PELVIC ORGAN PROLAPSE
TYPES AND STAGES
Ayman AL Qatawneh
University of Jordan
Gynaecology Department
Y
blager
I Supported
bypelvicfloormust
andfascia
Why
prolapse
p
andfascia
Note forcepswasfoundtodamagepelvicfloormuscleandfasciaandpubs
urethralligament Thatwhyforcepsisabandonedin
andUSA
Europe
Pelvic Organ Prolapse
Alwaysaskabout
Mostimp Q
parity Etiology
Weight instruments
deliveryforcepsandVarun
• PARITY The strongest risk factor
Oxford Family Planning Association Study 1997
gif 4kg
• Increasing Parity and Maximum Birth
Weight Samuelsson EC Am J Obs Gyn 1999
Rinne KM Eur J obs Gyn 1999
Swift SE Am J Obs Gyn 2000
• C/Section as effective as Kegel Exercises.
d protectagainst
pelvic Taskin O J Gynecol Surg 1996
organprolapsinfirst3
deliveries
30notprotective
Pelvic Organ Prolapse
Etiology
plotof dblood of floor andfaria
estrogen supply pelvic muscle
• AGE and MENOPAUSE. Conflicting.
Significant increased risk. Swift SE 2000
No relation. Olsen AL 1997
Progetto Menopause italian study 2000
familyhistory 3 5fold increased risk dueto collagendeficiency type t lowbuthighercollagen3and
thatbreakdowncollagen
collaginoseenzyme
to Responsibleforintegrityofpelvic
floorParis
type
Collagen
Pelvic Organ Prolapse
Etiology
forlongtime
q
• Constipation and Straining.
A Case-Control Study.
61% of women with Constipation and Straining
will develop POP.
4% of women with NO Constipation and Strain
will develop POP.
Spence-Jones C Br J Obset Gynecol 1994
Pelvic Organ Prolapse
Etiology
• HEAVY LIFTING job
• OBESITY
COPDAsthma
• CHRONIC PULMONARY DISEASE M Chronic
cough
and smoking
(increase abdominal pressure)
Pelvic Organ Prolapse
Etiology
• HYSTERECTOMY. Any is ariskfactor
pelvicsurgery
11.6% risk ( Prolapse)
1.8% risk ( Non Prolapse )
Marchionni M J Reprod Med 1999
• Colposuspension (Enterocele) Wiskind Am J 1992
• Sacrospinous Fixation (anterior
compartment prolapse) Bump RC Am J Obs Gyn 1996
Pelvic Organ Prolapse
Etiology
• Vaginal Route > Abdominal.
Damage to pudendal nerve.
Benson JT Am J Obs Gyn 1996
• Vaginal = Abdominal
Maher CF Qatawneh Am J 2004
Pelvic Organ Prolapse
Etiology
Collagen Abnormalities.
• C.T. disorder associated prolapse
• women genital prolapse joint hyper
mobility
• women genital prolapse > proportion type
111 (weaker but flexible) collagen than type
f
1
•
ototal collagen, collagenase, elastolytic
Verycommon
IS
RECIFE Rate is
highposttreatmentpostsurgery riskfactorsarenottreated
because
Mechanism of normal supports of
Uterus and Vagina
Interaction between :
• Pelvic muscles ( Levator Ani group)
Primary support gives a firm elastic base
on which organs rest.
2. Connective Tissue
Stabilize the organs in Correct position
What happens during Micturition and Defecation?
Mechanism of normal supports of
Uterus and Vagina
• Levels of vaginal supports.
1. Level I . Cardinals and Uterosacrals
Tsupportinthestigamatskadoureinprolapse
2. Level II.Arcus Tendineus(white line)
3.Level III.Perineal memb. and Body
Spu fDeletleattocystorek
bladder sarcustentini
HE
ordination
uterus
uterosaerdliga
RectungperordedeeetodPer inrertovagin Pas.r.tl
we
Normal
I Cystocele sdefectofofpubocervicalfascialevel2defect
Anterior Vaginal Wall Prolapse
Cystocele bladderprolapse
• Pathologic descent of the anterior vaginal
wall and the overlying bladder base.
• Two Types
1. Distension
2. Displacement
Uterine
prolapseordefectinutero
sacraland
1
cardinal level
Apical Prolapse
Uterine and Vault
•
as
Damage to the Uterosacral-Cardinal
ligament Complex.
Uterine Prolapse
• Loss of the integrity of the anterior and
posterior vaginal walls.
Post hysterectomy or vault
if
Vaultprfp
I Rectocele defect vaginalfascialevel2
inRecto
Posterior Vaginal Wall Prolapse
Rectocele and Enterocele
rectalprolapse
• Enterocele: is a hernia in which the
peritoneum is in contact with the vaginal
mucosa. Absent endopelvic fascia.
• Rectocele: Defect in the Rectovaginal
Septum .
General Symptoms associated
prolapse
• Bulge, heaviness, or dragging
• backache duetopressureonuterosacralligament
• vaginal dryness or irritation
bowel
stoempty
• need to push the prolapse back after
straining ( defecation)
• sexual activity embarrassing or painful
Urinary tract dysfunction and
prolapse uterus prolapse
Stress urinary incontinence
Bladder neck hyper mobility
Urinary frequency and urgency
Occult stress incontinence lead incaseof oncepushedbacktonormal
cystocele
toleakageofurine
Voiding dysfunction needtopushprolapsetoemptybladder
Recurrent UTI becausewith bladderprolapstovagina sbladdernot
urination
emptied
ofurineinbladder isgoodmediaforinfection
Stagnition
Ureters
inadvancedcases pressureonurterleading tohydronephrosis renalfailure
Symptoms related to rectoceles
• Incomplete bowel emptying
• obstructed defecation
• constipation
• inability empty rectum without reducing
prolapse
• fecal incontinence if rectal prolapse
Grading System
• Cystocele Anterior wall
1st degree . Half way to the Hymen
2nd degree . To the Hymen
3d degree. Outside the Hymen
• Uterine or Vault Cervix or Vaginal apex
1st degree.
2nd degree.
3d degree.
Grading System
• Rectocele Posterior wall
1st degree.
2nd degree.
3d degree.
• Enterocele enterocele sac
1st degree
2nd degree
3d degree
New Classification
POP-Q System
• ICS 1996 Bump et al.
Standardization of terminology
Pelvic Organ Anatomy
Site – Specific
Quantitative
Compartments or Segments.
import
É
to
prolapseextending
