PELVIC ORGAN PROLAPSE

POP

HESHAM A F SALEM MD

ALEX. UNIV.

POPDESCENT OF ANY OF THE PELVIC ORGANS BELOW ITS NORMAL

POSITION IN THE PELVIC CAVITY .

POP One of the commonest presentations in

gynecological practice. 11.1% of 80 years old women have been

exposed to the risk of POP . Olsen 1997. 22.7 per 10000 women had one

operation for POP in one year in the discharge list of American hospitals .

SUBAK 1998 has estimated the direct cost of POP surgery to be 1012 million US $ / year in the USA.

POPMORE THAN 50 % OF WOMEN UNDERGOING

SURGERY FOR POP PERFORMS MORE THAN

ONE PROCEDURE IN SINGLE SURGERY .

ARAH RINGOLD ET AL 2005

POP 29.2% RECURRENCES . Scaring and fibrosis produced by

conventional surgery restores only 50% of tissue strenghth .COSSON ET AL

2003 .J GYN OBST BIOL REP .

58% recurrence rate after I year of surgery in a prospective study . whiteside et al 2004 AM J OB/GYNE.

GOAL OF TREATMENT IS TO RESTORE ANATOMY ANF FUNCTION .

Rectocele and mucosal prolapse of the anus

Complete rectal and uterine prolapse

POP1. ANTERIOR : URETHRA , BLADDER . (central

and lateral )

2. CENTRAL : UTERUS ,CERVICAL STUMP ,VAGINAL VAULT .

3. POSTERIOR : RECTUM ,LOOPS OF INTESTINE (low ,mid , high) .

Anatomy

In upright or sitting position Bladder, upper two-thirds vagina and

rectum lie in a horizontal axis Urethra, distal one-third vagina and anal

canal are vertical in orientation Pelvic floor is horizontal and is like a

hammock – levator plate

THE PELVISWHAT IS SPECIAL ABOUT IT?

NARROW BONY CONTAINER . CONTAINS 3 DIFFERENT DISTENSIBLE

SYSTEMS . THEY ARE DISTENSIBLE TO MANY

MULTIPLES OF THEIR ORIGINAL SIZES .

3 HIGH PRESSURE POINTS . ONE LOW PRESSURE (low resistence )

SYSTEM ( vagina ,anal canal, urethra ) .

THE PELVISWHAT IS SPECIAL ABOUT IT

THE 3 SYSTEMS ARE IN VERY CLOSE PROXIMITY TO EACH OTHER .

THE 3 SYSTEMS ARE KEPT IN PLACE AND IN PROPER INTERRELATIONS BY THE ENDOPELVIC FASCIA .

WHEN ONE SYSTEM WORKS THE OTHER 2 ARE NEGATIVELY AFFECTED .

THE PELVISWHAT IS SPECIAL ABOUT IT

ONE HIGH PRESSURE SYSTEM CAN INVADE THE OTHER LOW PRESSURE ONE IF THE SUPPORTING ENDOPELVIC FASCIA IS TORN OR LOST .

THE PELVIC DIAPHRAGM ACTS ONLY AS A SOUTH GATE FOR THE PELVIS, AND HAS NOTHING TO DO WITH THE INTERRELATIONS BETWEEN THE DIFFERENT SYSTEMS .

USING THE MUSCLE TO CORRECT MALRELATIONS BETWEEN ORGANS NEEDS REVISION .

NORMAL DEFECATION

Anatomy The levator complex is composed of the

pubococcygeus, the iliococcygeus, and the coccygeus muscles. The most medial fibers of the pubococcygeus make up the puborectalis. These fibers loop around the posterior aspect of the rectum and create an anterior displacement of the rectum known as the anorectal angle.

The pelvic surface of the levator complex is innervated by sacral efferent from S2 through S4. The inferior surface is supplied by the perineal and inferior rectal branches of the pudendal nerve.

The levator ani musculature is attached to the inner sides of the bony pelvis by a condensation of pelvic fascia called the arcus tendineus.

Supporting ligaments and fascia

The urethropelvic ligament is a fibrous band of connective tissue that lines the undersurface of the bladder neck and attaches laterally to the arcus tendineus. The urethropelvic ligament provides the major support to the bladder neck and proximal urethra. Laxity of the urethropelvic ligament results in SUI.

