Pelvic organ

prolapse
By
Dr.Madhavi
2nd Yr Post Graduate
Dept Of OBG
  1.INTRODUCTION
 2.DEFINITION
 3.SURGICAL ANATOMY & SUPPORTS OF UTERUS &
SCHEME OF VAGINA.
PRESENTATION  4.PATHOPHYSIOLOGY
 5.ETIOLOGY/RISK FACTORS
 6.SYMPTOMS OF PROLAPSE
 7.CLASSIFICATION OF PROLAPSE
 8.POP-Q SYSTEM STAGING OF PROLAPSE
 9.DIFFERENTIAL DIAGNOSIS
 10.COMPLICATIONS
  Pelvic organ prolapse (POP) is one of
the common clinical conditions met in
day-to-day gynecological practice
INTRODUCTIO especially among the parous women.
N  The entity includes descent of the
vaginal wall and/or the uterus. It is
infact a form of hernia.
  Pelvic organ prolapse is
increasingly seen in women
with the aging of the
population.
 Causes of pelvic organ
prolapse are multi factorial
and contribute to the
INTRODUCTIO weakening of the pelvic
support connective tissue
N and muscles as well as
nerve damage.
 Patients may be
asymptomatic or have
significant symptoms such
as those related to the
lower urinary tract, pelvic
pain, defecatory problems,
fecal incontinence, back
pain, and dyspareunia.
  POP is defined as “descent of one or more
Definiton of the anterior vaginal wall,posterior
vaginal wall,the uterus(cervix),or the apex
of the vagina (vaginal vault or cuff scar)
after hysterectomy.
  About 30 to 50% of parous women
develop POP.
 Many are asymptomatic and have only
a minor degree of prolapse and many
PREVALAENC do not report the symptoms.
E  Globally the prevalence is 2 to 20%.
 In INDIA ,the reported overall
prevalence varies from 1 to 20%.
 Higher in perimenopausal ,post
menopausal and multiparous women.
  The pathophysiology of prolapse can
be better understood if the surgical
Surgical anatomy is known.
Anatomy  It includes
 uterine and
 Vaginal supports
  The uterus is
normally placed in
anteverted and
anteflexed position.
It lies in between
the bladder and
SUPPORTS rectum. The cervix
pierces the anterior
OF UTERUS vaginal wall almost
at right angle to
the axis of the
vagina.
 The external os
lies at the level of
ischial spines.
  The uterus is held in this position and
at this level by supports conveniently
3 Tier grouped under three tier systems.
system of  The objective is to maintain the
uterine position and to prevent descent of the
supports uterus through the natural urogenital
hiatus in the pelvic floor .
  Upper tier
 The upper most supports of the uterus
primarily maintain the uterus in
anteverted position. The responsible
structures are:
 Endopelvic fascia covering the uterus.
Upper Tier  Round ligaments.
 Broad ligaments with intervening
pelvic cellular tissues.
 The last two are actually acting as a
guy rope with a steadying effect on
the uterus. They have no action in
preventing descent of the uterus
  This constitutes the strongest support of
Middle tier the uterus.
 The responsible structures are
Fibromuscular supports
 1.Pubocervical ligament
2.Transverse cervical
ligament(MACKENRODT’S or CARDINAL
ligament)
3.Uterosacral ligament.
Fibromuscul Pericervical ring
ar supports  It consists of triradiate condensation of 3
ligaments at the pericervical region forming
suspension support to the cervix.
 The triradiate ligament forms a fibroelastic
collar around the supravaginal
cervix ,stabilizing the cervix at the level of
ischial spines.
  The endopelvic fascia
consist of connective
tissues and smooth
muscles. The blood
vessels and nerves
supplying the uterus,
bladder, and vagina
pass through it from the
lateral pelvic wall. As
they pass, the pelvic
Fibromuscul cellular tissues
condense surrounding
ar supports them and give good
direct support to the
of uterus viscera.
 The endopelvic fascia at
places is condensed
and reinforced by plain
muscles to form
ligaments —
Mackenrodt’s,
uterosacral, and
pubocervical.
  This gives the indirect support to the
uterus.
 The support is principally given by the
Inferior
tier  pelvic floor muscles (levator ani),
 endopelvic fascia,
 perineal body, and
 the urogenital diaphragm.
  1.pelvic diaphragm(levator ani)
Muscular  2.urogenital diaphragm
supports  3.perineal body.
  Pelvic diaphragm
/levator ani has 3
divisions
 Pubococcygeus
 Ischiococcygeus.
Pelvic  Pubo rectalis.

