Pelvic organ prolapse is a benign common condition that

can lead to genital tract dysfunction and significantly

diminished quality of life.
Approximately 3% of women complain of feeling a
vaginal protrusion
while up to 50% of women will be found to have prolapse
on examination
The lifetime risk of surgery for POP is 12–19%, with more
than 300,000 women undergoing surgery a year in the
USA.
Approximately 8% of women in the UK report symptoms
of prolapse .
 A 71-year-old woman presents to her gynecologist
having noted a “ball” at her vaginal opening while
showering. She denies bleeding and urinary incontinence,
but does urinate frequently. Her past obstetrical and
gynecological history is notable for three uncomplicated
term VDs. She had normal monthly menses until
menopause at age 50. Her surgical history is remarkable
for tubal ligation following her third delivery.
Pelvic exam is remarkable for protrusion of the anterior
vaginal wall beyond the hymen while straining and
descent of the cervix to near the hymen with straining. She
has no palpable pelvic masses.
 Uterovaginal prolapse is caused by failure of the
interaction between the levator ani muscles and the
ligaments and fascia that support the pelvic organs.
 The levator ani muscles are puborectalis,
pubococcygeus and iliococcygeus…. They are
attached on each side of the pelvic side wall from
the pubic ramus anteriorly (pubococcygeus), over
the obturator internus fascia to the ischial spine to
form a bowl-shaped muscle filling the pelvic outlet
and supporting the pelvic organs
 There are three levels of supporting ligaments and
fascia, which work together to provide a global and
dynamic system to support the uterus, vagina and
associated organs
▪ Level 1 (apical) support is provided by the
uterosacral ligaments, which attach the cervix to the
sacrum.
▪ Level 2 support is provided by the fascia that
surrounds the vagina, both anteriorly and posteriorly,
lying between the vagina and the bladder
(pubocervical fascia) or rectum (rectovaginal fascia).
▪ Level 3 support is provided by the fascia of the
posterior vagina, which is attached at its caudal
end to the perineal body.
➢ Defects in level 1 support ► on examination by
the descent of the uterus within the vagina.
(manifest as vaginal vault prolapse after
hysterectomy).
➢ Defects in level 2 support ► prolapse of the
vaginal wall into the vaginal lumen (causing
anterior or posterior vaginal prolapse and on
examination, the affected vaginal wall will be seen
bulging into the vagina).
➢ Defects of the perineal body ► development of lower
posterior vaginal wall prolapse, but the loss of the
perineal body increases the size of vaginal opening and
therefore predisposes to anterior vaginal prolapse as
well.
KEY LEARNING POINTS
❖ The levator ani muscles support the pelvic organs
and relieve excessive pressure from the ligaments
and fascia.
❖ The uterosacral ligaments provide essential apical
support (level 1 support).
❖ Vaginal fascia supports the vagina (level 2 support).
❖ The perineal body is very important in supporting
the lower vagina (level 3 support).
 Risk Factors Associated with Pelvic Organ Prolapse
 Pregnancy
 Vaginal childbirth ( Multiparity, Forceps delivery,
Perineal trauma, Long labour, Birthweight >4 kg.
 Menopause ( Aging, Hypoestrogenism)
 Chronically increased intraabdominal pressure
(Chronic obstructive pulmonary disease,
Constipation, Obesity), Occupation
 Pelvic floor trauma( Genetic factors, Race,
Connective tissue disorders)
 Spina bifida
 POP can cause symptoms directly due to the
prolapsed organ or indirectly due to organ
dysfunction secondary to displacement from the
anatomical position.
 Signs: include descent of one or more o the
following: the anterior vaginal wall, posterior
vaginal wall, uterus and cervix, vaginal apex, or the
perineum
 Symptoms likely to correlate with POP:
➢ Bulge (vaginal bulging, pelvic pressure, and
splinting or digitation)- Splinting is manual
bolstering of the prolapse to improve symptoms,
where as digitation aids stool evacuation
➢ Fullness.
➢ Dragging and deterioration with activity
(sensation of vaginal bulge, heaviness or a visible
protrusion at or beyond the introitus)
 Symptoms relieved by rest(lower abdominal or
back pain, or a dragging discomfort relieved by
lying or sitting)
 Pelvic organ prolapse is descent of the anterior
vaginal wall, posterior vaginal wall, uterus
(cervix), the vaginal apex after hysterectomy,
rectum, or the perineum, alone or in combination.
 The history should elicit the presenting
symptom(s) and severity, and include questions if
there is any coexisting urinary, faecal or sexual
symptoms and note should be made of whether it
occurs at patient straining or at rest and whether
traction has been applied.
Symptoms Associated with Pelvic
Organ Prolapse
 Symptoms unlikely to correlate with POP
➢ Backache.
➢ Pain.
➢ Urinary and/or bowel dysfunction.
➢ Sexual dysfunction.
Prolapse is described in three stages of descent:
 • Stage I where the prolapse does not reach the
hymen.
 • Stage II where the prolapse reaches the hymen.
 • Stage III when the prolapse is mostly or wholly
outside the hymen. When the uterus prolapses
wholly outside this is termed procidentia.
In women who have undergone hysterectomy, the
vaginal vault can prolapse
Another commonly used POP staging system is the
`` Baden–Walker Halfway Scoring System`` :

