I. Introduction To Pelvic Organ Prolapse: Normal Support of Pelvic Organs

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Introduction to POP

a. Normal support of organs b. Functions of the pelvic floor c. Pathophysiology d. Diagnosis II. Urethrocele & Cystocele
a. S/Sx b. Diagnosis c. Management d. Recurrence III. Rectocele
a. S/Sx b. Diagnosis c. Management d. Recurrence e. Complications IV. Enterocele
a. Diagnosis b. Operative Management
• Vaginal birth and operative vaginal birth: increases risk for POP and V. Uterine Prolapse
urinary incontinence 5-10 years after delivery compared with a. Associated factors b. S/Sx c. Diagnosis d. Management e. Recurrence VI.
Important considerations for
decision making VII. Terminology for POP
a. Goal of Staging
caesarean section
• Many are asymptomatic
• Most prolapses with specific symptom are not clinically bothersome
• Frequently neglected or ignored
• Emphasis on women’s health and quality of life: demand of such care will escalate, expected to be familiar
• 2nd most common indication for benign gynecologic surgery (1 st is myoma and 3rd is endometriosis) b. POP-Q c. Staging of ICST
NORMAL SUPPORT OF PELVIC ORGANS VIII. Management
Provided by key anatomic structures, including the pelvic flor muscles a. Pessary b. Operative Management IX. Vaginal Apex Prolapse
a. S/Sx
and connective tissue attachments
LEVEL OF SUPPORT
b. Diagnosis c. Management
I. INTRODUCTION TO PELVIC ORGAN PROLAPSE
• Common in parous women
• Failure of various anatomic structures to support the pelvic viscera
• Descent of one or more of the vaginal walls or cervix
• Abnormal descent or herniation of the pelvic organs from their normal attachment sites and normal position in the pelvis
• Pelvic structures involved and the abnormalities that result from these relaxation problems o Anterior vagina: urethrocele, cystocele,
paravaginal defect
(PUCA) o Posterior vagina: rectocele, enterocele (PRE) o Uterus/cervix: uterine/cervical prolapse o Vaginal apex: vaginal vault
prolapse – post hysterectomy,
often with an enterocele
Figure 1. Abnormalities that result from pelvic floor muscle relaxation problems
• Problem: defect of a specific vaginal segment
• Defects are associated in the following compartments: anterior, lateral, posterior, and apical
• Common in parous women, many are asymptomatic o Prevalence for asymptomatic POP: 30-50% o Prevalence for symptomatic POP: 3%
• 13% lifetime risk of undergoing prolapse surgery
• White and Latina women have 4-5 times higher risk of symptomatic POP compared with African-American
• Single vaginal birth – 10-fold higher
PELVIC FLOOR MUSCLES AND CONNECTIVE TISSUE ATTACHMENTS
Level I
Support of vaginal apex and cervix provided by uterosacral and cardinal ligaments and associated connective tissues o Uterosacral:
posterior support of cervix o Cardinal: supports laterally
Level 2
Mid-vagina is attached to the arcus tendineus fasciae pelvis on the lateral pelvic side walls and superior fascia of the levator ani by
condensations of the levator fascia (e.g. endopelvic and pubocervical fascia)
Level III
Support of the distal (inferior) vagina provided by perineal membrane muscles, and all attachments are connected through endopelvic
connective tissue o Inferior structures
Figure 2. Normal support of pelvic organs
MUSCLES OF THE PELVIC FLOOR Layer Muscles Innervation
Superficial perineal layer
• Bulbocavernosus
• Ischiocavernosus
• Superficial transverse perineal
• External anal sphincter

• BISTE
Pudendal nerve
Deep urogenital diaphragm layer
• Compressor urethra
• Urethrovaginal sphincter
• Deep transverse perineal
• CUDT
Pudendal nerve
Pelvic diaphragm
• Levator ani: pubococcygeus (pubovaginalis, puborectalis), puborectalis, iliococcygeus
• Coccygeus/ischiococcygeus
• Piriformis
• Obturator internus
Sacral nerve root S3-S5
Figure 3. Model for the development of pelvic floor dysfunction in
women

GYNECOLOGY Pelvic • Imaging is not necessary in the evaluation but ultrasound and MRI
increases understanding of these support defects
• Pelvic support structures weakened by: o childbirth: gravida 5-8,
but usually felt after menopause

Organ Disorders ▪ Most


common cause o pelvic trauma
o stress and strain o aging
process
PELVIC DIAPHRAGM
• in nulliparous women who have: o congenital malformations o
• aka endopelvic fascia weaknesses of the endopelvic connective tissue and
• a wide but thin muscular layer of tissue that forms the inferior border of the musculature of the pelvic floor
abdominopelvic cavity Table 1. Risk factors for the development of pelvic organ prolapse
• composed of broad, funnel-shaped sling of fascia, collagen, elastic tissue,
and muscle
• extends from symphysis pubis to coccyx and from one lateral sidewall to
another
• important in supporting abdominopelvic viscera and facilitates equal
distribution of intra-abdominal pressure during activities like coughing
• primary muscles: interwoven for strength and encircles the terminal
portions of urethra, vagina, and rectum

