Pelvic organ

prolapse (POP) Amer Salamat

Definition

Decent of one or more of the pelvic organs (uterus,

urinary bladder, urethra, rectum , and loops of bowel),

downwards into the vagina.

Prolapse is a condit ion in which organs are normally

supported by the pelvic f loor herniate or protrude into

the vagina due to weakness in their support ing

structure.

Epidemiology

• Common problem in women(12-30% of women)

Increase s ign i f icant ly by both age and mul t ipar i ty.

• 11-19% l i fe t ime r isk of surgery ( 80-85 y)

- Of these, 29% requi re repeat surgery

• 5-7% develop post -hysterectomy vaul t pro lapse

Relevant Anatomy

Supports of the uterus:

1) Main support: (l igaments)

a. Transverse cervical l igament (the

Mackenrodt’s l igament): the most

important one

b. Uterosacral l igament

c. Pubocervical l igament

2) Addit ional support:

Pelvic f loor muscles:

The levator ani muscles is the most

important and consists of :

1) Ischio-coccygeus muscle

2) I l io-coccygeus muscle

3) Pubo-coccygeus muscle ( the most important

part of the levators muscle)

3) The anteverted anteflexed position

of the uterus (posterio angulation of the

vagina)

Support of the vagina: Three levels of

support(DeLancey):

1) Level I (upper level)

Cervix and upper vagina(Uterosacral -cardinal l igaments)

Loss of level I support?

Uterine and vault prolapse

Uterine

prolapse

Vaginal vault prolapse

2) Level I I (middle level )

Middle th i rd of vagina

At tached lateral ly to the pelvic s ide wal ls by:

Pubocervical fascia anter ior ly

Rectovaginal fascia poster ior ly

Levator ani muscles ( through the tendinous fasciae pelvis)

Loss of level I I support : Cystocele, Rectocele.

Cystocele

Rectocele

3) Level I I I ( lower level)

Lower third of the vagina

Perianeal membrane (posterior)

Urogenital diaphragm (anterior)

Loss of level I I I support: distal rectocele, urethrocele

Rectocele

Risk Factors

• Increase in t ra-abdominal pressure (s t ra in ing, chronic

cough, chronic const ipat ion, weight l i f t ing, in t ra -

abdominal tumor “ f ibro id, ovar ian cyst ” )

• High impact exerc ises

• Age/menopause

• Obesi ty

• Smoking

• Mult ipar i ty

• Congeni ta l weakness- rare (def ic iency in co l lagen

metabol ism)

• In jury to pe lvic f loor muscles ( Ia t rogenic/ pe lvic

surgery-Hysterectomy)

• Medical i l lnesses (DM, HTN)

Pathophysiology

Congenital acquired

Congenital

• 2% of nu l l iparous

• Congeni ta l weakness of the pelvic supports associated wi th :

1) Shor t vagina

2) Spina b i f ida

3) Deep uterovaginal , and uterosacral pouches

• Prolapse in ear ly age

• “nu l l iparous” ,or “vaginal ” pro lapse

Acquired

Direct in jury to pelvic musculature and fasciae, as wel l as

par t ia l denervat ion of pelvic f loor muscles.

1) Obstetr ic ch i ldb ir th t rauma

- Vaginal del ivery is the most f requent c i ted r isk factor for POP

- In jury to the pelvic supports, due to s t retch of the pelvic

t issues, levator ani muscle, and i ts nerve supply.

- CS del ivery?

Such trauma may be aggravated by one or more of:

1) Mult iparity: major predisposing factor, r isk of POP

increased 1:2 t imes with each vaginal del ivery. Also

rapid successive pregnancies not al lowing t ime for

proper involution of pelvic t issues.

2) Increased duration of 2nd stage of labor: high fetal

birth weight, and wrong forceps appl ication.

3) Direct pelvic f loor injury: unsutured or poorly repaired

perianeal tear

2) Postmenopausal atrophy:

Advanced age cited as major r isk factor for prolapse.

The incidence of POP doubles every decade of l i fe between the 30-60

years of age.

Due to the degenerative changes, with loss of col lagen caused by estragon

deficiency.

