vxc

1. PELVIC ORGAN
PROLAPSE
Dr. Hazem Al-Mandeel
481 GYN
Department of Obstetrics & Gynecology

2. Objectives
• To define pelvic organ prolapse
• Recognize pelvic anatomy
• Determine the Pathophysiology
• Discuss the predisposing factors
• Understand the grading systems
• Be aware of the options of management

3. Pelvic Organ Prolapse
• Is the descent of the pelvic organs as a
result of the loss of muscular and fascial
structural support .

4. Anatomic Supports
• Muscular : Levator Ani (Pelvic Floor Ms.)
• Ligaments : Uterosacral-Cardinal Complex
• Fascial : Endopelvic (Pubocervical &
Rectovaginal)

5. Levator Ani
• Major structure of pelvic floor
• Anterior/posterior orientation
• Perforated by urogenital hiatus
• Consists of : Pubococcygeus
Iliococygeus
Puborectalis
Coccygeus

8. Endopelvic Fascia
• Fibromuscular layer
• Local condensations are ligaments
• Principal ligaments are Uterosacral
Cardinal
• Pubocervical and Rectovaginal Fascia
important in specific surgical correction

12. Pathophysiology
• Direct Trauma to pelvic soft tissues
• Neurological injury
• Connective tissue disorders

13. Predisposing Factors
• Hereditary (genetic) predisposition
• Race: White > Black > Asian
• Pregnancy and Vaginal Childbirth
• Age and Menopause
• Raised intra-abdominal pressure (e.g.:
obesity, cough, constipation, lifting, etc)
• Iatrogenic: surgical procedure

14. Types of Pelvic Organ Prolaopse
1. Urethra
2. Bladder
3. Uterus/ Vaginal Vault
4. Small Bowel
5. Rectum
6. Perineum

15. Compartments
• Anterior : Cystocele
Urethrocele
• Middle : Uterine prolapse
Enterocele/vault prolapse
• Posterior : Rectocele
Rectal prolapse

21. Classification of Prolapse
• Baden Walker (1972)
• Each site graded from 1 – 4
• POPQ: quantifies using specific points
• Measured relation to the hymenal ring
• More widely used

22. Symptoms of Prolapse
• Pelvic pressure
• Pelvic pain
• Feeling of a “lump”
• Back pain
• Urinary dysfunction
• Bowel dysfunction

23. Complications of Prolapse
• Bleeding
• Infection
• Recurrent UTI’s
• Urinary obstruction
• Renal failure

24. Associated conditions
• Urinary Incontinence : Stress
Urge
Mixed
• Fecal Incontinence : sphincter injury

25. Options of Management
• No Treatment ( pelvic floor exercise)
• Conservative: such as
Physiotherapy or Pessary
• Surgical Treatment

28. Aims of prolapse surgery
• Alleviate symptoms
• Restore normal anatomy
• Restore normal visceral function
• Avoid new bladder or bowel symptoms
• Preserve sexual function
• Avoid surgical complications

29. Classisfication of prolapse
surgery
• Vaginal
Primary
Vaginal hysterectomy
Anterior/Posterior repair
Secondary
Sacrospinous fixation
Iliococcygeus fixation
Uterosacral fixation
Recurrent+/- reinforcement
Synthetic mesh/autologous/
donor/Xenograft
• Abdominal
Primary
Paravaginal repair
Hysteropexy
Secondary +- reinforcement
Sacrocolpopexy
Uterosacral/Sacrospinous
fixation
• Laparoscopic
All of the Abdominal
procedures +/-
reinforcement

30. Conclusions
• Pelvic organ prolapse is common
• Results from injury to soft tissue and nerves
• Childbirth most significant association
• Treatment requires understanding of anatomic
relationships
• Treated with a combination of physio/pessary and
often complex surgery