diaphragm  Medial fibers of

pubococcygeus form a
sling around rectum
called puborectalis that
provides sling support
to the rectum.
 Consists of
Urogenital  Sphincter urethrae
diaphragm  Deep transverse perineal muscles.
  It consists of a
confluence of the nine
muscles between the
introitus and the anus
and measures 4*4*4 cm
 Levator ani(paired)
 Superficial transverse
perineal
Perineal muscles(paired)
body  Deep transverse
perineal
muscles(paired)
 Fibers of external anal
sphincter
 Longitudinal muscle
coat of rectum.
 Bulbospongiosis
 Vaginal supports are
important in holding the
Supports of vagina, bladder, urethra,
and rectum in their
vagina- position.

De Lancey’s They are divided into 3

levels.
concepts
  Mackenrodts and uterosacral
ligaments.
Level 1 support for upper vagina
Suspension type of support.
Defect in level 1 vaginal supports
leads
to uterovaginal prolapse,vault
prolapse
and enterocele.
Level 2
 Rectovaginal and pubocervical fascia
support for mid vagina
Lateral support
Defect in level 2 leads to
paravaginal and
pararectal defects.
  Perineal body and urogenital diaphragm
 Support for distal vagina
Level 3  Fusion support
 Defect in level 3 vaginal supports leads to
urinary incontinence, gaping introitus and
defect perineum
  Described Factors that prevent vaginal
prolapse .
They are
BONNEY’S  Constriction by levator ani muscles when
ever abdominal pressure raises.
Anology of
 Suspension of the vagina to the pelvic
vaginal walls by the uterosacral and Mackenrodt’s
prolapse ligaments.
 Flap valve effect:the uterosacral ligament
maintains the uterus in anteverted
position.
Etiology  1.Primary / predisposing factors.
/Risk factors  2.secondary risk factors.
  1.Trauma due to vaginal
delivery,leading to weakness of pelvic
organ supports.
Primary  2.post menopausal estrogen
deficiency,leading to asthenia and
factors atrophy of pelvic floor supports.
 3.congenital or inherent weakness of
pelvic floor supports.
  Home delivery by
 Precipitate labour
untrained dias.
 Increased number  No timely episiotomy
of pregnancies  Inadequate repair of
 Decreased inter perineal injuries.
pregnancy interval  Crede method of
OBSTETRIC/ delivery of
 Big baby/CPD
Trauma due placenta(vigorous
 Prolonged labour
to child push on uterus to
expel placenta)
 Bearing down
birth before full  Early return to
dialatation of strenuous work
cervix.
 Post pelvic floor
 Prolonged second exercises not
stage practiced
  Leads to asthenia and atrophy of
pelvic floor muscles
Post
 Leads to reduction in collagen
menopausal synthesis.
Estrogen  Aggravation of injuries to pelvic fascia
deficiency that occurred during child birth and
manifestations of prolapse.
 Seen in
 Spina bifida or split pelvis.
Congenital or
inherent  Muscular dystrophies
weakness of  Connective tissue disorders-Marfan
syndrome and Ehlers-Danlos
pelvic floor syndrome.
muscles  Seen in younger age causes
nulliparous prolapse.
  This includes the factors lead to
increase in intra abdominal pressure
like
 Smoking
 Chronic cough
SECONDARY  Chronic constipation
FACTORS  Obesity
 Large intra abdominal tumours and
ascites.
 Lifting heavy weights-laborers.
  Damage to the levator ani may be a
direct damage to muscle fibers or
more often , damage to innervation.
 When the muscles are damaged ,the
pelvic floor opens and uterus and
Pathophysiolo vagina protrude into the upper vagina.
gy  The axis of the vagina changes and
the cervix and apex of the vagina
protrude into the upper vagina.
 The ligaments and fascia hold the
organs in place initially , but stretch
and yield with time.
  The genital prolapse is broadly
grouped into:
 • Vaginal prolapse
 • Uterine prolapse
GENITAL  While vaginal prolapse can occur
PROLAPSE independently without uterine
descent,
 the uterine prolapse is usually
associated with variable degrees of
vaginal descent.
Vaginal  Anterior wall
prolapse  Posterior wall
  Anterior wall
Cystocele — The cystocele is formed by
laxity and descent of the upper two-thirds of
the anterior vaginal wall.
 As the bladder base is closely related to this
Vaginal area, there is herniation of the bladder
Prolapse through the lax anterior wall.
Urethrocele— When there is laxity of the
lower-third of the anterior vaginal wall, the
urethra herniates through it.
