Pelvic organ prolapse - Diagnosis and treatment

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Pelvic Floor Anatomy and
Pelvic Organ Prolapse
Tevfik Yoldemir, MD
Marmara University
Department of Obstetrics and Gynecology
Division of Reproductive Endocrinology and Infertility
Abdomino-pelvic cavity
• Respiratory diaphragm
• Vertebral column
• Abdominal muscles
• Pelvic floor
• Intra-abdominal pressure
• Visceral weight & Gravity in erect body
• Maintain visceral function
Genital Support
• Pelvic floor- Pelvic visceral attachment to
pelvic walls through endopelvic fascia
• Levator ani muscles- a pelvic diaphragm
with a cleft in anterior portion
• Urogenital diaphragm connects perineal
body to ischiopubic rami
• Bulocavernous, ischiocavernous,
sup.transverse perineal, anal sphincter m.
Levator ani muscles
• Pelvic diaphragm composed of levator ani,
coccygeus, obturator internus, and
piriformis muscles
• Levator ani consists of medial
pubococcygeus and lateral iliococcygeus
muscles
• Pelvic diaphragm composed of levator ani,
coccygeus, obturator
The Pelvic Diaphragm The Urogenital Diaphragm

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The Function of Pelvic Floor
• Support pelvic and abdominal organs
during stress of increased abdominal
pressure
• Allow for opening of the pelvic floor to
accommodate excretory functions and
parturition
• Endopelvic fascia and visceral ligaments
contains smooth muscles
The Pelvic Floor Attachments
• Pelvic floor support depends on its
connection to the pelvic bones
• An evolutionary solution for support of
visceral organs
• Pelvic floor muscles oppose gravity and
increased abdominal pressures
Prevention of Prolapse Attachments of Pelvic Floor
• Tendinous arch of pelvic fascia-pubocervical
fascia arises
• Tendinous arch of levator ani- levator ani
muscles arise
• Pubourethral ligaments
• Pubovesical ligaments
Attachments of Pelvic Floor Pelvic Floor Dysfunction
• A variety of fascial and anatomic defects
• Cystocele, rectocele, uterine prolapse,
enterocele, vault prolapse
• Adequate diagnosis and staging of pelvic
floor dysfunction is essential

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Diagnosis of
Pelvic Floor Dysfunction
• Detailed physical examination
• Pelvic ultrasound
• Fluoroscopy of rectum & bladder
• Magnetic resonance imaging (MRI)
Normal Anatomy
The axes of pelvic support
• Three support axes
• Upper vertical axis (cardinal-uterosacral
ligament complex)
• Horizontal axis leads to lateral and
paravaginal supports
– Two platforms pubocervical fascia and
rectovaginal septum
• Lower vertical axis supports the lower third
of the vagina, urethra and anal canal
DeLancey’s three levels of
vaginal support
• Apical suspension
– Upper paracolpium suspends apex to pelvic walls and sacrum
– Damage results in prolapse of vaginal apex
• Midvaginal lateral attachment
– Vaginal attachment to arcus tendineus fascia and levator ani
muscle fascia
– Pubocervical and rectovaginal fasciae support bladder and
anterior rectum
– Avulsion results in cystocele or rectocele
• Distal perineal fusion
– Fusion of vagina to perineal membrane, body and levators
– Damage results in deficient perineal body or urethrocele
Normal anterior anatomy Anterior compartment defects
• Urethral hypermobility
– Distal 4 cm of anterior vaginal wall
– Cotton swab test
– If describes an arc greater than 30 degrees
from horizontal with valsalva
– Results in genuine stress incontinence
• Cystocele

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Cystocele
• Main support of urethra and bladder is the pubo-vesical-cervical
fascia
• Essentially a hernia in the anterior vaginal wall due to
weakness or defect in this fascia
– Midline weakness allows bladder to descend causing central
cystocele
– Tearing of endopelvic fascial connections from lateral sulci to
arcus tendinii causes lateral or displacement cystocele
– Detachment of pubocervical fascia from pericervical ring causes
a transverse or apical cystocele
• Symptoms include pelvic pressure and bulge or mass in
the vagina
Cystocele
• Classified as Grade I, II, or III
• Grade III is prolapse outside the introitus
• Surgical repair is treatment of choice
– Anterior Colporrhaphy
– Paravaginal repair
– Colpocleisis
• Vaginal pessary
Evaluation of a cystourethrocele Anterior defect
Cystocele Bladder neck descent

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Bladder neck descent Cystocele
• Most Gr 1 and 2 cystoceles are
asymptomatic
• High grade cystoceles are associated with
vaginal buldging, vaginal pressure,
dyspareunia, UTI, obstructive voiding,
urinary retention
• A high grade cystocele may mask urethral
hypermobility and stress incontinence
Physical examination of
Cystocele Enterocele
• Simple enterocele
• Complex enterocele- associated with vault
prolapse and anterior or posterior vaginal
prolapse
• Cause vaginal pressure, dyspareunia, low
back pain, constipation, symptoms of
bowel obstruction
Physical examination of
Vaginal Cuff Prolapse Posterior compartment defects
• Rectocele
• Perineal deficiency
– Bulbocavernous and superficial transverse
muscle heads retracted
• Perineal descent
– Sagging and funneling of the levator ani
around the perineum such that anus becomes
most dependent
– Difficulty with defecation

