Pelvic Organ Prolapse

Prof HOSSAM HUSSEIN

Pelvic Organ Prolapse

Incidence

Difficult to determine but common

~41% of women aged 50-79 years show some degree of
prolapse
Most common reason for hysterectomy (13%)
Accounts for 20% of women on waiting lists for major
gynaecological surgery
Life-time risk of surgery for prolapse – 11%
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
Pelvic Organ Prolapse
• Is the descent of the pelvic organs as a result of the loss of muscular
and fascial structural support .
Anatomic Supports
• Muscular : Levator Ani (Pelvic Floor Ms.)
• Ligaments : Uterosacral-Cardinal Complex
• Fascial : Endopelvic (Pubocervical & Rectovaginal)
Levator Ani
• Major structure of pelvic floor
• Anterior/posterior orientation
• Perforated by urogenital hiatus
• Consists of : Pubococcygeus
Iliococygeus
Puborectalis
Coccygeus
Endopelvic Fascia
• Fibromuscular layer
• Local condensations are ligaments
• Principal ligaments are Uterosacral
Cardinal
• Pubocervical and Rectovaginal Fascia important in specific surgical
correction
Pathophysiology

• Direct Trauma to pelvic soft tissues

• Neurological injury

• Connective tissue disorders

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
 Risk Factors

• Parity — The risk of POP increases with increasing parity

• Prospective cohort study of more than 17,000
• The risk of hospital admission for POP increased
• 1st birth- 4-fold
• 2nd - 8-fold
• 3rd - 9-fold
• 4th- 10-fold
• Among parous women, it has been estimated that 75 percent of prolapse can
be attributed to pregnancy and childbirth

• Advancing Age- Older women are at increased risk for POP

• Every additional 10 yrs of age increased prolapse risk by 40%
 Risk Factors

• Obesity
• Overweight and obese women (body mass index >25) have a two-fold higher risk of
having prolapse than other women

• Hysterectomy
• Hysterectomy is associated with increased apical prolapse
• ? Vaginal > Abdominal ?

• Other risk factors

• Chronic constipation is a risk factor for POP, likely due to repetitive increases in
intraabdominal pressure
• COPD, etc conditions that also increase intraabdominal pressure
 Risk Factors

• Race and Ethnicity-

• African Americans lower prevalence than other ethnic groups
• Risk of Latina and white women is four to five fold higher than AA
Factors linked to pelvic organ prolapse
Types of Pelvic Organ Prolaopse
1. Urethra
2. Bladder
3. Uterus/ Vaginal Vault
4. Small Bowel
5. Rectum
6. Perineum
Compartments
• Anterior : Cystocele
Urethrocele
• Middle : Uterine prolapse
Enterocele/vault prolapse
• Posterior : Rectocele
Rectal prolapse
Terminology
• Anterior compartment prolapse (cystocele)
• Hernia of anterior vaginal wall often associated with descent of the bladder

• Posterior compartment prolapse (Rectocele)

• Hernia of the posterior vaginal segment often associated with descent of the
rectum

• Apical compartment prolapse (uterine prolapse, vaginal vault prolapse)

• Descent of the apex of the vagina into the lower vagina, to the hymen, or
beyond the vaginal introitus
• The apex can be either the uterus and cervix, cervix alone, or vaginal vault
• Apical prolapse is often associated with enterocele.

• Enterocele
• Hernia of the intestines to or through the vaginal wall
 Pelvic Organ Prolapse