This may appear independently or usually
along with cystocele and is called cysto
urethrocele
 Cystocele — The
cystocele is formed by
laxity and descent of the
upper two-thirds of the
anterior vaginal wall.
cystocele  As the bladder base is
closely related to this
area, there is herniation
of the bladder through
the lax anterior wall.
  Relaxed perineum — Torn perineal
body produces gaping introitus with
bulge of the lower part of the posterior
vaginal wall.
Posterior
 Rectocele— There is laxity of the
wall
middle-third of the posterior vaginal
wall and the adjacent rectovaginal
septum. As a result, there is herniation
of the rectum through the lax area.
Rectocele
and
Enterocele
  Enterocele— Laxity of the upper-third
of the posterior vaginal wall results in
herniation of the pouch of Douglas. It
may contain omentum or even loop of
small bowel and hence, called
Posterior enterocele.
wall  Traction enterocele is secondary to
uterovaginal prolapse.
 Pulsion enterocele is secondary to
chronically raised intra-abdominal
pressure.
  This may occur following either
vaginal or abdominal hysterectomy.
Secondary
 Undetected enterocele during initial
vault
operation or inadequate primary
prolapse repair usually results in secondary
vault prolapse .
  There are two types :
 Uterovaginal prolapse is the prolapse of the
uterus, cervix and upper vagina.
 This is the commonest type. Cystocele
occurs first followed by traction effect on the
cervix causing retroversion of the uterus.
Intra-abdominal pressure has got piston like
Uterine action on the uterus thereby pushing it down
prolapse into the vagina.
 Congenital
 There is usually no cystocele. The uterus
herniates down along with inverted upper
vagina. This is often met in nulliparous
women and hence called nulliparous
prolapse. The cause is congenital weakness
of the supporting structures holding the
uterus in position.
  1.shaw’s classification
 2.Jeffcoat’s classification
 3.POP-Q system classification
Classificatio
 4.Baden-walker halfway system
nsof classificataion.
prolapse  5.Malpas classification.
 6.Friedman classification.
  Simplest and most widely used
Shaw’s classification.
classificatio  It classifies prolapse into 4 stages and
n uses ischial spine as the reference
point.
  1.first degree:descent of the cervix
Grading of below the ischial spine,but not into the
uterine introtus.
descent  2.second degree:descent of the cervix
according to upto the introitus.
shaw’s  3.third degree :descent of the cervix
classificatio outside the introtus.
n  4.fourth degree or procidentia:entire
uterus outside introitus.
Uv prolapse
  Vaginal prolapse:
Anterior vaginal wall
Upper two third descent:Cystocele
Shaw’s
Lower one third
classificatio descent:Urethrocele.
n Posterior vaginal wall
Upper one third descent:Enterocele.
Lower two third descent:Rectocele.
  First degree:
descent of cervix upto introitus
(shaw’s first and second degrees)
Jeffcoat’s  Second degree:
classificatio
descent of cervix below the level of
n introitus.
 Third degree:
procidentia
  Friedman and little classification:
 1A:Descent halfway to hymen.
Friedman  1B:Descent until hymen
classificatio  2:descent till introitus
n  3:outside introitus
 4:complete procidentia.
  POP-Q Pelvic organ prolapse
quantification system classification.
 It is approved by the International
POP-Q continence society and is now widely
system recommended.
classificatio  The classification objectively
n. quantifies the prolapse.
 It allows an accurate quantification of
pelvic supports for scientific
comparisions and is reproducible.
 The system identifies nine locations in the vagina
and vulva in centimeters relative to the hymen,
which are used to assign a stage (from 0 to IV)
of prolapse at its most advanced site .
 Although probably more detailed than necessary
for general practice, clinicians should be familiar
with the POP-Q system because most published
studies use it to describe research results.
 Its two most important advantages over previous
grading systems are
 (i ) it allows the use of a standardized technique
with quanti tative measurements at straining
relative to a constant reference point (i .e. , the
hymen), and
 (i i ) its ability to assess prolapse at multiple
vaginal sites.
  The classification uses six
points along the vagina
(two points on the
anterior,middle, and
posterior compartments)
measured in relation to the
hymen.
 The anatomic position of
POP-Q the six defined points
should be measured in
Examinatio centimeters
 proximal to the hymen
n (negative number) or distal
to the hymen (positive
number), with the plane of
the hymen representing
zero.
 Three other measurements
in the POP-Q examination
include the genital hiatus,
perineal body , and the total
vaginal length .