UROGENITAL DIAPHRAGM
• aka triangular ligament
• primary muscles; strong, muscular membrane
• extends from symphysis pubis and ischial tuberosities and stretches
across the triangular anterior portion of the pelvic outlet
• external and internal to the pelvic diaphragm
• has two layes that enfold and vocer the striated deep transverse perineal
muscle (surrounds the vagina and urethra)
• major function is to support urethra and maintenance of the urethrovesical DIAGNOSIS 3D COLOR THICKNESS MAPPING (DOPPLER
function STUDY)
• Thicker, bulkier levator ani muscles found in asymptomatic women vs loss
FUNCTIONS OF THE PELVIC MUSCLE FLOOR of levator muscle bulk found in women with POP and stress incontinence
• Support pelvic organs and abdominal contents, especially when standing • Explanations: - Muscle atrophy from denervation or muscle wasting from
or during contraction of the transversus abdominis (Valsalva maneuver) muscle insertion detachment from childbirth, and possible age and
• Support the bladder to help it stay closed, actively squeezing when hormonal status - more vertical axis and wider genital hiatus in women with
coughing to help avoid leakage POP
• Used to control wind and when “holding on” with your bowel (controls horizontal upper vagina)
• Important sexual function, helping to increase sexual awareness both for
yourself and your partner during coitus SYMPTOMS OF PELVIC ORGAN PROLAPSE
Table 2. Pelvic organ prolapse symptom categories
PATHOPHYSIOLOGY
• Symptoms of POP are often not specific to the area that is prolapsing, and • Because more than one pelvic floor disorder is often present, urinary,
many women have no symptoms bowel, and sexual symptoms should be assessed in addition to prolapse
• Classic symptoms: vaginal heaviness and pressure, a vaginal bulge, symptoms in any woman with POP
pelvic pain, or vaginal bleeding (from erosions of exposed vaginal • If a woman with objective prolapse does not have any bothersome
epithelium) symptoms or evidence of associated medical risks such as urinary retention
• Back pain and pelvic pain are not reliably associated with prolapse or renal impairment from urethral or ureteral kinking, she does not need
treatment.
• Place 2 fingers into the vagina so that each finger opposed the ipsilateral
vaginal walls, ask patient to bear down – lateral vaginal support system

GYNECOLOGY Pelvic • Assess the apex – cervix and upper vagina


• Repeat exam with patient standing and bearing down – maximum descent

Figure 4. Cystocele (left) and urethrocele (right)


SIGNS AND SYMPTOMS

Organ Disorders • Sensation of fullness and pressure, organs are falling out
• Pulling ache in the pelvis
• Occasional urgency and feeling of incomplete emptying
• Questions on how symptoms affect the woman’s quality of life, address • Stress incontinence due to urethral hypermobility
role and social limitations – usual daily chores, exercise, and social event • Soft, bulging mass of the anterior vaginal wall o in some patients, this
participation, emotional health limitations mass must be replaced manually before
• Pelvic Organ Prolapse Quality of Life (PQOL) scale and Urinary the patient can void o strain or cough accentuates
Distress Inventory: validated, self-administered questionnaires the bulge o mass may descend to or beyond the
• Understanding the woman’s goals for treatment is important introitus

PHYSICAL EXAMINATION DIAGNOSIS


• During the pelvic examination, grade the strength and quality of the pelvic • POP is best measured with a patient straining in the lithotomy position
floor contraction (ask the patient to tighten levators around the examining • Maximum prolapse is observed with a full bladder in standing position
finger) • The physician should ask the patient if this reproduces her maximum
• assess external genitalia, noting estrogen status, diameter of introitus, bulge and, if not, repeat the examination in the standing position
and length of perineal body • A retractor or posterior wall blade of a Graves speculum to depress the
• bimanual examination posterior wall
• rectal examination: external sphincter tone, rectocele, and enterocele • Ask the patient to strain to note the degree of prolapse
• General points: - assessment of pelvic floor muscle strength: practical • Best perf
application - assessed by visual inspection, palpation, EMG, perineorrhaphy • Measure the amount of apical and posterior prolapse as well in order
- voluntary contraction as strong, weak, absent - E.g. Oxford scale 1-5 to not miss defects in the other compartments
• Degrees: mild, moderate, and severe or marked
• Mild: no signs and symptoms, but might progress so management is to
II. URETHROCELE AND CYSTOCELE prevent progression
• Loss of anterior vaginal wall support is the most common site of primary • Marked: totally covering the vaginal canal
POP • Physician should also palpate the bladder neck and note whether it is well
• Attenuation or rupture of the pubovesical cervical fascia supported
• Descent of the urethra (urethrocele), bladder neck, or bladder (cystocele) • Urethra is adequately supported if there are adequate supports of the
into the vaginal canal bladder neck
• Cystocele only – continent; bladder protrudes or descends with vaginal • If cystocele and urethrocele are present, bladder neck is invariably not
wall relaxation supported
• Less commonly with an enterocoele • It is important to perform POP-Q or at least qualitative measurements of
• Urethrocele is also present – stress incontinence; descent of the urethra the whole vagina, as often more than one compartment is affected
and bladder neck • Checking the vaginal tissues for ulceration and bleeding should also be
• Level I apical and Level II – identified breaks in distal and medial done
attachments near the pubic symphysis, lateral attachments to the arcus • Pelvic floor muscle bulk, symmetry, and function should be assessed
tendineus fascia pelvis, and proximal and lateral attachments near the during the bimanual exam by asking the woman to tighten her muscles like
ischial spines she is trying to inhibit voiding or flatus
• More common in women with wide subpubic arches (gynecoid type)
• Wide subpubic arches (gynecoid type) which allow the full force of the DIFFERENTIAL DIAGNOSIS Urethrocele
fetal head against this area during descent in labor Cystocele
• Narrower arches, such as those associated with the android or • Inflamed and enlarged Skene’s
anthropoid pelvic types seem to protect this region from the descent of glands (generally tender)
the fetal head • Urethral diverticula
• Note the point of maximal descent of the anterior, lateral, posterior, and • Soft, pliable, and non-tender
apical walls in relation to the ischial spines and hymen • Bladder tumors
• Bladder tumors NON-OPERATIVE TREATMENT
• Bladder diverticula • For women with mild (eg. Stage 2) POP
• Bladder diverticula • Pelvic floor physical therapy and Kegel exercises, which can decrease
• Soft, pliable, and non- the risk of prolapse progression and can be effective at improving the
tender sensation of pressure from mild POP
• Soft, pliable, and non- • Pelvic floor physical therapy can also treat associate urinary,
tender bowel, and sexual dysfunction
• Soft, pliable, and non-
• Supporting the herniation of the bladder into the vagina with:
tender
PESSARY
MANAGEMENT
• Vaginal Pessary o Smith-
• Depending on patient preferences, goals, signs, symptoms, and Hodge pessary o Ring o
complications (urinary retention and renal hydronephrosis) Inflatable pessary o Donut o
Gellhorn
Kahit mukhang simple, awkward at mahirap i-ensure na gets ng patient
ang instructions at tama ang execution. o Effective kung ipapahawak mo