Supporting ligaments and fascia

The pubocervical fascia is a fibrous sheet of connective tissue that lines the base of the urinary bladder and inserts laterally into the arcus tendineus. An intact pubocervical fascia prevents the herniation of the bladder and the proximal urethra into the vagina. Damage to the pubocervical fascia may cause the bladder to herniate through the vagina, resulting in cystocele formation and SUI

Supporting ligaments and fascia

The cardinal ligaments arise from the arcus tendineus and anchor to the uterine cervix. The cardinal ligaments stabilize and support the uterus, vagina, and bladder. Weakening of the cardinal ligaments may cause a cystocele and uterine descensus.

Supporting ligaments and fascia

The uterosacral ligaments originate from condensation of the fibrous connective tissue overlying the sacral promontory and insert into the uterine cervix. The uterosacral ligaments stabilize the uterus in the bony pelvis. Weakening of the uterosacral ligaments may cause a prolapsed uterus or vaginal vault prolapse.

Vaginal ligaments

The vagina can be anatomically divided into the proximal, middle, and distal regions. The proximal segment, called the vault or cuff, is stabilized by the parametrium, which includes the cardinal and uterosacral ligaments. Uterine and vault prolapse are both associated with damage to these supportive structures.

The mid portion of the vagina is attached laterally to the pelvic sidewalls by the lower portion of the paracolpium to the arcus tendineus fascia pelvis (ATFP), which creates the superior lateral vaginal sulcus observed during a physical examination.

Vaginal ligaments

The pubocervical fascia stretches between the ATFP to support the anterior vaginal wall and bladder. A cystocele can occur when damage to the pubocervical fascia in the central or lateral areas (or both) allows the bladder to prolapse into the vagina.

Vaginal ligaments In a similar fashion, the posterior

vaginal wall in the mid vagina is supported centrally and laterally by the rectovaginal fascia, which is attached to the fascia of the levator ani musculature. These attachments prevent the rectum from prolapsing into the vagina and causing a rectocele.

Vaginal ligaments

The distal vagina is firmly attached to the surrounding structures, including the urethra and symphysis pubis anteriorly, levator ani laterally, and perineal musculature posteriorly. Damage to the perineal musculature by childbirth or surgery are common causes of a relaxed outlet.

NATURE OF PELVIC LIGAMENTS THEY ARE NOT TRUE LIGAMENTS . THEIR MAIN FUNCTION IS BALANCE OF PELVIC

ORGANS . THEY SUSPEND PELVIC ORGANS WHEN THE

LEVATOR SUPPORT FAILS . LEVATOR IS NOT REPAIRABLE NOR REPLACABLE. LIGAMENTS ARE REPAIRABLE OR REPLACABLE . LIGAMENTS ARE CONDENSATIONS OF A

CONTINUM CALLED THE ENDOPELVIC FASCIA .

Boat in dock analogy

Boat- pelvic organs Water- levator muscles Moorings- Endopelvic fascial

ligaments Problem is with the water or moorings

or both Result is sinking of the boat Really the boat itself is fine

Boat in dock analogy The main support for the pelvic viscera is

provided by a group of muscles collectively called the levator ani. An intact pelvic floor allows the pelvic and abdominal viscera to "rest" on the levator ani, significantly reducing the tension on the supporting fascia and ligaments. These pelvic ligaments are not true ligaments and are simply condensations of endopelvic fascia covering the pelvic structures.

Boat in dock analogy

The pelvic floor musculature and the pelvic ligaments work together to provide support to the pelvic floor structures. Most of the weight of the pelvic viscera is supported by the levator ani, whereas the pelvic ligaments stabilize these structures in position, much as a ship's weight is supported by the water and the moorings simply keep the ship from straying from the dock. When the levator ani is damaged, excessive force is placed on the ligaments, creating a predisposition for pelvic prolapse.

PROLAPSE

Mutifactorial involving both neuromuscular and endopelvic fascial damage

Relaxation of the tissues supporting the pelvic organs may cause Downward displacement of one or more of

these organs into the vagina, which may result in their protrusion through the vaginal introitus.