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Rectocele
• Chiefly a hernia in the posterior vaginal
wall secondary to weakness or defect in
the rectovaginal septum or fascia of
Denonvilliers
• Symptoms include difficulty evacuating
stool, a vaginal mass, and fullness
sensation
• Rectovaginal exam confirms diagnosis
Rectocele
• Damage generally due to excessive
pushing in childbirth or chronic
constipation
• Surgical treatment if symptomatic
– Posterior Colporrhaphy
– Laxatives and stool softeners
• Temporary relief
• Pessary not helpful
Evaluation of a rectocele Rectocele
• Defect of prerectal and pararectal
fascia,and rectovaginal septum
• Present in 80% asymptomatic patients
• Vaginal mass,vaginal pressure,
dyspareunia,constipation
Physical examination of
Rectocele Uterine Prolapse
• Laxity of uterosacral ligaments
• May present with vaginal mass,
dyspareunia, urinary retention, back pain
• Grade 4 prolapse is associated with
ureteral obstruction

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Physical examination of
Uterine Prolapse
Complete Uterovaginal
procidentia
Bladder descent Apical defect
Pelvic Floor Relaxation
• Associated with damage to
pubococcygeus muscle
• The muscle is lax, atrophied, poor tone
• Urinary stress incontinence
• Genital prolapse
• Sexual Problem
• Rectal stasis
Muscular Component of
Pubococcygeus muscle
• Large diameter slow twitch type I fibers
predominant- provide static visceral
support
• Fast twitch type II fibers- assists in active
closure of pelvic visceral organs
• 40% of women have lost function or
coordination of this muscle

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The Structures supporting
Bladder and Urethra
• Arcus tendineus fascia pelvis
• Levator ani (pubococcygeus muscles)
• Pubovesical muscles or ligaments
• Vaginal muscle attachments to fascia and
levator ani
Physical examination of Pelvic
Floor Dysfunction
• General examination- cancer screen, stool
OB, urinalysis, physical examination
• Neurological examination- paresthesia of
dermatome, bulbocavernous reflex,
voluntary contraction of anal sphincter
• Pelvic examination- cystocele,
rectocele,uterine prolapse, vault prolapse
• Urinary incontinence by Valsalva
maneuver or coughing
Patient position for evaluating
pelvic floor defects
Staging of Pelvic Organ
Prolapse
• Stage 0 - no prolapse
• Stage I - the most distal portion is >1cm above
level of hymen
• Stage II - The most distal portion is <1cm
proximal or distal to plane of hymen
• Stage III - The most distal portion is >1cm below
plane of hymen, but < total vaginal length - 2 cm
• Stage IV - complete eversion of total length of
lower genital tract, the distal portion is > TVL-2
cm, i.e. cervix or vaginal cuff
Evaluation of
Pelvic Floor Muscle Function
• Assessing patient’s ability to contract and
relax pelvic muscles separately
• Measuring the force of contraction
• Palpation of thickness of pelvic floor
musculatures
• Electromyography
• Pressure recording

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Measurement of Bladder Base
Descent (The Q-tip Test)
Lower Urinary Tract Symptoms
caused by Pelvic Organ Prolapse
• Stress incontinence
• Frequency, urgency, urge incontinence
• Hesitancy, weak stream, incomplete
empty
• Manual reduction of prolapse for voiding
• Positional change to start or complete
voiding
Incontinence Assesment
Bowel Symptoms caused by
Pelvic Organ Prolapse
• Difficulty with defecation
• Incontinence of flatus
• Incontinence of liquid stool
• Incontinence of solid stool
• Fecal staining of underwear
• Digital manipulation to complete defecation
• Feeling of incomplete evacuation
• Rectal protrusion during or after defecation
Sexual symptoms caused by
Pelvic Organ Prolapse
• Vaginal coitus?
• Frequency of vaginal coitus?
• Painful coitus?
• Satisfaction with sexual activity?
• Change in orgasm?
• Incontinence experienced during sexual
activity?

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Local symptoms caused by
Pelvic Organ Prolapse
• Vaginal pressure or heaviness
• Vaginal or perineal pain
• Sensation or awareness of tissue
protrusion from vagina
• Low back pain
• Abdominal pressure or pain
• Observation or palpation of a mass
Principles of reconstructive
pelvic surgery
• Site-specific repair
• Rebuild weakened endopelvic fascia,
repair fascial tears, and reattach prolapsed
tissues to stronger sites
• Goal is a vagina of normal depth, width
and axis
• Denervation or muscle trauma cannot be
corrected surgically
Cystocele Repair Cystocele Repair
Burch Lateral defects

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PVR Burch + PDR
Colposuspension

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Rectocele
Rectocele Rectocele
Pelvic Muscle Exercises Medications

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Pessaries