Pelvic
sila ng anterior pelvic area nila para maramdaman nila if “tumitigas” yung
GYNECOLOGY area (ISOMETRIC contraction). o Make sure na di nagpipigil ng hininga ang
patient ‘pag ginagawa ‘to. Bawal ang Valsalva mga beshies. Pahingahin sa
bibig.

Organ Disorders • For older women


ESTROGEN VAGINAL CREAM

• May improve vaginal atrophy, mucosal irritation, or ulceration, and patient


comfort if the prolapsed vaginal epithelium is irritated or ulcerated
• Intermittent use of large tampon
• No evidence that estrogen therapy will prevent or treat POP

OTHERS
• Patient education
• Lifestyle modification
• Behavioral modification - may help urinary symptoms
such as urgency

OPERATIVE TREATMENT
• A young woman with a large cystocele is advised to avoid operative repair
until completion of family size
• Generally performed in conjunction with the repair of all other pelvic
support defects
• If rectocele, uterine descensus, and enterocele is noted, this must also be
treated
Figure 5. Examples of pessaries: (A) inflatable (B) donut (C) gellhorn (D) • Unusual
cube (E) ring with support accompan

• Cesarean delivery for subsequent pregnancies o if pessary management


is not adequate o the abnormality is so uncomfortable that repair must be
performed before childbearing is complete

KEGEL EXERCISES
• Strengthen the pelvic floor and abdominal musculature
• Effective for: urinary incontinence, fecal incontinence, sexual dysfunction
• Offered to all patients: both symptomatic and asymptomatic patients
• Has no adverse effects
• Free and can be done anytime
• Kegel exercises can be done in a variety of positions and even during a • If rectocele, uterine descensus and enterocele is noted, this must also be
variety of daily activities o lying down o sitting position in a meeting o when treated. o Unusual for anterior supports of the vagina to relax without an
talking on the phone o while reading your trances o while listening to the accompanying relaxation of the posterior wall.
lectures • Procedure: 1. Place a Foley catheter 2. Incise the vaginal epithelium
• Procedure in doing Kegel exercises: o contract transversally just above the anterior lip of the cervix in the region of the
pelvis muscles for 3 seconds o relax pelvic bladder reflection (Identified using the inflated bulb of a Foley catheter). a. If
muscles for 3 seconds o do this 10-15 times; the woman has undergone a hysterectomy in the past, the transverse
several times a day incision may be made approximately 1 to 1.5 cm anterior to the vaginal
vault to the level of the bladder neck. b. If a urethrocele is present, the tension. 4. The pubocervical fascia that is attached is separated from
incision is continued under it by
the urethra as well blunt and sharp dissection. o Pubocervical fascia: fibromuscular
tissue underneath the
vaginal epithelium

Figure 6. Midline incision using extended scissors

3. Separate the vaginal wall from the underlying tissue with Figure 7. Dissection of the vaginal epithelium off the underlying
Metzenbaum scissors. The cut edge of the vagina is held under connective tissue and fibromuscular layer
• pelvic
Occasionall support
y, if pessary defects.
is not
adequate
and the
GYNECOLOGY
abnormality
is so
Pelvic
uncomforta
ble that

be
performed
Organ Disorders
repair must

before
childbearin
5. The surgeon places a suture over the bladder neck (Kelly stitch), as
g is far away from the cut edge and parallel to the previous incision,
complete -
bringing together the pubocervical fascia (will provide support) on either
cesarean
side. o Absorbable Polyglycol 2-0 sutures can be used on each side
delivery of the defect o Do Kelly stitch especially if
should be with incontinence.
considered
for
subsequent
pregnancies
• Surgery is
also
considered
if: - pelvic
floor
strengtheni
ng Figure 8. Kelly Stitch
exercises
and 6. Vaginal edge is closed
pessary doo After the imbrication of the pubocervical fascia is completed, the
not vaginal edges are trimmed and the vagina closed with a row or
atient declines non-operative options interrupted 2-0 polyglycol or catgut sutures

COLPORRHAPHY (Operative
Repair of a Cystocele)
• Performed
in
conjunction
with the
repair of all
Figure 9. Vaginal edge trimming and closure 2 consecutive voiding, no further steps are necessary.
• Occasionally, after an anterior repair, voiding does not occur after 5
From Katz Comprehensive Gynecology (2017) days of bladder drainage.
• Cystoscopy should be performed to assess the bladder and ureteral • Patient that require re-catheterization for 24 to 48 hours to a week,
integrity after procedure is completed. recheck for voiding and residual urine as an outpatient in 1 week. o It is
• Midurethral sling surgery for associated stress urinary incontinence rarely necessary to treat the patient with antibiotics during this period.
or stress urinary incontinence on prolapse reduction can be performed However, lower urinary tract infections are common and should be
through a separate incision over the midurethra. treated as they occur. o No need to routinely give antibiotics.
• Alternatives if the midurethral slings are not available o
Kelly plication o Brunch urethropexies o Fascial slings