POP-Q Grid
Example of
grid for
prolapse
  Based on the nine sites ,prolapse is
STAGING staged from 1 to 4 according to the
most distal portion of the prolapse.
POP-Q
system
staging of
prolapse
  Descent of six anatomical sites in relation to
hymen during maximal straining.
 Six anatomical sites are:
Baden –  Urethral,Vescical,Uterine,Culde-sac,Rectal
Walker and Perineal body
halfway  First degree:Descent half way upto hymen
system  Second degree :Descent upto hymen
classificatio  Third degree:Descent half way through the
hymen.
n
 Fourth degree:Maximum progression through
the hymen.
  First
degree:Descent half
way upto hymen
 Second
Baden – degree :Descent
Walker upto hymen
halfway  Third
degree:Descent half
system way through the
classificatio hymen.
 Fourth
n degree:Maximum
progression through
the hymen.
  It is an etiological classification of prolapse
and is classified as follows.
 Anterior vaginal wall prolapse
Malpas  Posterior vaginal wall prolapse
classificatio  Uterovaginal wall prolapse
n  General prolapse
 Nulliparous prolapse
 Post hysterectomy vault prolapse.
  1.postural symptoms
 2.urinary symptoms
Symptoms  3.rectal symptoms.
of prolapse  4.vaginal discharge.
 5.Backache.
 6.Subfertility
 The symptoms are variable. Even with minor
degree, the symptoms may be pronounced,
paradoxically there may not be any appreciable
symptom even in severe degree.
However, the following symptoms
Symptoms are usually associated:
(a) Feeling of something coming down per
vaginum,
especially while she is moving about. There may
be variable discomfort on walking when the mass
comes outside the introitus.
(b) Backache or dragging pain in the pelvis.
The above two symptoms are usually relieved on
lying down.
(c) Dyspareunia.
  Difficulty in passing urine, more the strenuous
effort, the less effective is the evacuation. The
patient has to elevate the anterior vaginal wall
for evacuation of the bladder.
d)  Incomplete evacuation may lead to frequent
Urinarysymptoms desire to pass urine.
(in presence of  Urgency and frequency of micturition may
cystocele). also be due to cystitis.
 Painful micturition is due to infection.
 Stress incontinence is usually due to
associated urethrocele.
 Retention of urine may rarely occur.
  (e) Bowel symptom (in presence of
rectocele).
 Difficulty in passing stool. The patient has to
push back the posterior vaginal wall in
symptoms position to complete the evacuation of feces.
 Fecal incontinence may be associated.
 ( f).Excessive white or blood-stained
discharge per vaginum is due to associated
vaginitis or decubitus ulcer.
  A composite examination —
inspection and palpation: Vaginal,
Clinical rectal, rectovaginal or even under
Examinatio anesthesia may be required to arrive
n at a correct diagnosis.
and
Diagnosis  General examination — details,
Of POP including BMI, signs of myopathy or
neuropathy, features of chronic airway
disease or any abdominal mass should
be done.
  Pelvic Organ Prolapse (POP) is
evaluated by pelvic examination in
both dorsal and standing positions.
Clinical The patient is asked to strain as to
examination perform a Valsalva maneuver during
examination.
.
 This often helps to demonstrate a
prolapse which may not be seen at
rest.
  A negative finding on inspection in
dorsal position should be reconfirmed
by asking the patient to strain on
squatting position.
Clinical  Prolapse of one organ (uterus) is
examinatio usually associated with prolapse of the
n adjacent organs (bladder, rectum).
 Etiological aspect of prolapse should
be evaluated
  There is a bulge of varying degree of
the anterior vaginal wall, which
increases when the patient is asked to
strain. This may be seen on inspection.
 In others, to elicit this, one may have to
separate the labia or depress the
Cystocele posterior vaginal wall with fingers or
using Sims’ speculum.
 The mucosa over the bulge has got
transverse rugosities. The bulge has
got impulse on coughing, with diffuse
margins and is reducible.
 The bulging of the anterior vaginal wall
involves the lower-third also. One may
Cysto- find the urine to escape out through the
urethrocele urethral meatus when the patient is
asked to cough — stress incontinence.
 To elicit the test,the bladder should be
full.
  There is gaping introitus with old scar
Relaxed of incomplete perineal tear. The lower
perineum part of the posterior vaginal wall is
visible with or without straining.
  When the two conditions exist together, there
is bulging of the posterior vaginal wall with a
transverse sulcus between the two.
Rectocele  The mid vaginal one being rectocele with
diffuse margins and reducible. This is
and visualized by retracting the anterior vaginal
enterocele wall by Landon’s retractor.
