Pelvic Organ Prolapse PDF

# Pelvic Organ Prolapse ## Dr. Nishant Kumar Thakur MD Obstetrics & Gynaecology ## Definition - Pelvic organ prolapse is a bulge of pelvic organs and their associated vaginal segment into or through the vagina. - Normally, external OS lies at the level of ischial spine & internal os at the upper...

# Pelvic Organ Prolapse ## Dr. Nishant Kumar Thakur MD Obstetrics & Gynaecology ## Definition - Pelvic organ prolapse is a bulge of pelvic organs and their associated vaginal segment into or through the vagina. - Normally, external OS lies at the level of ischial spine & internal os at the upper border of pubic symphysis. So any descent of the uterus from these levels is a case of prolapse. ## Support of uterus - Primary supports: - Muscular/Active support: 1. Pelvic diaphragm- Levator ani (Pubococcygeus, Iliococcygeus, Puborectalis) & Ischiococcygeus 2. Urogenital diaphragm- Superior & Inferior fascia of Urogenital diaphragm, Deep transverse perinei muscle & sphincter urethrae muscle. 3. Perineal body: | Paired Muscles | Unpaired Muscles | |---|---| | Superficial transverse perinei. | External anal sphincter | | Deep transverse perinei | Longitudinal muscle fold of rectum & anal canal. | | Bulbocavernosus. | | - Fibromuscular/ Mechanical support: 1. Uterine axis (Anteversion 90° & anteflexion 120°. 2. Transverse cervical ligament 3. Pubocervical ligament 4. Uterosacral ligament 5. Round ligament - Secondary supports: 1. Broad ligament. 2. Uterovesical fold of peritoneum. 3. Rectovaginal fold of peritoneum. ## Levels of vaginal support | Number | Level | |---|---| | 1 | Level 1: Cardinal & Uterosacral ligament attachment to the cervix & upper vagina | | 2 | Level II: Paravaginal attachment of lateral vagina & endopelvic fascia to the Arcus tendinous. | | 3 | Level III: Perineal body Superficial & Deep perineal muscles & fibromuscular connective tissue. | ## Risk Factors Associated with Pelvic Organ Prolapse (POP) - Vaginal birth: - Risk of POP is increased 1-2 times with each vaginal delivery. - Pregnancy: - High progesterone level causing laxity of pelvic tissue. - Age: - In women aged 20-59 years, the incidence of POP roughly doubled with each decade. - Menopause: - Hyperestrogenism. - Connective tissue disease: - Marfan syndrome, - Ehlers-Danlos syndrome. - (Ratio of collagen I to Collagen III & IV is decreased) - Race: - Hispanics & white women have high incidence. - Chronically increased intra-abdominal pressure: - COPD - Chronic constipation - Obesity - Repeated heavy lifting - Pelvic floor trauma: - Forceps/Vacuum Delivery - Episiotomy - Spina Bifida Occulta. - Cigarette smoking. - Causes a1-antitrypsin deficiency. # Clinical Types of Pelvic Organ Prolapse ## Types of Genital Prolapse - Vaginal - Anterior wall - Cystocele (upper 2/3) - Urethrocele (lower 1/3) - Cystourethrocele (combined) - Posterior wall - Relaxed perineum - Rectocele - Vault prolapse - Uterine - Uterovaginal - Congenital - Pelvic organ prolapse (POP) (according to compartment defects) - Anterior - Bladder - Middle - Uterus - Posterior - Pouch of Douglas # Vaginal Prolapse ## 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 area, there is herniation of the bladder 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 cystourethrocele. ## Posterior Wall - Relaxed perineum: - Torn perineal body produces gaping introitus with bulge of the lower part of the posterior vaginal wall. - Rectocele: - There is laxity of the 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. ## Vault Prolapse - 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 enterocele. - Traction enterocele is secondary to uterovaginal prolapse. - Pulsion enterocele is secondary to chronically raised intra-abdominal pressure. - Secondary vault prolapse: - This may occur following either vaginal or abdominal hysterectomy. - Undetected enterocele during initial operation or inadequate primary repair usually results in secondary vault prolapse. # Uterine Prolapse - Uterovaginal prolapse: - Prolapse of the