POST-OPERATIVE BLADDER DRAINAGE


• The surgeon should decide which method is best suited to the needs of
Suprapubic Catheter Technique
his or her institution. o Develop a system that the surgeon and nursing team
• Alternative
can
understand and follow. • The drainage tube can be clamped, allowing the patient to void when she
can and allowing residual urine measurements to be taken.
Transurethral Catheterization • Simple to use and have a lower incidence of infection than transurethral
catheterization.
• Indwelling catheter
• Patients may complain of extravasation of urine around the site and
• Procedure: Leave a no. 16 Foley catheter in place for 1 day and allow the
occasionally of hematoma formation.
patient to try to void after removal.
• Voiding trial: To assess the risk of postoperative urinary retention o Auto
Clean Intermittent Self-Catheterization (CISC)
Fill:
• Can be threatening for patients to learn
▪ Catheter is removed, and the bladder is allowed to fill
spontaneously • Once learned, many patients prefer not having an indwelling catheter and
can measure their own post void residual urine volumes.
▪ Voided volume and residual volume (USG or straight catheterization
are measured. o Back Fill • Not necessary if short periods of catheterization are anticipated
o Bladder retrograde filled with 300 mL saline, then catheter
POST-OPERATIVE HEALING AND RESTRICTIONS
is removed. o At least 2/3 of the total bladder
volume must be measured. • The healing process is slow, and the tissue is generally weak initially
o Example: Postvoid residual of less than 100 mL after voiding • Patients are advised to avoid straining from constipation, heavy lifting and
200 mL of a 300 mL total bladder volume. o RCT: Back fill technique is strenuous activity for about 6 weeks.
a better predictor of adequate • Nothing should be placed in the vagina until it heals
postoperative bladder emptying; more preferred by patients. • Women should be able to resume other nonstrenuous normal activities as
• If voiding does not occur prior to discharge: o Continuous drainage or soon as complete healing is ensured.
CISC for 1 – 7 days and recheck for
voiding and residual urine as outpatient RECURRENCE
• Recurrent anterior vaginal wall prolapses remain as the most frustrating
problem for the gynecologic surgeon and patients
• 3 – 14%
• Controlled studies reporting long-term outcomes are lacking

RECURRENT ANTERIOR VAGINAL WALL PROLAPSE


• Common
• The physician should consider replacing the catheter for 24 to 48
• CURRENTLY PROPOSED:
hours: o Residual urine >150 mL on 2 successive voiding o If the amount
voided is <200 mL o If residual urine <150 mL (Normal is 50mL; but o Augmentation of anterior vaginal wall prolapse repair with
since the patient underwent surgery, 150mL may serves as the limit) on graft materials
From 3A a bladder
Batch 2018 ultrasound
Trans: can estimate
• After voiding residual
of at least 200 volume.
mL the
patient should
be
catheterized
for the
presence of
residual urine
or
alternatively,
• Chronic
Figure 11. Line drawing example of posterior support defect. The
urinary tract
anterior compartment is well supported. The leading point of the
infections,
prolapse is point Bp (+5), which is 5cm beyond the hymen. Total vaginal
prophylaxis
length is 8cm, and point C (-6), and the cuff position has descended
with a2cm.
sulfaAa
or = Proximal anterior wall; Ba = Distal anterior wall; TVL =
nitrofurantoin Total vaginal length
(weak MANAGEMENT NON-
antibiotic) can OPERATIVE TREATMENT
be • Pessaries, Kegel Exercises and Estrogen
administered • Gastrointestinal symptoms must be evaluated, include screening for
• Advise thecolorectal cancer.
patient to do
• Constipation and Straining – A dietary fiber and fluid intake review should
bladder drill o
be obtained. o First line therapy: At least 25g. of fiber, six to eight glasses of
Instruct to
fluid, regular exercise, and allowing time for defecation after meals can be
empty
recommended to regulate bowel habits
bladder q4-
6hrs
OPERATIVE TREATMENT
POSTERIOR COLPORRHAPHY
• Posterior colporrhaphy is performed at the time of an anterior
GYNECOLOGY Pelvic colporrhaphy with or without enterocele repair or operation for descensus.
• Most also have gaping vaginas and weakness in their perineal body hence
a perineorrhaphy is performed as well.

Organ Disorders
o Open Abdominal Retropubic Bladder Neck Suspension is not
recommended anymore
• Improve anatomic result, but associated with complications like: o
Mesh exposure o Pelvic Pain o Dyspareunia

III. RECTOCELE
• Posterior vaginal wall prolapse o Protrusion of the rectum into the vagina,

signifying a relaxation of the rectal supports Figure 10. Rectocele Figure 12. Perineorrhaphy. Following the completion of the repair of the
rectocele, the perineal body may need to be reconstructed. The
bulbospongiosus and the superficial transverse peroneus muscles are
SYMPTOMS AND SIGNS
plicated in the midline with absorbable sutures.
• Heavy or “falling out” feeling in the vagina
• Vaginal bulge • Procedure: 1. Estimate the degree of perineorrhaphy 2. The margins of
• Disruption of sexual activity the perineum to be narrowed down are generally marked by placing Allis
• Constipation o May need to splint the vagina with her fingers to effect clamps on the hymen such that reapproximating the clamps at their
bowel extreme at the introital opening
movement
• A feeling of incomplete emptying of the rectum at the time of the bowel
movement

DIAGNOSIS
• Procedure: 1. Retract the anterior vaginal wall upward with one-half of a
Graves or Pederson speculum and have the patient strain. 2. The rectum
will bulge into the vagina, and this bulge may
protrude through the introitus. 3. Place one finger in the
rectum, one in the vagina and palpate
the hernia o Often the rectovaginal septum is paper-thin, and the
rectocele can be palpated to its upper margin.