 Ultimate differentiation of the two entities is
by rectal or rectovaginal examination.
 In enterocele, the bulging is close to the
cervix and cannot be reached by the finger
inside the rectum.
  In first degree of uterine descent, the
diagnosis is made through speculum
examination when one finds the
cervical descent below the level of
Uterine ischial spines on straining.
prolapse  In second or third degree of prolapse,
inspection can reveal a mass
protruding out through the introitus,
the leading part of which is the
external os.
  To diagnose a third degree
prolapse,palpation is essential.
Clinical  If the thumb placed anteriorly and the
fingers posteriorly above the mass
examinatio outside the introitus are apposed, it is
n a third degree .
 Degree of prolapse or POP
quantification should be done.
  1.Gartner’s cyst
Differential  2.Congenital elongation of cervix.
Diagnosis  3.Chronic invertion.
 4.Fibroid polyp.
 The cystocele is often confused with a
cyst in the anterior vaginal wall, the
commonest being Gartner’s cyst
(retention cyst in remnants of Wolffian
duct).
  Features of Gartner’s cyst are:
 Situated anteriorly or anterolaterally and of
variable sizes.
 Rugosities of the overlying vaginal mucosa
are lost.
Gartner’s  Vaginal mucosa over it becomes tense and
shiny.
cyst  Margins are well-defined.
 It is not reducible.
 There is no impulse on coughing.
 The metal catheter tip introduced per
urethra fails to come underneath the vaginal
mucosa
  Bimanual examination reveals shallow
vaginal fornices and normal length of
the vaginal cervix with normal size
Congenital uterine body.
elongation  The introduction of a sound reveals
of the marked increase in length of the
cervix uterine cavity.
 This signifies elongation of the
supravaginal part of the cervix.
 Congenital elongation of the cervix
 • It is unassociated with prolapse
(usually).
 • Vaginal part of the cervix is
elongated.
Uterine
 • External os lies below the level of
Prolapse ischial spines.
 • Vaginal fornices are narrow and
deep.
 • Cervix looks conical.
 • Uterine body is normal in size and in
position
 • Leading protruding mass is broad.
• There is no opening visible on the leading
part.
• It looks shaggy.
Chronic • Internal examination reveals — cervical rim is
inversion on the top
around the mass.
• Rectal examination confirms the absence of
the uterine
body and a cup-like depression is felt.
  The mass is saggy with a broad leading
part.
 No opening is visible on the leading part.
Fibroid  Internal examination reveals the pedicle
polyp  coming out through the cervical canal or
arising from the cervix.
 Rectal examination reveals normal shape
and position of the uterus.
 The following assessments should be
performed:
Bladder  a clean catch or catheterized urine sample
to test for infection,
Function  a postvoid residual (PVR) volume, and
Evaluation assessment of bladder sensation, which can
be performed as a part of office
cystometrics.
  Diagnostic imaging of the pelvis in women with
pelvic organ prolapse is not routinely performed.
However , if clinically indicated, tests that may be
performed include
 fluoroscopic evaluation of bladder function,
 ultrasound of the pelvis, and
Imaging  defecography for patients in whom intussusception
or rectal mucosal prolapse are suspected.
 Magnetic resonance imaging is increasingly being
used for the evaluation of pelvic pathology such
as mullerian anomalies and pelvic pain; however ,
generalized use in women with prolapse is not
currently clinically indicated and is used primarily
for research purposes.
 Complications of Prolapse
1. Kinking of ureter with resulting renal damage can
occur in procidentia and enterocele. The ureter can also
be included in the sutures at the vaginal vault during
surgery.
complicatio 2. Urinary tract infection (chronic) in a large cystocele
ns with residual urine can lead to upper renal tract
infection and renal damage.
3. In rare cases, cancer of the vagina is reported over
the
decubitus ulcer and if the ring pessary is left in over a
long period.
  It is a trophic ulcer, always found at the
dependent part of the prolapsed mass lying
outside the introitus.
 There is initial surface keratinization →cracks
→infection →sloughing →ulceration.
Decubitus
 There is complete denudation of the surface
ulcer epithelium.
 The diminished circulation is due to
constriction of the prolapsed mass by the
vaginal opening and narrowing of the uterine
vessels by the stretching effect.
  Berek & Novak’ s Gynecology
 Textbook Of Gynecology DC dutta’s

References  Clinical obstetrics and gynaecology by

Sharmila arun Babu.
 Howkins & Bourne Shaw’s Textbook of
Gynaecology
 Essentials of gynaecology Lakshmi seshadri