Gyniecological subject

1. Uterovaginal Prolapse

2. Pelvic organ prolapse (POP) is defined as the downward displacement of pelvic
organs from their original position into or beyond the vagina.

3. Incidence and epidemiology
The lifetime risk of surgery for POP is 12–19%
On routine examination, loss of vaginal or uterine support will be seen in
up to 30–70% of women who present for routine gynecological care.

4. The most common form of prolapse is that of the anterior wall of the
vagina (cystocele). Prolapse of the posterior wall (rectocele) is far less
frequent and apical prolapse (descent of the uterus or vaginal vault if the
patient has had a hysterectomy) the least common
Patients can present with one or more of the forms and in any
combination. Most pelvic organ prolapse is asymptomatic.
The natural progression of the condition is poorly understood.

5. Anatomical Classification
describes which organ is primarily involved in the descent:
Urethrocele: the anterior vaginal wall and urethra descend into the vaginal opening
Cystocele: descent of the anterior vaginal wall and bladder
Cystourethrocele: prolapse of the bladder and urethra along with the anterior
vaginal wall
Uterovaginal prolapse: descent of the uterus, the cervix, and the vaginal vault (the
topmost part of the vagina)
Enterocele: prolapse of the posterior uppermost part of the vagina, with loops of
small intestine which have accumulated inside
Rectocele: descent of the lower posterior wall of the vagina, with the rectum which
bulges into it

7. An enormous variation exists in the clinical presentation, from minimal
descent to complete eversion of the vagina along with the uterus, bladder
and rectum. It can also occur in patients who have previously experienced
a hysterectomy
• Stage I where the prolapse does not reach the hymen.
• Stage II where the prolapse reaches the hymen.
• Stage III when the prolapse is mostly or wholly outside the hymen.
When the uterus prolapses wholly outside this is termed procidentia.

9. Aetiology
The aetiology is poorly understood. Predisposing risk factors for the development of
prolapse include
Vaginal childbirth
Age the incidence of prolapse doubling with every decade of life
Obesity
Genetics lower rates of POP reported in Black and Hispanic women compared with
white women
Chronically increased intra‐abdominal pressure, such as chronic cough and heavy
lifting.
previous hysterectomy

10. Relevant anatomy
POP is caused by failure of the interaction between the levator ani muscles
and the ligaments and fascia that support the pelvic organs. The levator ani
muscles are puborectalis, pubococcygeus and iliococcygeus. They are attached
on each side of the pelvic side wall from the pubic ramus anteriorly
(pubococcygeus), over the obturator internus fascia to the ischial spine to form
a bowl-shaped muscle filling the pelvic outlet and supporting the pelvic organs

12. There is a gap between the fibres of the puborectalis on each side to
allow passage of the urethra, vagina and rectum, called the urogenital
hiatus. The levator muscles support the pelvic organs and prevent
excessive loading of the ligaments and fascia.
There are three levels of supporting ligaments and fascia, which work
together to provide a global and dynamic system to support the uterus,
vagina and associated organs

13. Level 1 (apical) support is provided by the uterosacral ligaments, which attach the
cervix to the sacrum. Obviously, support at this level is crucial in contributing to
support of the vaginal walls that are attached to the cervix.
Defects in level 1 support can be seen on examination by the descent of the uterus
within the vagina. Level 1 support remains critical even after hysterectomy, so it is
important during that procedure to reattach the uterosacral ligaments to the vaginal
vault. In women who have previously undergone hysterectomy, level 1 support
defects will manifest as vaginal vault prolapse .

14. Level 2 support is provided by the fascia that surrounds the vagina, both anteriorly
and posteriorly, lying between the vagina and the bladder (pubocervical fascia) or
rectum (rectovaginal fascia). These fascial sheets fuse together at the vaginal edge
and then are attached to the pelvic side wall, fusing to the fascia overlying obturator
internus. These fascial attachments result in the vagina lying as a flattened
tube(laterally) at rest. Defects in the fascia providing level 2 support will lead to
prolapse of the vaginal wall into the vaginal lumen (causing anterior or posterior
vaginal prolapse). The bladder or rectum will prolapse behind the vaginal wall due to
the fascial attachment to it. On examination, the affected vaginal wall will be seen
bulging into the vagina.