grasped and placed under tension 6. Perirectal connective tissue is


separated from the vaginal nondominant hand into the rectum, assistant
mucosa by blunt and sharp dissection 7. Surgeon’s finger of picks up perirectal tissue on either side
3. The tissue
hysterectomy
of has also been performed d. If vaginal vault prolapse
the introitus
is also
is present, a separate repair is
then incised indicated for support of the vaginal apex e. The finger in the
betweenrectum
these ensures that no suture is placed in
the rectum 9. The vaginal edges are then trimmed, and
Vaginal wall s closed with a row of either continuous or interrupted
the vagina
separated from suture
absorbable
the underlying
tissue and RECURRENCE
rectum at the
• Successful repair is higher for posterior colporrhaphy (96%) than site-
introital tissue in
specific and anterior wall repair (89%)
a progressive
• Recurrence
manner startingis uncommon and lower
• Evidence does not support use of grafts
in the midline
• Anatomic position is often corrected by posterior colporrhaphy, while
carried
functionforward
may NOT. o Defecatory problems may remain so warn patients.
to the apex of
the vagina COMPLICATIONS
•above the limitcan be a problem postoperatively, especially if levator ani
Dyspareunia
of the rectocele
plication is done
• Levator ani plication may best be indicated in non-sexually active women
Metzenbaum
because of possible vaginal narrowing and band formation.
scissors 5.

PERINEAL MUSCLE
vaginal wall is
Perineorrhaphy
completely
• Perineal muscle
incised, the separation
• “Flower arrangement”
edges are
• Procedure: 1. Polyglycol sutures are placed in the lateral margins of the
transverse incision, bringing bulbocavernosal and superficial perineal

GYNECOLOGY Pelvic muscles together from either side to the midline. 2. The operator should
be sure that the bulbocavernosal muscle insertions are included in the
sutures by pulling the suture and noting whether the tension identifies the
muscle bundles.
3. The

Organ Disorders 0 poly


closed
chrom

• Prevention: Incorporation of uterosacral and cardinal ligaments into the


vault repair after hysterectomy.

Figure 14. Identifying margins of levator ani

8. Place 3 to 5 delayed absorbable suture into the perirectal tissue

on either side Figure 15. Placement of

sutures
Figure 16. Enterocele

a. The perirectal tissue usually includes portions of levator ani


DIAGNOSIS
muscles b. When the sutures are tied, the tissues are
• Noticed as a separate bulge above the rectocele
interposed between rectum and vagina, thereby reducing the
• May be large enough to prolapse through the vagina
rectocele c. These sutures also serve to tuck the vagina to the
levator ani area, thereby avoiding future vaginal prolapse if a • Specific diagnosis by transillumination the bulge and seeing small bowel
shadows within the sac. o It is possible to differentiate the enterocele from enterocele sac
a rectocele by with vaginal wall
rectovaginal examination. reflected. B.
• The content of an enterocele are always small bowel and may also Appearance of
include omentum open enterocele
sac with sac neck
• The contents may be easily reducible or may be fixed to the peritoneum of
identified. C.
the sac by adhesions.
Placing of purse-
string suture at the
OPERATIVE MANAGEMENT
neck of the
• Enterocele may be reduced transabdominally as a primary enterocele sac. D.
procedure or at the time of other abdominal procedures Excision of
• In the primary procedure, the sac should be reduced upward, and if the enterocele sac.
uterosacral ligaments are present, this may be brought in the midline.

Figure 17. Repair • If uterosacral ligaments can be identified, vaginal hysterectomy has been
of enterocele. A. performed in association with enterocele repair
Appearance of
IV. ENTEROCELE
• True hernia of the peritoneal cavity emanating from the Pouch of Douglas
between the uterosacral ligaments and into the rectovaginal septum
• Frequently occur after an abdominal or vaginal hysterectomy
• Result of a weakened support for the Pouch of Douglas.