Hormone replacement therapy (HRT)

Not protect against developing POP

Never been demonstrated to have a negative effect

Types and degrees

1) Anter ior vaginal wal l pro lapse (anter ior compartment)

- Urethrocele, Cystocele, cysto -urethrocele.

2) Poster ior vaginal wal l pro lapse (poster ior compartment)

- Rectocele, Enterocele.

3) Apical vaginal pro lapse (central compartment)

- Utero-vaginal pro lapse, Vaul t pro lapse

Grading

• POP-Q

• Baden walker grading system

Pelvic Organ Prolapse

Quantification (POP-Q)

For c l in ica l purposes, the degree of POP is commonly

descr ibed as above , a t , or beyond the in t ro i tus wi th or

wi thout Valsa lva

POP-Q

•Def ines pro lapse by measur ing descent o f spec i f ic segments

o f the reproduct ive t ract dur ing Valsa lva re la t i ve to a f ixed point ; the

hymen

•Highly re l iab le , reproduc ib le

But

•Too many var ia t ions to a l low grouping pat ien ts in to comparab le

popula t ions for s tudy purpose

•Too complex for s imple c l in ica l communica t ion

Six s i tes:

Points Aa, Ba, C, D, Ap ,Bp, geni ta l h ia tus ( gh), per ineal body (pb), and to tal

vagina l length ( tv l )

Hymen is f ixed point o f re ference

Point Aa: po int in mid l ine of anter ior vagina l wal l 3 cm proximal to external urethral

meatus (approximately the b ladder neck or urethral ves ical junct ion)

I t can only range f rom -3 cm (no pro lapse) to +3 cm (complete pro lapse)

Point Ba: the most d is tal po int o f the upper anter ior vagina l wal l .

Point Ba is -3 when there is no pro lapse and would have a pos i t ive va lue equal to

Point C in a pat ient wi th to tal vagina l evers ion.

POP-Q Ordinal stages

Created to make

comparison and clinical

communications more

practical

Stage

0

I

II

III

IV

Description

No descend of pelvic structures during straining

The leading surface of the prolapse does not descend

below 1 cm above the hymenal ring

The leading edge of the prolapse extends from 1 cm

above the hymen to 1 cm through the hymenal ring

The prolapse extends more than 1 cm beyond the

hymenal ring, but there is no complete vaginal eversion

Complete eversion of the vagina

Baden Walker Grading of POP

• First degree

Lowest par t o f pro lapse descends hal fway down the vagina

to the in t ro i tus

• Second degree

Lowest par t extends to the leve l o f in t ro i tus and through on

s t rain ing

• Third degree

Lowest par t extends through in t ro i tus and l ies outs ide the vagina

• Procidentia

Descr ibes complete uter ine pro lapse

Clinical presentation

1) Asymptomat ic : in mi ld cases wi th normal vagina l or u terovagina l

descent .

2 ) Symptomat ic : assoc ia ted wi th moderate or marked pro lapse:

a . Sensat ion of pe lv ic heaviness: especia l l y towards the end of the day

that improves or d isappears by rest .

b . A mass f i l l ing the vagina or prot rud ing f rom the vu lva : that may be

fe l t by the pat ien t on s t ra in ing or squat t ing , and d isappear by ly ing

supine, or by manual reduct ion

c. Low backache: prominent by the end of the day, being aggravated by

heavy work, and weight l i f t ing, and disappears by rest and lying supine.

Mostly with uterine prolapse, due to stretch on uterosacral l igaments.

d. Urinary symptoms: are common in the presence of cystocele.

- Frequency of micturit ion (mechanical irr i tat ion of tr igone), also may

develop at night (nocturia) when cystit is develops due to residual urine.

- Stress urinary incontinence SUI.

