UV PROLAPSE

SHEHRYAR SHAIKH
JARRY MASOOD
FAHIM RIZVI
ASHAR MOINUDDIN
Pelvic Organ Prolapse (POP)

 POP is the herniation of pelvic organs to and beyond the vaginal

walls

 It is caused by the failure of interaction between the levator ani

muscles and the ligaments and the fascia that support the pelvic
organs.
Levels of pelvic support

 There are three levels of suppourting ligaments and fascia which

workd together to suppourt the uterus:

1. Level 1
2. Level 2
3. Level 3
Level 1(apical suppourt)

 It is provided by the uterosacral ligament

 It attaches cervix to sacrum

 Defects in level 1 suppourt can be seen on examination by the descent

of uterus within vagina

 Level 1 suppourt remains critical even after hysterectomy, so it is

important to reattach the uterosacral ligament during the procedure

 In women who have previously undergone hysterectomy, level 1

support defects will manifest as vaginal vault prolapse.
Level 2
 Level 2 support is provided by the fascia that surround the vagina, both
anteriorly and posteriorly.

 Anteriorly, suppourt is provided by the pubocervical fascia, which lies between

the bladder and the vagina.

 Defects in the fascia providing level 2 suppourt will lead to prolapse of the
vaginal wall into the vaginal lumen.

 Posteriorly, support is provided by the rectovaginal fascia which lies between

the rectum and the vagina.

 Deficency anteriorly results in anterior vaginal wall prolapse and deficency

posteriorly results in posterior vaginal prolapse.

 On examination, the affected vaginal wall will be seen bulging into the vagina.
Level 3

 It is provided by the fascia between the distal posterior vagina and

perineal body

 Defects of the perineal body usually cause the development of

lower posterior vaginal wall prolapse but the loss of the perineal
body increases the size of the vaginal opening andd therefore
predisposes to anterior vaaginal prolapse as well
Terminologies
 Anterior Compartment Prolapse – hernia of anterior vaginal wall, which
can be associated with:

1. Cystocele (bladder descent) with upper half anterior wall prolapse

2. Urethrocele (urethral descent) with lower half anterior wall prolapse

3. Cystrourethrocele (descent of bladder and urethra)

 Posterior compartment prolpase – hernia of posterior vaginal wall, which

can be associated with:

1. Enterocele (small bowel descent) with upper 1/3 rd posterior wall

prolapse

2. Rectocele (rectal descent) with lower 2/3 rd posterior wall prolapse

 Apical Compartment Prolapse:

1. Uterus: Prolapse of uterus with inversion of vaginal apex

2. Cervix: Prolapse of caervix with inversion of vaginal apex

3. Vaginal apex: Prolapse of the upper vagina through the vagina

4. Vault: Post-hysterectomy prolapse of the vaginal vault

Symptoms of pelvic organ prolapse

 POP can cause symptoms directly due to the prolapsed organ or

indirectly due to organ dysfunction secondary to displacement from
the anatomical position.

 Prolapse symptoms include:

1. Sensation of vaginal bulge
2. Heaviness or visible protrusion at or beyond the introitus
3. Lower abdominal or back pain
4. Dragging discomfort relived by lying or sitting
Indirect Symptoms of prolapse

 Depend on which other organs are involved in the prolapse

 May include symptoms like difficulty in voiding urine or emptying

the bowel and sensation of incomplete emptying of bladder or
rectum. Patients may have to support or reduce the prolapse with
their fingers to be ableto void or evacuate stool completely (termed
Digitation)

 Urinary or fecal incontinence may also be present.

 It is also important to ask about sexual activity, weather they have

disomfort during intercourse and loss of sensation
Clinical Assessment of prolapse

 History should include presenting symptoms and severity and

questions to ascertain if the patient has any coexisting urinary,
faecal or sexual symptoms.

