below the hymenal ring
III
From 1cm beyond the hymenal ring but without complete
eversion of vagina
IV Essentially complete eversion of vagina
Quantitive grading of POP
[ICS, AUGs, SGS 1996]
28. Feeling like you are sitting on a small ball
Difficult or painful sexual intercourse
Frequent urination or a sudden urge to empty the bladder
Low backache
Uterus and cervix that stick out through the vaginal
opening
Repeated bladder infections
Feeling of heaviness or pulling in the pelvis
Vaginal bleeding
Increased vaginal discharge
CLINICAL MANIFESTATION
31. D/D OF CYSTOCELE
Gartner duct cyst
1. Anterior or antero-lateral
2. No rugosity
3. Vaginal mucosa is tense &
shiny
4. Well defined margins
5. Not reducible
6. No impulse on coughing
7. A metal catheter tip
introduced through
urethra fails to come
underneath vaginal
mucosa.
Cystocele
1. Midline anterior
2. Present
3. No
4. Ill defined margins
5. Reducible
6. Present
7. Come underneath
vaginal mucosa
31
34. RECTOCELE VS ENTEROCELE
34
Enterocele Rectocele
Situated High up around the posterior
fornix
Low down around
introitus
Inspection Visible peristalsis No
Sim’s speculum
on posterior
vaginal wall
Slowly withdraw sim’s
speculum, enterocele will
emerge from high up around
the fornices
Visible after full
withdrawl of speculum.
Per-rectal Loops of intestine can be
felt in between the
examining fingers but
fingers cant be apposed
Two fingers can be
apposed , but no loop
felt.
37. INVESTIGATIONS
Routine pre operative investigations
Urine for C/S if any symptoms suggestive if UTI
Urodynamic studies:
No urinary symptoms – not justified.
Do only if significant urinary symptoms.
37
43. CONSERVATIVE
1. Improvement of general health
2. Estrogen replacement therapy may improve
minor degree prolapse in post menopausal women.
3. Pelvic floor exercise- Kegel’s exercise.
4. Pessary treatment.(doughnut, gellhorn,inflatable)
43