0 Normal position for each respective site

1 Descent halfway to the hymen
2 Descent to the hymen
3 Descent halfway past the hymen
4 Maximum possible descent for each site
 For the pelvic examination the women should
ideally be examined in the dorsal lithotomy
position with Valsalva. This has been shown to
be as effective as an examination in the standing
position.
 The most important assessment is whether the
vaginal prolapse reaches to, or beyond, the
hymen. Finally, it is important to assess whether
the perineal body is intact or has become
attenuated, resulting in an enlarged vaginal
opening.
 For women with symptoms of pressure or vaginal
bulge only, there is rarely a need to arrange any
investigations, other than those relating to
anesthetic preassessment
 Lower urinary tract symptoms should be evaluated
independently with urinalysis.
 Urodynamic testing may be helpful where there are
significant urinary symptoms.
 functional tests of the lower bowel may include
endoanal ultrasound to check for anal a sphincter
defects, rectal manometry, flexible sigmoidoscopy
and a defaecating proctogram
 Conservative:
➢ Conservative treatment It is always preferable and
should not proceed with a surgical procedure without
first offering a trial of conservative treatment.
➢ It includes pelvic floor muscle exercises and the use
of supportive vaginal pessaries. A course of
supervised pelvic floor exercises will reduce the
symptoms of prolapse and for women who are keen
to avoid surgical treatment.
➢ Lifestyle advice such as weight loss and smoking
cessation
➢ it is unlikely to be helpful for women whose prolapse
is beyond the vaginal introitus.
➢ Pessary use can be very effective at relieving
symptoms and has the advantage of avoiding surgery,
specially in the medically unfit and elderly.
➢ Ring pessaries need an intact perineal body while
Shelf pessaries, Gelhorn pessaries are useful for
women with deficient perineal bodies.
➢ It is usual practice to replace a pessary every 6
months and to examine the patient for signs of vaginal
ulceration.
➢ Complications are uncommon and usually minor
(bleeding, discharge, pessary incarceration
``requiring general anesthesia to remove``, and rare
cases of rectovaginal or vesicovaginal fistula)
 Surgical management: Principles of POP surgery:
➢ Remove/reduce the vaginal bulge.
➢ Restore the ligament/tissue supports to the apex,
anterior and posterior vagina.
➢ Replace associated organs in their correct
positions.
➢ Retain sufficient vaginal length and width to
allow intercourse.
➢ Restore the perineal body.
➢ Correct or prevent urinary incontinence.
➢ Correct or prevent fecal incontinence.
➢ Correct obstructed defecation.
 Vaginal repair using mesh improves the anatomical
outcome and reduces the risk of recurrent prolapse.
Mesh repair carries the risk of later erosion and
need for removal and only be considered for
women with recurrent vaginal prolapse.
 Surgery should be reserved for patients who have
at least stage 2 POP on examination and have
bothersome symptoms using vaginal or abdominal
approaches(open or minimal access surgery (MAS)
undertaken either laparoscopically or robotically
Surgical options
Restorative :Vaginal :
●● Anterior colporrhaphy.
●● Posterior colporrhaphy.
●● Vaginal hysterectomy.
●● Sacrospinous fixation.
●● Sacrospinous hysteropexy.
●● Uterosacral plication.
Abdominal :
●● Sacrocolpopexy (open/laparoscopic/robotic).
●● Sacrohysteropexy (open/laparoscopic/robotic).
Obliterative
●● Colpocleisis. Vaginal closure