Pelvic organ

Prolapse
DR, ABBAS MLANDULA MD

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Learning tasks
At the end of this session, students are expected to be able to:
•Explain aetiology/risk factors of pelvic organ prolapse
•Outline epidemiology of pelvic organ prolapse
•Explain clinical features of pelvic organ prolapse
•Establish diagnosis/ provisional and differential diagnosis of pelvic organ
prolapse
•Provide pre-referral treatment of pelvic organ prolapse
•Provide follow-up services of pelvic organ prolapse
•Provide control and preventive measures of pelvic organ prolapse

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Activity: Brainstorming
What is pelvic organ prolapse?

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Definition
Pelvic organ Prolapse:
Is the protrusion of the pelvic organs into or out of the vaginal
canal.
Is the abnormal descent or herniation of the pelvic organs from
their normal attachment sites or their normal position in the pelvis.
The entity includes descent of the vaginal wall and/or the uterus.
The pelvic structures that may be involved include the uterus
(uterine prolapse) or vaginal apex (apical vaginal prolapse),
anterior vagina (cystocele), or posterior vagina (rectocele).

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Epidemiology
Pelvic organ prolapse (POP) affects millions of
women worldwide.
Genital prolapse occurs in about 10-30% of
multiparous women and in 2% of nulliparous
women
The lifetime risk for woman undergoing surgery for
genital prolapse or incontinence is 11%.
Some studies show that the prevalence of pelvic
organ prolapse increases steadily with age (Olsen,
1997; Swift, 2005)

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Etiology
Most cases are the result of damages to the vaginal
and pelvic support tissues due to childbirth or due
to chronically elevated intra-abdominal pressure
Repeated childbirth may result into stretching and
injury of:
 Ligaments (see p. 204)
 Endopelvic fascia (see p. 204)
 Levator muscle (myopathy)
 Perineal body
 Nerve (pudendal)
 Muscle damage

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Risk factors
•Child birth
•Postmenopausal atrophy
•Poor collagen tissue repair with age
•Increased intra-abdominal pressure as in chronic lung disease and
constipation
•Occupation (weight lifting)
•Asthenia and under nutrition
•Obesity
•Increased weight of the uterus as in fibroid or myohyperplasia

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Activity: Brainstorming
What are clinical features of Pelvic organ prolapse?

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Clinical features
History:
•Feeling of something coming down per vaginum, especially while
moving about.
•Backache or dragging pain in the pelvis.
•Dyspareunia.
•Urinary symptoms
 Difficulty in passing urine. The patient has to elevate the anterior vaginal wall for evacuation of
the bladder.
 Increased frequency
 Urgency
 Painful micturition (in case of cystitis)
 Stress incontinence is usually due to associated urethrocele.
 Retention of urine may rarely occur

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Clinical features cont…
History cont…
•Bowel symptom (in presence of rectocele).
 Difficulty in passing stool. The patient has to push back the posterior vaginal wall in position to
complete the evacuation of feces.
 Fecal incontinence may be associated.

•Excessive white or blood-stained vaginal discharge due to associated

vaginitis or decubitus ulcer.

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Clinical features cont…
Physical examination:
•Rectocele:
 A bulge of the anterior vaginal wall, which
increases with straining
 Has positive cough impulse
 Is reducible

• Cystourethrocele:
 Bulging of ant. Vaginal wall involves the
lower 1/3
 There may be stress incontinence

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Clinical features cont…
Physical examination cont…
•Rectocele and Enterocele:
 Often co-exist
 A bulge of the posterior vaginal wall with sulcus btn
them
 Rectovaginal examination: enterocele is close to the
cervix and cannot be reached at by the rectal finger

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Clinical features cont…
Physical examination cont…
•Uterine prolapse:
 First degree: Cervical descent below ischial spine on
straining
 2nd and 3rd degree: Mass protruding out through the
introitus leading part being external os
 Decubitus ulcer or dark pigmentation at the leading
part
 Shallow vaginal orifices
 Increased length of uterine cavity on introducing
uterine sound

Third degree uterine prolapse

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Differential diagnosis
Cystocele:
 Gartner’s cyst
 Inclusion dermoid cyst
 Urethral diverticulum

Uterine prolapse:
 Congenital cervical elongation
 Chronic uterine inversion
 Fibroid polyp

