IMLE Preparatory Course

Lecture 61
Obstetrics and Gynecology

Pelvic Organ Prolapse

Normal pelvic anatomy
Introduction

 Pelvic organ prolapse (POP) is a common

group of clinical conditions affecting
women.

 The prevalence rates increase with age

and POP currently affects millions of
women.
 Pathophysiology of prolapse
 Includes anterior and posterior vaginal
prolapse, uterine prolapse, & enterocele.

 Is multifactorial and may operate under a

"multiple-hit" process in which genetically
susceptible women are exposed to life events
that ultimately result in the development of
clinically important prolapse.
Four areas in which pubocervical fascia can
break or separate—four defects
VAGINAL PROLAPSE
Prolapse of the Uterus
Enterocele (small bowel)
URETHROCELE & CYCTOCELE
Posterior vaginal prolapse /
RECTOCELE
Presentation of prolapse

 Presents with the sensation of a bulge or

protrusion in the vagina.

 Urinary or fecal incontinence, a sense of

incomplete bladder emptying, and
dyspareunia are also seen.
 Evaluation of prolapse
 Requires a comprehensive approach, with attention
to function in all pelvic compartments based on a
detailed patient history, physical examination, and
limited testing.

 The degree of prolapse can be evaluated by having

the woman perform the Valsalva maneuver while
in the lithotomy position.
 Treatment of prolapse
 Is warranted based on specific symptoms,
prolapse management choices fall into 2 broad
categories:

 Nonsurgical, which includes pelvic floor

muscle training and pessary use.
 Surgical, which can be reconstructive (eg, sacral
colpopexy) or obliterative (eg, colpocleisis).
 Clinical Importance
 Demand for health care services related to pelvic floor
disorders will be increased to twice the rate of the
population itself by 2030

 Although the overall rate of prolapse surgery has

dropped, this represents a substantial drop in the rate of
surgery for women less than 50 years old & a moderate
increase for women aged 50 years and greater
Diagnostic Approach
 Women with prolapse often have urinary symptoms

 Some women have stress incontinence symptoms due to

urethral incompetence, but many women, particularly those with
advanced anterior vaginal prolapse, are continence

 Defecatory symptoms such as excessive straining,

incomplete rectal emptying, or the need for perineal or
vaginal pressure to accomplish defecation

 Influence of prolapse on sexual functioning should be

addressed in women of all ages
Diagnostic Approach

 Women with prolapse often have urinary

symptoms

 Some women have stress incontinence symptoms

due to urethral incompetence, but many women,
particularly those with advanced anterior vaginal
prolapse, are able to maintain continence.
Diagnostic Approach
 The use of vaginal speculums or retractors is very
helpful in determining what vaginal sites are
affected by prolapse

 An unidentified vaginal bulge can be clearly

identified as the vaginal apex, once the anterior
and posterior vagina are retracted
 Diagnostic Approach
 The maximal extent of prolapse is demonstrated
with a standing straining examination when the
bladder is empty

 Pelvic muscle function should be assessed after the

bimanual examination → palpate the pelvic muscles
a few centimeters inside the hymen, along pelvic
sidewalls at the 4 & 8 o’clock
 Diagnostic Approach
 Resting tone & voluntary contraction of the anal
aphincters should be assessed during rectovaginal
examination
 Bladder Testing

 At minimum, for all patients with prolapse, 3 pieces of

information should be obtained

 Screening for urinary tract infection

 Postvoid residual urine volume
 Presence or absence of bladder sensation
 Bladder Testing
 Women with prolapse and urinary incontinence should
have stress testing performed with the prolapse
reduction because this will mimic bladder and urethral
function when the prolapse is treated

 In the setting of a positive reduction stress test → it is

recommend that an incontinence procedure should be
performed at the time of prolapse surgery
 Indications for Treatment
 Choice of treatment for prolapse depends on symptoms
severity and severity of prolapse