uterus, cervix, and upper vagina. - This is the most common type. - Cystocele occurs first followed by traction effect on the cervix causing retroversion of the uterus. - Intra-abdominal pressure has got piston like action on the uterus thereby pushing it down into the vagina. - Congenital prolapse: - 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. # Complex Prolapse Is one when prolapse is associated with some other specific defects. It includes the following: - Prolapse with urinary or fecal incontinence, - Nulliparous prolapse, - Recurrent prolapse, - Vaginal and rectal prolapse or prolapse in a frail woman. # Clinical Features - Symptoms: - Buldge symptoms: - Sensation of vaginal buldging or protrusion. - Seeing or feeling a vaginal or perineal buldge - Pelvic or vaginal pressure. - Heaviness in pelvis or organ - Urinary symptoms: - Incontinence - Frequency - Urgency - Weak or prolonged urinary stream. - Hesitancy - Feeling of incomplete emptying - Manual reduction of prolapse to start or complete voiding - Position change to start or complete voiding. - Bowel symptoms: - Incontinence of flatus or liquid/ solid stoll. - Feeling of incomplete emptying. - Hard straining to defecate. - Urgency to defecate. - Digital evacuation to complete defecation. - Splinting vagina or perineum to start or complete defecation. - Feeling of blockade or obstruction during defecation. - Sexual symptoms: - Dyspareunia. - Decreased lubrication. - Decreased sensation. - Decreased arousal or orgasm - Pain symptoms: - Pain in vagina, bladder and rectum. - Pelvic pain. - Low back pain. # Clinical Examination and Diagnosis of POP - Composite examination: - Inspection and palpation: Vaginal, rectal, rectovaginal or even under anesthesia may be required to arrive at a correct diagnosis. - General examination: - Details, including body -mass index (BMI), signs of myopathy or neuropathy, features of chronic airway disease (COPD) or any abdominal mass should be done. - Pelvic examination: - Bladder should be emptied. - Position is Lithotomy. - In both dorsal and standing positions. - The patient is asked to strain as to perform a Valsalva maneuver during examination. - This often helps to demonstrate a prolapse which may not be seen at rest. - Levator ani muscle tone is assessed by placing examining fingers (index and middle) inside the vagina and thumb outside. - The muscle (pubovaginalis) is palpated in the lower third of vagina. Patient is asked to squeeze the anus and the muscle tone is felt. - Bowel function evaluation - Bladder function evaluation: - Clean catch / catharized urine sample for infection. - Post void residual volume (≤ 100ml is acceptable) - Rectal examination helps to detect deficient perineum. - Imaging: - Fluoroscopic evaluation of bladder function - USG pelvis - Defecography for patient in whom intussuption or rectal mucosal prolapse is suspected. - MRI: evaluation of pelvic pathology such as Mullerian anomalies, pelvic pain. # Pelvic Organ Prolapse Quantification (POP-Q) - Recommended by the International Continence Society as it standardizes terminology and is most objective, site specific and anatomical. - Prolapse in each segment is measured relative to the hymen. - Six points are located with reference to the plane of the hymen: - Two on the anterior vaginal wall (points Aa and Ba), - Two at the apical vagina (points C and D), and - Two on the posterior vaginal wall (points Ap and Bp). - Genital hiatus (Gh), perineal body (Pb), and total vaginal length (TVL) are also measured. - All POP-Q points, except TVL, are measured during patient Valsalva and should reflect maximum protrusion. | Points | Description | Range | |---|---|---| | Aa | Anterior wall 3cm from hymen | -3cm to +3cm | | Ba | Most dependent portion of rest of anterior vaginal wall | -3cm to +TVL | | C | Cervix or vaginal cuff | +TVL | | D | Posterior fornix(if no prior hysterectomy) | +TVL OR omited | | Ap | Posterior wall 3cm from hymen | -3cm to +3cm | | Bp | Most dependent portion of rest of posterior