GYNECOLOGY Pelvic Organ Disorders


• The uterosacral ligaments can be fixed to the peritoneum of the sac and the vaginal vault connective tissue with multiple sutures of 0-
polyglycol: McCall Stitch or McCall Culdoplasty – effectively shortens the cul-de-sac and shortens enterocele neck
• Support of vaginal apex such as sacrospinous ligament suspension needed for optimal repair
• If uterosacral ligaments cannot be identified by previous total abdominal hysterectomy, the rectocele repair should be continued to the
enterocele sac neck, reinforce the support of the cul-de-sac as high as possible o This usually involves the joining of levator ani muscles up
to
the area of enterocele sac.
• Correctly repaired enteroceles with appropriate rectocele repair usually will not recur.
V. UTERINE PROLAPSE (DESCENSUS PROCIDENTIA)
• Descensus of the uterus and cervix into or through the barrel of the vagina
• Stage 4 - complete eversion
• Associated with injuries of the endopelvic fascia, including the cardinal and uterosacral ligaments
• Injury to the neuromuscular unit with relaxation of the pelvic floor muscles, particularly the levator ani muscles
• Occasionally, the prolapse is the result of increase abdominal pressure, such as patients with ascites or large pelvic or intraabdominal
tumors superimposed on the poor pelvic supports.
• In some instances, sacral nerve disorders, especially injuries to S1 to S4, or diabetic neuropathy may be responsible.
• Using Computed topography, Sze and associates demonstrated that women with advanced genital prolapse had larger transverse inlet
diameters, but not anterior-posterior diameters than women without prolapse, suggesting an anatomic disposition.
Figure 18. Uterine prolapse
TOTAL PROLAPSE OF THE UTERUS
• The patient is in danger in developing dryness, thickening, chronic inflammation of the vaginal epithelium
• Stasis ulcers may result as edema and interference with the blood supply of the vaginal wall occur
• These ulcers rarely become cancerous, but biopsies should always be taken to ensure that they are not
ASSOCIATED FACTORS THAT INCREASE TENSION ON THE PELVIC MUSCULATURE
• Chronic Respiratory Disease – chronic bronchitis, asthma, bronchiectasis
• Severe obesity
• Congenitally damaged or relaxed pelvic floor supports may cause prolapse in young, nulliparous women
• Most patients are multiparous, the prolapse in part a result of childbirth trauma
• Descensus is almost always associated with rectocele and cystocele and, at times, enterocele, supporting the concept of overall relaxation
of the pelvic support structures
SIGNS AND SYMPTOMS OF UTERINE PROLAPSE
• Because prolapse almost always related to anterior and posterior vaginal wall relaxation, symptoms that were reported earlier for
rectocoele and cystocoele may be present
• Common for the cervix or vaginal epithelium to become damaged and ulcerated – patient may report pain or vaginal bleeding or discharge
from the cervix and vagina when secondary infection occurs.
Table 3. Pelvic Organ Prolapse Categories for Clinical Evaluation
Lower urinary tract symptoms
Urinary incontinence Frequency, urgency, nocturia Voiding difficulty; slow stream, incomplete
emptying, obstruction Urinary splinting
Bowel symptoms
Constipation Straining Incomplete evacuation Bowel splinting Anal incontinence
Sexual symptoms
Interference with sexual activity Dyspareunia Decreased sexual desire
Others
Pelvic pressure, heaviness, pain Presence of vaginal bulge/mass Low back pain Tampon not retained Quality of life impacts
DEGREES OF UTERINE PROLAPSE Table 4. Degrees of Uterine Prolapse (OLD TERMS; for biopsy purposes only)
Degree Description First Degree A prolapse in the upper barrel of the vagina
Prolapse is through the vaginal barrel to the
Second Degree
region of introitus
Cervix and the uterus prolapse out of the
Third Degree
introitus
Fourth Degree / Total Prolapse
Vagina is everted around the uterus and cervix and is completely exteriorized Doc: not used anymore. For history taking purposes only
VI. IMPORTANT CONSIDERATIONS FOR NON- SURGICAL AND SURGICAL DECISION
MAKING
• Medical condition and age
• Severity of symptoms
• Patient’s choice
• Patient’s suitability for surgery
• Presence of other pelvic conditions
• Presence or absence of urethral hypermobility
• Presence or absence of pelvic floor neuropathies
• History of previous pelvic surgery
VII. TERMINOLOGY FOR PELVIC ORGAN PROLAPSE
• In 1996 standardized terminology for the description of female pelvic organ prolapse and pelvic floor dysfunction was adapted by
International Continence Society, the American Urogynecological Society, and the Society of Gynecological Surgeons
• Pelvic Organ Prolapse – Quantification System (POP – Q)
From Comprehensive Gynecology:
• Common symptoms noted by patients with uterine prolapse are a feeling of pelvic pressure and heaviness, fullness, bulge or “falling out” in
the perineal area

GYNECOLOGY Pelvic Organ Disorders


o This is an objective, site-specific system for describing, quantitating, and staging pelvic support and was developed to enhance both
clinical and academic communication with respect to individual patients and populations of patients. o The terminology replaces such terms
as cystocele, rectocele, enterocele and urethrovesical junctions with precise descriptions relating to specific anatomic landmarks. The
first points are on the anterior vaginal wall and categorize anterior vaginal wall prolapse accordingly.
GOAL OF THE STAGING SYSTEM
• These organization hope that by using this system, the following will be achieved: o A cleared understanding of the patient’s prolapse o
Accurate transmittal or information to others o Standardize research information
QUANTIFICATION DEFINITION AND STAGES PELVIC ORGAN PROLAPSE – QUANTIFICATION SYSTEM
Figure 19. Quantitative description of pelvic organ prolapse six sites (points Aa, Ba, C, D, Bp, and Ap), genital hiatus (gh), perineal body (pb),
and total vaginal length (tvl) used for pelvic organ support quantitation.
Table 5. Quantification Definition and Ranges
Point Description Range
Aa
STAGING OF PELVIC FLOOR PROLAPSE USING INTERNATIONAL CONTRINENCE SOCIETY TERMINOLOGY
• STAGING o To record measurements, these points should be expressed in
centimeters above or below the hymen. o It is important for the examining individual to express the position and other circumstances of
the examination (i.e., straining or not, patient flat on table or in examining chair, etc.). o When the examination is recorded according to the
anatomic
points just cited, staging may be performed.
Table 6. Stages of Pelvic Organ Prolapse
STAGE Description
0
• No prolapse is demonstrated
• Points Aa, Ap, Ba, and Bp are all at -3cm and either point C or D is between total vaginal length -2cm
1
• Criteria for stage 0 are not met
• But the most distal portion of the prolapse is >1cm above the level of the hymen
2
• The most distal portion of the prolapse is less or equal to 1 cm proximal or distal to the plane of the hymen
3
• The most distal position of the prolapse is >1cm below the plane of the hymen
• Essentially complete eversion of the total length of
• But protrudes no farther than <2cm than the total vaginal length in cm 4
the lower genital tract
Figure 20. Clinical Classification of Pelvic Organ Prolapse (See appendix for a larger picture)
VIII. MANAGEMENT
• Minimum prolapse does not require therapy unless the patient is very uncomfortable
• Degrees of prolapse that place the cervix at or through the introitus probably cause greater discomfort and are usually more bothersome to
the patient
Condition Management
If cervix is at or through the introitus
Located in the midline of the anterior wall 3 cm proximal to the external urethral meatus and is roughly the location of the urethrovesical
crease
-3 to +3
Represents the most distal position of any
Ba
-3 to +TVL
part of the anterior vaginal wall prolapse
C
Represents either the most distal edge of the cervix or the leading edge of the vagina if a hysterectomy has been performed
- / = TVL
D
Represents the location of the posterior fornix (pouch of Douglas) in a woman with a cervix
-/+ TVL
Located in the midline of the posterior
Ap
-3 to +3
vaginal wall 3 cm proximal to the hymen
Point most distal of any part of the upper
Bp
-3 to +TVL
posterior vaginal wall
Perpendicular distance from midurethral
Gh
No limit
meatus to posterior hymen
Pb
• Replacement of the uterus and cervix to their usual position in the pelvis and then the institution of support using pessary devices
If the patient is a young woman and pregnant
• Replace the uterus before it enlarges and becomes trapped in the lower pelvis or vagina
• Entrapment may cause:
o Edema o Incarceration o Loss of blood supply to the uterus
Perpendicular distance from the posterior aspect of the genital hiatus to the midanal opening
No limit
TVL
Posterior vaginal fornix or vaginal cuff if absent cervix to the hymen. Greatest depth of the vagina in cm. Measurement without straining
No
From Comprehensive Gynecology:
• All of the measurements are performed while the patient strains (bears down) except for total vaginal length (TVL)

