I. Introduction To Pelvic Organ Prolapse: Normal Support of Pelvic Organs
I. Introduction To Pelvic Organ Prolapse: Normal Support of Pelvic Organs
I. Introduction To Pelvic Organ Prolapse: Normal Support of Pelvic Organs
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
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
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
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.
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
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
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
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.
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
sutures
Figure 16. Enterocele
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.
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
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