Displacement of one or more of pelvic organs into the rectum or onto the perineum.

Factors promoting prolapse

Erect posture causes increased stress on muscles, nerves and connective tissue

Acute and chronic trauma of vaginal delivery Aging Estrogen deprivation Intrinsic collagen abnormalities Chronic increase in intraabdominal pressure

heavy lifting coughing constipation

Factors promoting prolapse

More recently, an association between collagen and connective tissue disorders and pelvic floor relaxation has been established.

Some vaginal prolapse conditions may even be caused by prior pelvic surgery. For example, a hysterectomy may cause an enterocele or vault prolapse to form if the vault is not adequately resuspended and the cul-de-sac is not prophylactically obliterated.

Factors promoting prolapse A rectocele is a prolapse of the rectum into

the vagina through a damaged rectovaginal septum. The most likely etiology for rectocele formation and perineal relaxation presumably is improper childbirth because these conditions are essentially confined to parous women.

In some cases, a relaxed outlet may be caused by an inadequately or incompletely healed episiotomy performed at the time of childbirth.

Factors promoting prolapse

A cystocele is a prolapse of the urinary bladder into the vagina through a damaged urethropelvic fascia . The most likely etiology for cystocele formation presumably is improper childbirth because these conditions are essentially confined to parous women.

Factors promoting prolapse

Uterine prolapse is descent of the uterus due to laxity or damage of the maine uterine ligaments during improper childbirth .

Pelvic organ displacements are usually the result of disruption of the endopelvic fascia in between the maine pelvic ligaments .

STRATEGY OF TREATMENT

1.MUSCLE DEFECT .2.FASCIAL DEFECT

STRATEGY OF TREATMENT EXERCISE IS THE ONLY WAY TO

STRENGHTHEN A MUSCLE . MUSCLE APPROXIMATION IS HELPFUL ONLY

IN DIVARICATION DEFECTS . REPAIRE OR REPLACEMENT OF FASCIA AND

LIGAMENTS IS THE IDEAL WAY TO CORRECT PROLAPSE .

HYSTRECTOMY TO TREAT UTERINE PROLAPSE IS AN UNWISE CHOICE .

FASCIA REPLACEMENT SURGERY EASIER THAN CONVENTIONAL SURGERY . SHORTER LEARNING CURVE . LESS INVASIVE . ORGAN SAVING . eg uterus , levator ani. LESS LAPAROTOMIES . FASTER RETURN TO USUAL LIFE ACTIVITIES . SOME NEW PROBLEMS HAS EVOLVED AND NEED

SOME TIME FOR BUILDING UP EXPIERIENCE TO MANAGE THEM .

EQUAL OR BETTER RESULTS .

FASCIA REPLACEMENT SURGERY Uterine prolapse : replacement of the

uterosacral ligament by plication or mesh promontofixation , sacrospinous fixation ,P IVS .

Rectocele : replacement of the rectovaginal fascia .

Cystocele , urethrocele : replacement of the pubocervical fascia and urogenital triangle .

Gsi : replacement of the pubocervical fascia by TOT ,TVT A IVS , TVT SECURE .

Perineology

Perineology is the result of the fusion between urogynecology and coloproctology. This "three-axis approach" is now becoming widely accepted.

The aim of Perineology is the understanding of the anatomy in the respect of biomechanics and physiology.

The functional state of the perineum can be summarized with a T.A.P.E. (Three Axis Perineal Evaluation).

Perineologist This approach has to be interdisplinary and not

multidisciplinary. There is only one boss who must be the "architect of the perineum", somebody who knows a lot about the anatomy and the physiology of the three axis.

This new specialist is called "perineologist". He could be the surgeon or somebody who tells the surgeon what to do. The perineologist must have a holistic view (integration of the psychology, the way of life, the abdominal wall muscles... in the approach).

MESSAGE

REPAIR SHOULD BE COMPREHENSIVE . MUSCLE EXERCISE IS IMPORTANT . TORN LIGAMENTS MAY BE REPAIRED

OR REPLACED . WE ARE IN NEED OF A PERINEOLOGIST

WHO CAN HANDLE THE PROBLEM OF POP IN A WIDER ANGEL OF VISION .