GYNECOLOGY Pelvic Organ Disorders


Postmenopausal woman
OPERATIVE MANAGEMENTS
• Vaginal hysterectomy with a vaginal vault suspension. o Carefully, isolate the uterosacral and cardinal ligaments so
that they may be used in the support of the vaginal vault o The uterosacral ligaments should be sutured together cul-de- sac is shortened or
obliterated and the risk of a subsequent enterocele is lessened o Other vaginal vault suspension procedures can be used instead
of the McCall type o Earlier discharge and faster healing of wounds than the
abdominal approach
VAGINAL HYSTERECTOMY IS NOT ADVISABLE
• Previous intraabdominal operation for an inflammatory process – endometriosis or pelvic inflammatory disease
• An abdominal hysterectomy may be performed, followed by a vaginal anterior and posterior colporrhaphy, if needed
• Alternatively, a laparoscopically assisted vaginal hysterectomy may be performed
Figure 21. Vaginal Hysterectomy and unilateral SO. (wala ako mahanap na hindi copyrighted huhu)
• Estrogen replacement for at least 30 days with vaginal estrogen cream to help improve the vitality of the vaginal epithelium, the cervix,
and the vasculature of these organs Prolapse of the uterus and cervix
• Vaginal hysterectomy with a vaginal vault suspension If cystocele and rectocele are also present
• Manchester (Donald or Fothergill) operation
Elderly women who are no longer sexually active
• Partial Colpocleisis
o Removal of a strip of anterior and
posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other
VAGINAL PESSARIES
• Removable device placed into the vagina. It is designed to support different sites of POP. Available pessaries – silicone or latex rubber
• Use of a pessary, usually of the Smith-Hodge, donut, cube, or inflatable variety
• Require the replacement of the uterus and cervix to the usual position in the pelvis
• Patient factors that determine the type of pessary – sexual activity, site of POP, stage of POP
• If fitted with correct pessary size – not aware of its presence
• No site defect protrudes when pessary in place
• Complications rare with proper use – regular removal, cleaning, and replacement, as well as use of vaginal estrogen cream for
postmenopausal women with vaginal atrophy
• Complications include vaginal infections, bleeding, discomfort, vaginal erosion and ulceration, and impaction.
• Young woman and pregnant, it is important to replace the uterus before it enlarges and becomes trapped in the lower pelvis or vagina
• Entrapment may cause edema, incarceration and even loss of blood supply to the uterus
• Postmenopausal woman, estrogen replacement for at least 30 days with vaginal estrogen cream may help improve the vitality of the
vaginal epithelium, the cervix, and the vasculature of these organs
• Makes fitting of a pessary or the operative procedure and the healing process more efficient
• The patient should not undergo operation until all ulcers of the vagina and cervix are healed, because to do otherwise is to risk infection
and breakdown of the repair
From Comprehensive Gynecology:
• Are available in varying sizes and should be properly fitted to the patient
• In general, the perineum must be capable of holding the pessary in place, or the pessary will fall out.
• There is currently no evidence from randomized controlled trials on pessary use to direct the selection of the device or to compare
pessaries with other treatments or surgery.
• Patient factors that determine the type of pessary: o Sexual activity o Site of POP o Stage of POP
PROSPECTIVE TRIAL A recent prospective trial found 75% of 203 women fitted with a pessary successfully retaining the device at 2 weeks.
Failure to retain the pessary was significantly associated with increasing parity and past hysterectomy. 48% of the women completed a
questionnaire at 4 months. The pessary reduced symptoms of POP including general symptoms of vaginal bulge. It also relieved urinary
symptoms such as voiding problems in 40% of women, urinary urgency in 38%, and urge incontinence in 29%. There was no improvement in
stress urinary incontinence. Bowel symptoms improved as well.