 Symptoms associated with stage I or II prolapse require

careful evaluation, especially if surgery is being
considered

 Many women with stress urinary incontinence have stage

I or II , although stress incontinence is not a symptom of
prolapse it is simply a coincident symptom
 Observation
 Observation is appropriate for women whose
symptoms are not sufficiently bothersome to
warrant active management

 There is no indications for treatment, particularly

surgery, for women with asymptomatic prolapse
“before the problem gets any worse”
 Nonsurgical Management
 Includes adjunct therapy to address concomitant
symptoms, pelvic floor muscle training, and
pessaries

 Ideally, nonsurgical management will decrease

the frequency and severity of symptoms, delay or
avoid surgery & potentially prevent worsening
the prolapse
Adjunct Therapy
 Addresses symptoms of urinary, defecatory & sexual
dysfunction

 Patient often present with defecatory symptoms, such as

excessive straining at stool and a feeling of incomplete
evacuation, and physical examination reveals stage II or
early stage III posterior vaginal prolapse (rectocele) →
evaluation from the GI perspective
Adjunct Therapy
 Age-appropriate screening for colorectal cancer:
diet history (fiber and fluid intake), exercise
history, review of medications for GI adverse
effects, and bowel movements

 Adjunct therapy includes advice on lifestyle

alterations, weight loss, and a general exercise
program
 Pelvic Floor Muscle Training
 Designed to increase the strength of abdominal
endurance of the pelvic muscles, thereby
improving support to pelvic organs

 “Kegel” exercises

 With virtually no adverse effects, its only

negative is the cost of providing instruction and
follow-up for patients
 Pessaries
 To decrease symptom frequency and severity, delay or avoid surgery, and
potentially prevent worsening of prolapse

 The most important relative contraindication for pessary use occurs

when the patient cannot comply with follow-up

 Pessary use must be discontinued for persistent vaginal erosions

 Unsuccessful fitting is associated with short vaginal length (less than 7cm)
and wide introitus ( 4 finger-breadths)
Pessaries
Pessaries
 Ring Pessary provides relief of uterine prolapse or anterior
vaginal prolapse.

 Gellhorn Pessaries provide a ringlike platform for the

cervix or apex. The pessary is stabilized by a stem that rests
on the perineum. These pessaries are used to correct marked
prolapse when the perineal body is reasonably adequate.
Pessaries
 Doughnut is made of soft rubber or silicone, and this type
of pessary provides support for severe uterine prolapse or
vault prolapse.

 Gehrung Pessary resembles two firm letter Us attached by

crossbars. It rests in the vagina with the cervix cradled
between the long arms; this arches the anterior or posterior
vaginal wall and helps reduce the vaginal prolapse.
 Pessaries
 Hodge Pessary an elongated, curved ovoid.
 This type of pessary is used to hold the uterus in place
after it has been repositioned.
Pessaries
 Inflatable Pessary functions much like a doughnut pessary.
The ball valve is moved up and down, when the ball is in the
down position, air inflates the pessary, when in the up
position, the air is sealed in and inflation is maintained.

 Cube This is a flexible rubber cube, with suction cups on

each of its six sides that adhere to the vaginal walls. This is
useful in women with severe prolapse
 Surgical Management - Approach
 Approach to prolapse surgery include vaginal,
abdominal, and laparoscopic routes or
combination of approaches

 Vaginal approach results in fewer wound

complications, less postoperative pain, shorter
hospital stay, and less cost than abdominal surgery
Surgical Management - Approach
 Surgical procedures for prolapse : cathegorized into 3 groups

 Restorative → use the patient’s

endogenous support structures
 Compensatory → replace deficient
support with some type of graft
 Obliterative → close the vagina
 Anterior Vaginal Repair
 Traditionally repaired with anterior colporrhaphy

 Vaginal epithelium separated from the underlying

fibromuscularconnective tissue, followed by
midline plication of the vaginal muscularis
with interrupted stitches.