15. Level 3 support is provided by the fascia of the posterior vagina, which is
attached at its caudal end to the perineal body. The perineal body is a dense
connective tissue mass underneath the lower third of the posterior vaginal wall
and is the insertion of the posterior vaginal fascia, fibres of levator ani and the
transverse perineal muscles. It is the perineal body that is torn or cut (by
episiotomy) during childbirth.
Defects of the perineal body usually cause the development of lower posterior
vaginal wall prolapse, but the loss of the perineal body increases the size of
vaginal opening and therefore predisposes to anterior vaginal prolapse as well

16. Clinical presentation The most consistent and specific symptom of POP is a
feeling of a bulge in the vagina or a sensation of protrusion of tissue out of the
vagina. In more advanced cases the prolapse can be seen and palpated outside the
vagina with the patient complaining of a ‘lump’. It is not uncommon for women to
be asymptomatic in the early morning and then for the symptoms to develop or
worsen throughout the day with activity and be relieved by lying down.

17. While some women may present with a single symptom of prolapse, they
typically have a more complex presentation that can include urinary symptoms
of incontinence, frequency, nocturia and voiding dysfunction; faecal symptoms
of incontinence and obstructed defecation; and sexual dysfunction. While these
symptoms present commonly in association with prolapse, they are not usually
caused by it and therefore are unlikely to be resolved by the surgery aimed at
correcting the POP

18. Evaluation
Patients presenting with a complaint of POP need to have a comprehensive
history taken. This should include a full urinary, bowel and sexual history. It is also
essential to establish which are the most worrisome symptoms and to clarify
which symptoms the patient hopes will be corrected.

19. All women presenting with symptoms of POP should have a thorough examination. This
should begin with palpation of the abdomen before proceeding to the pelvic examination
to exclude an abdominal mass or ascites.
For the pelvic examination the women should ideally be examined in the dorsal lithotomy
position with Valsalva.
DDX
Vaginal cyst
Pedunculated fibroid
Polyp
Chronic uterine invertion
.

20. A Sim’s speculum is used to systematically identify each component of the
prolapse. To assess for anterior prolapse the blade is used to retract the
posterior wall while inspecting the degree of prolapse of the anterior wall.
Conversely, for the posterior wall the blade is used to retract the anterior
wall while assessing the degree of prolapse of the posterior wall. During
this examination the position of the cervix, or in a post‐hysterectomy
patient the vault, is determined. The final part of the assessment is a
bimanual pelvic examination.

21. There is no need for a routine rectal examination or a barrier test to look for
urinary incontinence
There are a range of methods that have been described to classify prolapse. Of
these, the POP‐Q method is the internationally accepted standard.

23. Investigation
Lower urinary tract symptoms should be evaluated independently with urinalysis,
a urinary flow rate and assessment of the residual urine volume. In selected
cases, where there are significant urinary symptoms, urodynamic testing may be
helpful. Coexistent urinary incontinence should be investigated in the same way
that it would be if the patient did not have POP.

24. Patients with severe symptoms of bowel dysfunction,including obstructed
defecation and faecal incontinence, should be seen by the colorectal team
ahead of any surgical intervention.

25. There is little place for radiological investigations such as dynamic MRI and
transperitoneal ultrasound (TPUS) in the routine management of POP.
Dynamic MRI gives outstanding images but it is unlikely that it offers any
advantages over a detailed clinical examination in the management of
these patients. Likewise, TPUS does not seem to offer any advantages to
clinical evaluation

26. Management
Conservative
It is always preferable to seek a conservative solution ahead of a surgical one.
The condition is bothersome and can restrict normal activities but it is seldom
life‐threatening.
The surgeon must be mindful that all surgical procedures carry inherent risks
and should not proceed with a surgical procedure without first offering a trial
of conservative treatment. It is important to counsel the patient that
progression is not inevitable.

27. Options for conservative therapy include pelvic floor muscle training (PFMT)
and pessary use.
Lifestyle advice such as weight loss and smoking cessation should be
advised when relevant.