S 2 T 3a 10 of 13
support the anterior vaginal wall and bladder
• Of value in elderly women with comorbid medical conditions who have an

GYNECOLOGY Pelvic elongated cervix and well-supported uterus


• It is technically easier with shorter operative time than the vaginal
hysterectomy
• Suggested for repair in young women who wish to maintain their
reproductive abilities, but the loss of the cervix may interfere with fertility or
Organ Disorders lead to incompetence of the internal cervical os

Partial Colpocleisis
Manchester (Donal or Fothergill Operation) • In elderly women who are no longer sexually active
• In some women, a cystocele and rectocele may be present, the cervix is • A simple procedure for reducing prolapse
hypertrophied and elongated to the area of the introitus, but the • The classic procedure was described by Le Fort and involves the removal
supports of the uterus itself are good – meaning wala pang uterine of a strip of anterior and posterior vaginal wall, with closure of the margins
prolapse, mahaba lang talaga yung cervix kaya mukhang nag-prolapse. of the anterior and posterior wall to each other.
• This operation combines an anterior and posterior colporrhaphy with
the amputation of the cervix and the use of the cardinal ligaments to Le Fort Partial Colpocleisis
• This procedure may be performed with or without the presence of a uterus Figure 23. Goodall–Power modification of Le Fort operation. A,
and cervix, and when it is completed, a small vaginal canal exists on either Representation of vaginal incision on anterior and posterior wall. B, Early
side of the septum produced by the suturing of the lateral margins of the placement of sutures. C, Later placement of sutures. D, Vaginal incision
excision completely closed; perineorrhaphy being performed. E, Appearance at
• The line of dissection of the vaginal wall is carried to the level of the completion of procedure.
bladder neck anteriorly and to the reflection of bladder onto the cervix at the
upper margin of the vagina. Posteriorly the dissection is carried from just Uterosacral ligaments bilaterally could be sutured to the
inside the introitus to a position just posterior to the cervix sacrospinous ligaments
• The cut is rectangle in the anteroposterior walls • A special circumstance involves the treatment of women who wish to
• If a hysterectomy has been previously performed, the dissection may maintain their fertility despite the fact that they have a total uterine prolapse
begin approximately 1 cm on either side of the vaginal scar • Uterosacral or sacrospinous ligament fixation by vaginal approach or
• When the procedure is completed, the bladder neck is spared from any sacral hysteropexy by abdominal approach.
scarring and urinary incontinence is generally avoided
• BEST for larger prolapses
• Bladder neck plication may be carried out if the patient is incontinent. After IX. VAGINAL APEX PROLAPSE
healing of the plication a small introital area is noted; this has cosmetic • Sometime remote to the performance of either abdominal or vaginal
benefits in older women hysterectomy
• In addition, narrow canals are noted on each lateral vaginal wall. If the • Occurring in 0.1% to 18.2% of patients
cervix and uterus are still present and intrauterine pathology occurs, • Probably the result of continuing pelvic support weakness and failure of
bleeding along these canals could take place, alerting the physician to a the vaginal support structures, namely, cardinal and uterosacral ligaments
potential problem to maintain their tone or attachment to the vagina
• May be total and may be accompanied by a cystocele, a rectocele, an
enterocele, or a combination
Figure 22. Le Fort
procedure. A, • The result of continuing pelvic support weakness and failure of the vaginal
Incision of anterior support structures (cardinal and uterosacral ligaments) to maintain their
vaginal wall strip. B, tone or attachment to the vagina
Incision of posterior
wall strip. C. Signs and Symptoms
Removal of vaginal • Similar to s/sx of descensus of the uterus
strip. D and E, • Pelvic heaviness, backache, and a mass protruding through the
Placement of introitus
sutures. F, • May also occur: stress incontinence, urgency, frequency, dribbling, vaginal
Appearance of bleeding or discharge (if there is an ulcer), and, depending on the size of
vagina after the mass, difficulty with sitting or walking
procedure is
completed but before
perineorrhaphy is
performed.
Goodall-Power Modification of the Le Fort Operation
• Similar to Le Fort but a triangle cut is performed
• Allows for the removal of a triangular piece of vaginal wall beginning at the
cervical reflection or 1 cm above the vaginal scar at the base of the triangle,
with the apex of the triangle just beneath the bladder neck anteriorly and
just at the introitus posteriorly
• The cut edge of vaginal wall making up the base of the triangle anteriorly
is sutured to the similar wall posteriorly, and the vaginal incision is then
closed with a row of interrupted sutures beginning beneath the bladder neck
and carried side to side to the area of the introitus
• This procedure works well for relatively small prolapses
• Examination may help determine the contents of the herniation depending
on where the vaginal scar is located in relation to the

GYNECOLOGY Pelvic Organ Disorders


protruding mass and the extent to which the supports of the pelvis are lost.
• Rectovaginal examination is often helpful in delineating an enterocoele from a rectocele.
Management
• These include those that use the abdominal route, vaginal route or some combination thereof.
• (+) Vaginal cap/dimple
Certain facts to consider:
• The normal position of the vagina in the standing position is against the rectum and no more than 30° from the horizontal
• Pelvic relaxation is part of the problem and dictates that an existing cystocele, rectocele, or enterocele must be repaired as part of the
procedure
• The perineal body is almost always severely weakened in such patients and must therefore be reconstructed as well
Non-Operative Management
• Pessaries, estrogen and the healing of ulcers should be used as appropriate
• Pessaries, however, are rarely retained in such patients and attempts to treat these patients non ‐surgically are generally met with
frustration
Operative Management
• Includes those that use the abdominal route, vaginal route or combination
• Blind procedure!!! Only done by a urogynecologist #coolbeans
• For the abdominal approach, a variety of approaches have been tried for the fixation of the vaginal vault to the: o Anterior abdominal wall o
Lumbar spine o Sacral promontory o Various tendinous lines in the musculature of the true pelvis o Sacrospinous ligament – Most popular
because it is
accessible o Ito yung mga “pagsasabitan” ng vaginal vault. Gets? Gets.
• For the vaginal approach, fixation of the vaginal vault to the sacrospinous ligaments via the vaginal route, all had successful outcomes. o
Iliococcygeus fascia suspension – to suspend the vaginal vault to the fascia of the iliococcygeus muscle in patients with weak uterosacral
ligament
▪ Most commonly used by urogynecologists o McCall Culdoplasty – to suspend the vaginal vault to the

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