 Excision of excess epithelium & closure

Repair of anterior vaginal prolapse
 Posterior Vaginal Repair

 Vaginal epithelium separated from the underlying

fibromuscular connective tissue followed by
midline plication of the vaginal
muscularis with interrupted stitches and
excision of excess epithelium & closure
Site-specific repair of posterior vaginal prolapse
Posterior Vaginal Repair
 Dyspareunia after posterior colporrhaphy
→ blamed on levator ani plication &
narrowing can also occur with overzealous
perineorrhaphy
 The vaginal configuration is altered by the Burch
procedure→ the upward displacement of the anterior
vaginal tube → create a transverse ridge in the
posterior vagina
 Vaginal Apical Repair
 Apical vaginal prolapse includes uterine prolapse with or
without enterocele and vaginal vault prolapse, typically
with enterocele

 The standard treatment for symptomatic uterine prolapse

→ hysterectomy with procedure to suspend the
vaginal apex, address enterocele when indicated, repair
coexisting anterior & posterior vaginal prolapse → perform
anti-incontinence procedure
 Enterocele Repair
 Whether by vaginal,
abdominal, of laparoscopic
access, enterocele repair is
traditionally performed by
sharply dissecting the
peritoneal sac from the
rectum and bladder

 A purse-string suture can be

used to close the peritoneum as
high as possible
Repair of a
rectocele
 Sacrospinous Ligament Suspension

 Sacrospinous ligament
fixation entails
attachment of the
vaginal apex to the
sacrospinous ligament,
the tendinous component
of the coccygeus muscle
 Uterosacral Ligament Suspension
 Used prophylactically at
hysterectomy or therapeutically
for vaginal apical suspension

 Once access to the posterior cul-

de-sac has been attained, the
uterosacral ligament remnant can
be found

 Sutures in each ligament and

incorporated into the ant & post
fibromuscular layer of vagina
Vaginal hysterectomy for uterine prolapse
 Comparison of Vaginal Approaches to
Apical Repair
 Sacrospinous ligament suspension may leave the
anterior vaginal at greater risk for subsequent failure &
because the procedure is extraperitoneal → rare
ureteral and rectal injury

 Iliococcygeal suspension is straightforward procedure to

learn and teach. It carriers virtually no risk of ureteral or
small bowel injury, there are no vital structures nearby at
risk for surgical injury
Comparison of Vaginal Approaches to
Apical Repair
 Uterosacral ligament suspension traditionally
requires peritoneal entry → challenging in
posthysterectomy prolapse, especially in the setting of
bowel adhesions → engendering the rare occurrence of
bowel injury

 Uterosacral ligament suspension carreies a risk of

ureteral injury (usually kinking due to medial
displacement or suture ligation that impedes urinary
flow)
Abdominal Apical Repair
 Abdominal Sacral Colpopexy uses graft material attached to the
anterior and posterior vaginal apex and suspended to the anterior
longitudinal ligament of the sacrum for repair of apical prolapse

 Peritoneal closure over the graft & obliteration of the cul-de-sac for
treatment or prevention of enterocele

 The cure rate range from 78% to 100%

 Complications: intra-operative hemorrhage, laparotomy

(adhesion & small bowel obstruction) , and graft infection or
erosion
Comparison of Abdominal and Vaginal
Approaches to Apical Repair
 Success rates appear to favor the abdominal approach to
apical vaginal prolapse

 Abdominal sacral colpopexy is more durable in providing

apical support, but at the cost of increased
complications

 Younger women benefit more also likely to be more

from durability, with the reduced chance they will need
prolapse surgery in future
Colpocleisis
 In a healthy, sexually active woman the vagina may be surgically
attached to the sacrospinous ligament, sacrum or fascia support
system.

 In elderly women who do not wish to be sexually active

in the future → total colpocleisis is a simple, safe, and
effective surgical procedure that reliably relieves these women of
their symptoms

 Total colpocleisis procedure often coupled with a tension free

vaginal tape (TVT) sling procedure for urinary
incontinence
TVT
Tension-free vaginal tape (TVT)