29. Vaginal pessaries are devices which are inserted into the vagina for the
management of POP. They have been in use in various forms for hundreds of
years. They offer an excellent non‐surgical option for women with prolapse and
there are virtually no contraindications to vaginal pessary use. A significant
number of women express a preference for a non‐surgical management of their
prolapse.Pessaries can be used as a long‐term solution or as a semi‐diagnostic
test to evaluate which symptoms are removed with reduction of the pessary.
They can also be used as a temporary measure in women who want to delay
surgery until they have completed their family, pregnancy , purperium or while
waiting for surgery

30. The most common side effects, which are also the major reasons for
discontinuing use of a pessary, are vaginal discharge and the
development of granulation tissue in the vagina. Granulation tissue can
exacerbate the discharge
There is no evidence that either systemic or topical oestrogen is effective
therapy for POP and can lead to bleeding
.

34. There is some evidence that use of the selective oestrogen receptormodulator
raloxifene may reduce the need to undergo surgery ,but the vasomotor side
effects associated with this treatment are likely to preclude its use in clinical
practice.

35. Surgery
Women with symptomatic POP who decline conservative treatment or
experience no improvement with it may require surgical treatment.
The aim of surgery is to restore anatomy, relieve symptoms and restore
function.
Before proceeding with surgery it is essential to understand the patient’s
expectations are. The surgeon must be convinced that the proposed
procedure is appropriate and must also ensure that the patient knows what
can be achieved with surgery and, more importantly, what cannot.
Surgery should be reserved for patients who have at least stage 2 POP on
examination and have bothersome symptoms attributable to the POP.

36. Prolapse of the vaginal wall
Anterior repair
Posterior repair
Prolapse of the vaginal vault
Sacrocolpopexy
Sacrospinous fixation (SSF)
Prolapse of the uterus
Vaginal hysterectomy
Sacrohysteropexy
Sacrospinous fixation (SSF)
Manchester repair

37. Surgery can be undertaken using vaginal or abdominal approaches. The
abdominal approach can be through open abdominal surgery or minimal
access surgery (MAS) undertaken either laparoscopically or robotically.
.

38. Surgery for apical prolapse
The abdominal approach usually involves sacrocolpopexy which involves
suspending the vaginal apex to the anterior longitudinal ligament of the
sacrum with a synthetic mesh.
This can be carried out as an open procedure using a Pfannenstiel incision
but more recently the majority are performed either as a laparoscopic
sacrocolpopexy or a robotically assisted sacrocolpopexy.
Transvaginal apical support can also be achieved with a sacrospinous
fixation. This involves suspending the vaginal vault to the sacrospinous
ligament with sutures.
Typically this is a unilateral extraperitoneal approach. There are
descriptions of a bilateral approach, although this is often not possible in
patients with reduced vaginal volume.

39. the abdominal approach was superior to vaginal‐based sacrospinous
colpopexy, with reduced recurrent vault prolapse, postoperative stress
incontinence and dyspareunia. This was at a cost of longer operating
time, longer time to recovery and greater expense. It would seem
therefore that the abdominal supporting procedures should be reserved
for the younger, fitter and more active patients while the vaginal
procedures should be reserved for older and frailer patients.

40. Surgery for anterior compartment prolapse
Anterior vaginal wall defects rarely occur in isolation and are often
accompanied by descent of the vaginal apex (cervix or vaginal vault) or
posterior wall.
The need to repair other anatomic sites should usually be decided under
anaesthesia when the patient is fully relaxed and a detailed examination
can be carried out.

41. Traditionally, the anterior repair involves the midline plication of the vaginal
fascia followed by excision of the redundant vaginal wall epithelium and then
suture of the epithelium.

42. Surgery for posterior compartment prolapse
The operation involves a midline plication of the rectovaginal fascia, excision
of redundant epithelium and reconstruction of the epithelium.

43. Obliterative surgical procedures
Obliterative procedures are reserved for women who have failed
conservative therapy but who have significant comorbidities and are
therefore not candidates for extensive surgery and who do not plan for
future vaginal intercourse. The most common procedure is a colpocleisis.
This can be done in women who have had a hysterectomy and those who
have not

44. The procedure involves removal of strips of vagina from the anterior and
posterior vaginal epithelium, leaving a small strip of lateral epithelium on
each side. The anterior and posterior walls are then sutured together.
The main purpose of the side strips is to allow for vaginal or uterine
secretions to be discharged. The procedure is associated with excellent
results and very low complications