Anterior wall prolapse Posterior wall prolapse

Enterocele
 Terminology

• Procidentia
• Hernia of all three compartments through the vaginal introitus.
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
Baden Walker classification of prolapse
Classifications of uterine prolapse
• 1st degree uterine prolapse the cervix is below the ischial spine but
above the introits.
• 2nd degree uterine prolapse the cervix is bellow the vestibule but
not the whole uterus.
• 3rd degree uterine prolapse all the uterus is out the vestibules
 Clinical Presentation
Common Symptoms associated with Pelvic Organ Prolapse
Symptoms of Prolapse
• asymptomatic
• Pelvic pressure
• Pelvic pain
• Feeling of a “lump”
• Back pain
• Urinary symptoms
• Bowel symptoms
What are the symptoms of pelvic floor
prolapse?
• This depends on the types and the severity of the prolapse.
• Generally, most women are not aware of the presence of mild
prolapse.
• When prolapse is moderate or severe, symptoms may include
sensation of a lump inside the vagina or disturbance in the
function of the affected organs, such as:
Sensory
• Lump
• Pain/discomfort in
pelvis/vagina/buttocks/
lower back
• Often vague ‘ache’ or
‘dragging’
• Dyspareunia/
obstruction during
intercourse
• Excoriation/bleeding from
protruding tissue
Bladder
• stress incontinence
• urgency
• frequency
• incomplete emptying
• dribbling
• recurrent urine infections
Urinary
• Hesitancy
• Poor Flow
• Incomplete emptying
• Recurrent UTI’s
• Need to reduce
prolapse or adopt
specific postures to
initiate/complete
micturition
Bowel
• low back pain or discomfort
• incomplete emptying
• constipation
• manual decompression
• incontinence of flatus
Gastro-intestinal
• Constipation
• Incomplete emptying
• Tenesmus
• Digitation
• Incontinence
• Flatus/Staining from residual
stool
Sexual problems
• looseness and lack of sensation
• difficult entry and expulsion
• discomfort or painful intercourse
• vaginal bleeding in neglected cases
Other
• can see and feel it
• back ache
• dragging sensation
• increased discharge
• skin irritation
SIGNS / EXAMINATION:
Inspection
 Gaping introitus
 Perineal scars
 Visible cystocele and rectocele /
urethral
 Uterine prolapse
 Cx. Ulceration (contact)
= Decubitus ulcer

Degree of prolapse
 Examination

• Examination components
• Visual inspection
• Speculum examination
• Bimanual pelvic examination
• Rectovaginal examination
• Pelvic Floor Muscle evaluation
 Equipment

• Instruments
• Sims retractor (single blade speculum) or a bivalve speculum that can be
easily taken apart so that the anterior and posterior blades can be used
separately to observe individual compartments of the vagina (anterior,
posterior, apical).
• To make the measurements for the POPQ system, a ruler or a large cotton
swab or sponge forceps marked in 1 cm increments is used
• Ring Forceps occasionally used for evaluation of occult incontinence to reduce
prolapse
 Patient Positioning ???

• The examination is performed with resting and maximal straining position

• The patient is examined initially in the dorsal lithotomy position

• The examination is then repeated with the patient standing

• In the standing position, the patient places one foot on a well-supported footstool. The examining
gown is lifted slightly to expose the genital area during the examination
Visual Inspection
• The first part of the examination is a visual inspection of the vulvar, perineal, and
perianal areas with the patient in the dorsal lithotomy position

• As during other components of the examination, the inspection should be

performed initially with the patient relaxed and then while straining

• Findings that should be noted during this component of the examination include:
• Transverse diameter of the genital hiatus (eg, the space between the labia majora)
• Protrusion of the vaginal walls or cervix to or beyond the introitus (procidentia)
• Length and condition of the perineum
• Rectal prolapse

• In patients with prolapse to or beyond the hymen, the vaginal tissue is examined for
ulceration.

• Any other findings (eg, skin or mucosal lesions) should be noted and evaluated
appropriately
Speculum and Bimanual Exam
• The speculum and bimanual examinations are the principal components

• Prolapse of each anatomic compartment is evaluated as follows:

• Apical prolapse (prolapse of the cervix or vaginal vault) – A bivalve speculum is inserted into
the vagina and then slowly withdrawn; any descent of the apex is noted

• Anterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum is
inserted into the vagina with gentle pressure on the posterior vaginal wall to isolate
visualization of the anterior vaginal wall

• Posterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum into the
vagina with gentle pressure on the anterior vaginal wall to isolate visualization of the posterior
vaginal wall

• To complete the exam, a bimanual examination is performed in order to evaluate for any
coexisting pelvic abnormalities
 Rectovaginal Examination

• Diagnose an enterocele
• Differentiate between a high rectocele and an enterocele
• Assess the integrity of the perineal body
• Detect rectal prolapse
• The best method for detecting an enterocele is to perform the
rectovaginal exam with the patient standing (?); the small bowel can
be palpated in the cul-de-sac between thumb and forefinger
 Neurologic/Pelvic Floor Muscle
Evaluation
• Pelvic floor muscle testing
• The pelvic floor musculature is inspected to evaluate integrity and symmetry
• The examiner should also note the presence of scarring and whether pelvic
floor contraction pulls the perineum inward
• Palpation through the vagina or rectum helps in assessing pelvic floor squeeze
strength and levator muscle thickness.
• The tone and strength of the pelvic floor muscles can be assessed by asking
the patient to contract the pelvic floor muscles around the examining fingers.
• Women with poor pelvic floor muscle function may benefit from pelvic
physical therapy
Complications of Prolapse
• Bleeding
• Infection
• Recurrent UTI’s
• Urinary obstruction
• Renal failure
Associated conditions
• Urinary Incontinence : Stress
Urge
Mixed
• Fecal Incontinence : sphincter injury
Options of Management
• No Treatment ( pelvic floor exercise) see USI