vaginal wall | -3cm to +TVL | | TVL | Greatest depth of vagina when its apex is at normal position | 11cm | | Gh | Middle of external urethral meatus to posterior midline hymen | 4cm | | Pb | Posterior margin of genital hiatus to mid anal opening | 3cm | - After collection of site specific measurement, these are arranged in grid system of charting and stages are assigned according to the most dependent portion of prolapse. | | anterior wall | anterior wall | cervix or cuff | |---|---|---|---| | | Aa | Ba | C | | | | | | | | genital hiatus | perineal body | total vaginal length | | | gh | pb | tvl | | | | | | | | posterior wall | posterior wall | posterior fornix | | | Ap | Bp | D | # POP-Q Staging System - **Stage 0:** No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at - 3 cm and either point C or D is between – TVL (total vaginal length) cm and - (TVL – 2) cm (i.e., the quantitation value for point C or D is ≤ - [TVL - 2] cm). - **Stage I:** The criteria for stage 0 are not met, but the most distal portion of the prolapse is > 1 cm above the level of the hymen (i.e., its quantitation value is < – 1 cm). - **Stage II:** The most distal portion of the prolapse is ≤ 1 cm proximal to or distal to the plane of the hymen (i.e., its quantitation value is ≥ – 1 cm but ≤ + 1 cm). - **Stage III:** The most distal portion of the prolapse is > 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters (i.e., its quantitation value is > + 1 cm but < + [TVL – 2] cm). - **Stage IV:** Essentially, complete eversion of the total length of the lower genital tract is demonstrated. The distal portion of the prolapse protrudes to at least (TVL - 2) cm (i.e., its quantitation value is ≥ + [TVL - 2] cm). In most instances, the leading edge of stage IV prolapse will be the cervix or vaginal cuff scar. # Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse on Physical Examination | Grade | Description | |---|---| | Grade 0 | Normal position for each respective site | | Grade 1 | Descent halfway to the hymen | | Grade 2 | Descent to the hymen| | Grade 3 | Descent halfway past the hymen| | Garde 4 | Maximum possible descent for each site | # Degrees of Uterine Prolapse (Clinical) - **Normal:** External os lies at the level of ischeal spines. No prolapse. - **First degree:** The uterus descends down from its normal anatomical position but the external os still remains above the introitus. - **Second degree:** The external os protrudes outside the vaginal introitus but the uterine body still remains inside the vagina. - **Third degree:** The uterine cervix and body and the fundus descends to lie outside the introitus. - **Procidentia** involves prolapse of the uterus with eversion of the entire vagina. # Management of Prolapse ## Preventive - Adequate antenatal and intranatal care. - Adequate postnatal care: - To encourage early ambulance. - To encourage pelvic floor exercises by squeezing the pelvic floor muscles in the puerperium. - General measures: - To avoid strenuous activities, chronic cough, constipation and heavy weight lifting. - To avoid future pregnancy too soon and too many by contraceptive practice. ## Conservative - Indications of conservative management: - Asymptomatic women. - Old woman not willing for surgery. - Mild degree prolapse. - POP in early pregnancy. - Meanwhile, following measures may be taken: - Improvement of general measures. - Estrogen replacement therapy may improve minor degree prolapse in postmenopausal women. - Pelvic floor exercises in an attempt to strengthen the muscles (Kegel exercises). - Pessary treatment. ## Pessary Treatment - Indications of use are: - Early pregnancy - the pessary should be placed inside up to 18 weeks when the uterus becomes sufficiently enlarged to sit on the brim of the pelvis. - Puerperium - to facilitate involution. - Patients absolutely unfit for surgery specially with short life expectancy. - Patient's unwillingness for operation. - While waiting for operation. - Additional benefits: Improvement of urinary symptoms (voiding problems, urgency). ## Surgical Management - Surgery is the treatment of symptomatic prolapse where conservative management has failed or is not indicated. - Surgical procedures may be: - Restorative: - Correcting her own support tissues or - Compensatory - using permanent graft material. - Extirpative- - Removing the uterus and correcting the support tissues. - Obliterative- - Closing the vagina. ## Factors Determining the Choice of Surgery - Patient's age - Parity - Degree of prolapse - Type of prolapse (cystocele, enterocele) - Any prior surgery for prolapse - Associated factors (urinary/fecal incontinence, PID) - Any associated comorbid condition ## Type of Prolapse and The Common Surgical Repair Procedures | Organ descent | Clinical condition | Type of operation | |---|---|---| | VAGINAL WALL | | | | Anterior (Upper 2/3) or whole | Cystocele/cystourethrocele | - Anterior colporrhaphy | | | Paravaginal defect | - Paravaginal defect repair | | Posterior (Lower 2/3) | Rectocele | - Colpoperineorrhaphy | | Posterior (Upper 1/3) | Enterocele | - Vaginal repair of enterocele with PFR | | | | - McCall culdoplasty | | | | - Moskowitz procedure | | Combined anterior and posterior | Cystocele and rectocele | - PFR (combined procedure) | | | | | | VAGINAL WALL | | | | HYSTERECTOMY | | | | (Vaginal or abdominal) | | | | | FOLLOWING Vault prolapse (secondary) | | | | (Vaginal or abdominal) | | | UTEROVAGINAL | | | | vaginal walls | Uterus along with Uterovaginal prolapse | - Vaginal hysterectomy with PFR (Elderly woman, family completed) | | | | - Fothergill's operation (preservation of uterus) | | | | | | Organ descent | Clinical condition | Type of operation | |---|---|---| | Uterus (Without vaginal walls) | | | | | Congenital or nulliparous prolapse | - Cervicopexy or Sling (Purandare's) operation | | | (Young women) | | | Pelvic organ prolapse (POP) | | | | | POP with stress incontinence | - Vaginal: TOT operation | | | | - Abdominal: Burch operation | # Management of Uterine Prolapse - In young Nulliparous females or any female who desire future pregnancy/ congenital prolapse: Sling surgery (Cervicopexy/Purandare sling, Shirodkar sling, Composite/Virkud). - Females < 40 years who doesnot desire future pregnancy but wants to retain menstrual functions: Manchester operation (Fothergills operation). - Females ≥ 40 years and doesnot desire future pregnancy and does not want to retain menstrual function: Ward Mayo's vaginal hysterectomy. - Females who refuse surgery or has contraindication to surgery: - Young females- Ring pessary, old females :Le fort repair/Dani's repair. - Prolapse during pregnancy /puerperium or young females with contraindication to curgere Bing россаку # Pessary - 2 basic varieties: - Supportive variety: Ring Pessary. - Space occupying variety: Gellhorn pessary. - Indications: - Prolapse during pregnancy. - In puerperium – to facilitate involution. - Patient unfit or unwilling for surgery. - Women who have undergone atleasst one previous attempt at surgical intervention without relief. - Diagnostic: it may be placed diagnostically to identify which women are at - Problems associated with pessary: - It is never curative and is only palliative. - Can cause vaginitis. - Has to be changed every 3 months. - Forgotten pessary can cause vaginal ulcerations, erosions, and fistula formation. - May cause dyspareunia. - It does not cure stress incontinence ## Contraindications - Acute genital tract infection. - Adherent retroposition of uterus # Management of Vault Prolapse ## Conservative - Pessary treatment-generally not recommended . ## Surgical - Transvaginal approach: - Repair of enterocele along with PFR - Le Fort's operation - Colpocleisis (cases following hysterectomy) - Sacrospinous colpopexy. - Abdominal approach: - Vault suspension (sacral colpopexy). # Complications of Vaginal Repair Operations ## Complications of PFR: - Operative - Hemorrhage - Trauma: Bladder and rectum - Postoperative Urinary - Retention of urine is a common complication. - Sepsis.