 Clinical Examination should ideally be done in the lithotomy position

with a sims speculum. This allows retraction of the anterior and
posterior vaginal wall to allow full assessment of the degree of
prolapse and assess how much descent of the cervix and uterus is
present
 Rectal and Vaginal examination can be an aid to differentiate
rectocele from enterocele

 US to exclude pelvic or abdominal masses if suspected clinically

 If urinary incontinenct – urodynamic studies

 If rectal symptoms – Endoanal ultrasound, rectal manometry,

flexibble sigmoidoscopy and defecating proctogram
Stages of Prolapse

 Prolapse is described in three stages of descent:

1. Stage 1: Prolapse does not reach hymen

2. Stage 2: Prolapse reaches hymen

3. Stage 3: Prolapse is mostly or wholly outside the hymen. When the

uterus prolapses wholly outside, this is termed as procidentia

 A note should be made whether prolapse occurs at patient

straining or at rest and whether traction has been applied
 Vaginal Prolapse is staged using the method mentioned but the
most important assessment is whether the vaginal prolapse reaches
to or beyond the hymen.

 It is important the assess whether the perineal body is intact or has

become attenuated, resulting in an enlarged vaginal opening.
Etiology

 Vaginal delivery: Most important factor, uncommon in nulliparous

and increases with parity. It is due to damage to pudendal nerves
after childbirth

 Menopause: loss of collagenous connective tissue following

estrogen withdrawl

 Iatrogenic: Vaginal hyterectomy, Burch colposuspension

 Chronic factors: Coughing, Constipation, heavy lifting, pelvic mass

Treatment of prolapse

 Conservative treatment:
1. Pelvic floor muscle exercises: reduces symptoms but may will not
reduce the anatomical extend of the prolapse
2. Use of supportive vaginal pessaries: Leads to resolution of many
symptoms. Has an advantage of avoiding surgey. Eg: Ring
pessaries, Shelf pessaries, Gelhorn pessaries

 Ring pessaries are used first but intact perineal body is necessary for
these to be retained.
 Shelf and Gelhorn pessaries are useful in women with deficient
perineal body
 Pessaries are not currative
 Pesssaries are indicated if:
1. Patients wish

2. Childbearing not complete

3. Medically unfit

4. During and after pregnancy

5. While awaiting surgery

Surgery

 Offered if conservative treatments have failed or if the patient

chooses surgery.

 Procedure chosen depends on which compartment is affected and

whether the women wishes to retain her uterus and whether vagial
or abdominal route is chosen
Manchester (Fothergill) Repair

 Suitable when the women wishes to conserve her uterus

 Involves partial amputation of cervix and approximation of cardinal

ligaminets anterior to cervical stump

 It may be combined with anterior and posterior colporrhaphy

Sacrehsteropexy

 Suitable when the women wishes to conserve her uterus

 Involves attachment of utero-cervical junction to the sacrum using a

mesh and closure of Pouch of Douglas
Hyterectomy

 Suitable when the women doesn’t wish to conserve her uterus

 It is extremly important to re-attach the uterosacral ligament to the

vaginal vault and maintain level 1 suppourt
Anterior Colporrhaphy

 It is anterior vaginal repair done for anterior compartment prolapse

 Invloves application of sutures to reinforce fascia between vagina

and bladder

 Complications include Bladder injury and High recurrence rate

Posterior Colporrhaphy

 It is posterior vaginal repair done for posterior compartment

prolapse

 Involves application of sutures to reinforce fascia between vagina

and rectm

 Complications include Rectal injury and Dyspareunia

Sacrocolpoplexy

 Involves attachment of invereted vaginal vault to sacrum using a

mesh and closure of pouch of douglas
Sacrospinous ligament fixation

 It is a vaginal procedure, with low success rate

 Involves suturing the vaginal vault to the sacrospinous ligament.

Preventive measures

 Weight Reduction

 Avoid traumatic instrumental delivery

 Encouraging postnatal pelvic floor exerises

 Treatment of chronic cough and constipation