• Conservative: such as
Physiotherapy ( see SUI) or Pessary (postpone operations,
puerperium, pregnancy, postmenopausal unfit)

• Surgical Treatment
 Treatment

• Physical Therapy-
• Pelvic floor muscle exercises (PFME) appears to improve stage and symptoms
• The best designed randomized trial included 109 women with stage I to III
prolapse who were assigned to either PFME for six months or control group
• Women in the PFME group had significant reductions in the frequency and bother of
most prolapse, bladder, and bowel symptoms (exceptions were urge urinary
incontinence symptoms, difficulty with stool emptying, and solid stool fecal
incontinence)
• Improvement in POP stage was found more frequently in the PFME group (19 versus 8
percent)
 Treatment

• Estrogen therapy ?
• Use of estrogen and estrogenic agents (raloxifene) appears to be associated with a decrease in undergoing surgery for POP, according
to a systematic review of randomized trials

• This systematic review included six trials, however, none of these evaluated the role of estrogen in treating POP
 Treatment

• Vaginal pessary
• The mainstay of non-surgical treatment for POP is the vaginal pessary
• Pessaries are silicone devices in a variety of shapes and sizes, which support the pelvic organs
• Approximately half of the women who use a pessary continue to do so in the intermediate term of one to two years
• Pessaries must be removed and cleaned on a regular basis

• CONTRAINDICATIONS
• Local infection — Active infections of the vagina or pelvis, such as vaginitis or pelvic inflammatory disease, preclude the use of a
pessary until the infection has been resolved
• Latex sensitivity — The Inflatoball pessary is made of latex; therefore, it is contraindicated in women with latex allergies. The other
pessaries discussed below are nonallergenic.
• Noncompliance — Noncompliance with follow-up could be harmful since an undetected and untreated erosion could put the patient
at risk of developing a fistula
• Sexually active women who are unable to remove and reinsert the pessary — Inability to manage the pessary around coital activity
could be discouraging
Treatment
 Treatment

• Fitting the pessary

• Women to be fitted for a pessary are first examined with an empty bladder in the dorsal lithotomy
position
• Pessaries are inserted into the vagina with the dominant hand, while the nondominant
hand separates the introitus and depresses the perineal body.
• After the pessary is inserted into the vagina, the woman is asked to strain and cough
repeatedly on the examination table, ambulate in the office, and void and strain while
sitting on a toilet
• This "office trial" helps determine if she will be able to retain the pessary and void when
she returns home, and if bothersome urinary incontinence will develop.
• She should have a negative cough stress test following pessary placement, as she is
unlikely to be satisfied if there are significant SUI symptoms
• Women should be reassured that it is not an emergency if the pessary is expelled; they
should just bring the pessary back to the office and a different type or size of pessary will
likely be effective
• Follow-up
• A follow-up visit is scheduled one to two weeks later.
• The pessary is removed and cleaned with soap and water, and the vagina is
examined for erosions
• If the pessary fits well and there were no side effects, motivated and able
patients are taught how to remove, clean, and reinsert their pessary at least
once per week, with follow-up in one to two months, and every 6 to 12
months thereafter
• If the patient cannot, or chooses not, to remove and reinsert her pessary,
then she returns for follow-up in one to two months, and every three to four
months thereafter for pessary cleaning and assessment by the provider.
 Treatment

• Offer most women low-dose estrogen vaginal cream (0.25 to 0.5 g applicator, two to three nights
per week) to treat co-existing vaginal atrophy and dryness from estrogen deficiency
• KY or other non-hormonal lubrication may be used for those patients where estrogen is contraindicated (breast ca,
etc)
• In some women, the width of the introitus may decrease in size after several weeks of pessary
use. In such women, a new smaller size pessary is prescribed to allow for easier removal and
insertion
 Treatment-Surgical

• Candidates
• Symptomatic POP
• Failed or declined conservative management
• Women finished with childbearing
• Reports of uterine sparing procedures
• Young or Elderly-
• Risk of recurrence in young (sacral colpopexy) and comorbidities in elderly (colpocliesis)
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

 Classisfication of prolapse
surgery
• Vaginal • Abdominal • Laparoscopic

Primary Primary All of the Abdominal

Vaginal hysterectomy procedures +/-
Paravaginal repair
Anterior/Posterior repair reinforcement
Hysteropexy

Secondary
Sacrospinous fixation Secondary +- reinforcement
Iliococcygeus fixation Sacrocolpopexy
Uterosacral fixation Uterosacral/Sacrospinous
fixation
Recurrent+/- reinforcement
Synthetic mesh/autologous/
donor/Xenograft
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