- Inabil i ty to complete micturit ion unless the anterior vaginal wall is

pushed upwards and supported by the f inger

- Acute urinary retention mostly in the 1st tr imester

e. Rectal symptoms: heaviness in the rectum with diff iculty when

trying to defecate. (constant desire to defecate)

f . Decubitus ulcer

h. Vaginal discharge

i . Dyspareunia

Differential diagnosis

• Vaginal cyst

• Cervical polyp

• Elongation of the cervix

• Tumor of the urethra/ bladder

• Large urethral divert iculum

• Skene’s and Bartholin’s gland cyst/abcess

Approach

- His tory (age, r isk factors and compl icat ions)

- Phys ical examinat ion:

• le f t la teral pos i t ion or dorsal pos i t ion

• Speculum examinat ion

• Urinary s t ress incont inence

• Rectal examinat ion

• Rectovaginal examinat ion

Investigations

1. Routine blood chemistry, CBC, KFT, LFT

2. Urine analysis, culture.

3. Urodynamic studies.

4. IVU and cystoscopy.

5. Pelvic and Abd. Ultrasound

6. Wound swab

Prevention

• Minimizing chi ldbirth trauma (avoid diff icult

labor, immediate proper repair of episiotomy

and perineal tear).

• Minimizing chronical ly increased intra -

abdominal pressure:

- Chronic cough

- Constipation

- Obesity

• HRT

• Smaller family size

• C section

Treatment

The choice of treatment of prolapse depends on several factors

including:

1. Type and degree

2. Preserve coital function

3. Preserve fert i l i ty

4. Acceptance of surgical treatment

5. Level of f i tness

Treatment

1. Conservative

2. Surgical

Conservative

• Treating underlying condit ions

• Lifestyle modif ication

• Pelvic f loor physiotherapy (Kegal exercises)

• Estrogen replacement therapy

• Vaginal pessary

Pessary treatment

Ind icat ions:

1. Temporary to a l low for t reatment of under lying condi t ions (promote heal ing

of decubi tal u lcer pr ior to surgery)

2. Pat ients who refuse surgery

3. Dur ing pregnancy

4. Medical ly unf i t pat ients

5. Therapeut ic test

Surgery

Indications:

1. Failed conservative

2. Severe degree

3. Complete family size, doesn’t desire to preserve fert i l i ty

Surgical management of POP

Anterior compartment

Posterior compartment

Apical compartment

Anterior repair

Two surgical approaches:

• Tradi t ional Rx: less compl icat ions

Lower r isk of reoperat ion

• Prosthet ic Rx ( use of synthet ic mesh): Higher success rate

Surgical Rx

• Improves QoL

• Improves sexual funct ion

Posterior repair

Perineal reconstruction

Uterine preserving (Hysteropexy)

Su s p e n d t h e u t e r u s

R a t i o n a l e t o p r e s e r v e t h e u t e r u s

• Fert i l i t y

• Role in orgasm and female sexual i t y

• Female sexual ident i ty

• Lack of u ter ine pathology

R o u t e s

• Abdomina l : Sacrohys teropexy

• Vaginal : Manchester repai r, sacrosp inous hysteropexy

and uterosacra l l igament p l icat ion

• Laparoscop ic : Round l igament p l icat ion,

sacrohys teropexy, u terosacra l p l icat ion

Hysterectomy or hysteropexy

Uter ine preservat ion d id not increase r isk of recurrence

Hysterectomy e l iminates r isk of cervical / u ter ine pathology

• The r isk is very min imal

• Of postmenopausal women who had vagina l cys t . :

o 2 .6 % found to have premal ignant or mal ignant

u ter ine pathology

o 0 .3% had endometr ia l carc inoma

Potent ia l d isadvantages of hysterectomy

• Increased r isk of pe lvic neuropathy

• Disrupt ion of natural support (u terosacra l l igament)

Vault

suspension

Sacrocolpopexy

Sacrospinous colpopexy

Posterior intravaginal slingplasty

Sacrocolpopexy

Sacrospinous colpopexy

PFR

Complication

1) General complications

•Anesthetic problems: very rare

•Bleeding: Serious requiring transfusion (

< 1%)

•Post operative infection: Small r isk

•UTI : 6% if a catheter has been used

2. Specific complications

• Const ipat ion: common

• In jury to b ladder, urethra, ureters, rectum :

uncommon

• Urine retent ion: rare, avoid b ladder neck

sutures

• Postoperative stress urinary

Incontinence:

o After a large anter ior wal l repair

o Urodynamics pr ior to surgery

• Mesh Complications:

o Mesh extrus ion : 5-10%

o Vaginal pain

o Dyspareunia

Thank you