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Investigations
•Mid-stream urine for analysis and culture .
•Renal ultrasound and IVU in cases of procidentia
and severe cystocele to exclude hydroureter &
hydronephrosis which may occur as a result of
kinking of the ureters
•Cystometry in cases of incontinence in order to
exclude urge incontinence
•Cystourethroscopy

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Treatment
Pre-referral treatment:
•Treat underlying cause as appropriate
•Treat complications such as UTI as appropriate
•Pelvic floor exercises in an attempt to strengthen the muscles (Kegel
exercises).
•For 2nd and 3rd degree genital prolapse;
 Cover with gauze soaked with normal saline for safe transfer/referral

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Treatment cont…
Specific treatment:
•Estrogen replacement therapy may improve minor degree prolapse in
postmenopausal women
•Pessary
•Surgery

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Treatment cont…

Pessaries

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

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GYNAECOLOGY
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 Complications
•Urinary tract infection: Cystis and pyelonephritis
•Incarceration: At times, infection of the para-vaginal and cervical tissues makes
the entire prolapsed mass edematous and congested. As a result, the mass
may be irreducible.
•Peritonitis: Rarely, pelvic peritonitis may occur through the posterior vaginal
wall.
•Carcinoma: Carcinoma rarely develops on decubitus ulcer

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Follow up
Evaluations for symptoms and signs and development of complications of the
disease and/or complications

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Prevention
•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

• Prevention of postmenopausal atrophy of pelvic support by:

 Balanced diet
 Exercise
 Calcium
 Increased use of HRT.

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Prevention cont…
Adequate antenatal and intranatal care
 Avoiding of: prolonged labour , bearing down before full cervical dilatation and difficult
instrumental delivery

Adequate postnatal care

 To encourage early ambulance.
 To encourage pelvic floor exercises by squeezing the pelvic floor muscles in the puerperium.

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Key points
Pelvic organ prolapse is the protrusion of the
pelvic organs into or out of the vaginal canal
It is a result of injury to the pelvic support by
conditions such as childbirth or increased intra-
abdominal pressure. Other factors includes
obesity, menopause and undernutrition
Common presentation includes sensation of
something in the vagina and lower back pain both
which tend to be relieved on lying down
Treatment involves correction of unerlying
causes/factors, use of pessaries and surgery

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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Key points cont…
Treatment involves correction of underlying
causes/factors, use of pessaries and surgery
POP can be prevented by avoiding the risk
factors, proper antenatal, intranatal and
postnatal care

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 Review questions
1. What is Pelvic organ prolapse?
2. Outline the risk factors for Pelvic organ prolapse.
3. What are the clinical presentation of Pelvic organ prolapse?
4. Outline the management of Pelvic organ prolapse.

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

10/17/2023
GYNAECOLOGY
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 References

•D.C Dutta. Textbook of Gynecology. 6th edition

•https://emedicine.medscape.com//article/954252
•Williams textbook of Gynaecology (Mc Graw 2008)
•Cardozo L, Staskin D, eds. Textbook of Female Urology and
Urogynecology, Second Edition. Informa HealthCare; 2006.
•Progetto Menopausa Italia Study Group. Risk factors for
genital prolapse in non-hysterectomized women around
menopause. Results from a large cross-sectional study in
menopausal clinics in Italy. Eur J Obstet Gynecol Reprod
Biol. Dec 2000;93(2):135-40.
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 References cont…
•Hagen S, Stark D, Maher C, Adams EJ. Conservative management
of pelvic organ prolapse in women. Cochrane Database Syst
Rev. 2008.
•Katz VL, Lentz G, Lobo RA, Gershenson D. Comprehensive
Gynecology. 5th ed. Mosby; 2007.
• Daneshgari F, Kefer JC, Moore C, Kaouk J. Robotic abdominal
sacrocolpopexy/sacrouteropexy repair of advanced female pelvic
organ prolaspe (POP): utilizing POP-quantification-based staging
and outcomes. BJU Int. Oct 2007;100(4):875-9.
•[Guideline] American College of Obstetricians and Gynecologists
(ACOG). Pelvic organ prolapse. Washington (DC). Sep 2007

CMT 06210: APPRENTICESHIP IN OBSTETRICS AND

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