PELVIC ORGAN PROLAPSE

Mohan C. Regmi
 PELVIC ORGAN
PROLAPSE
A BULGE OR PROTRUSION OF PELVIC
ORGANS AND THEIR ASSOCIATED
VAGINAL SEGMENTS INTO OR THROUGH
THE VAGINA
 CLASSIFICATION
1. ANTERIOR COMPARTMENT DEFECTS
 CYSTOCELE
 URETHROCELE
 PARAVAGINAL DEFECTS
 UTERINE PROCIDENTIA

2. POSTERIOR COMPARTMENT DEFECTS

 RECTOCELE
 ENTEROCELE
 PREVALENCE
 11% OF WOMEN UPTO 80 YEARS AGE
 1/3 rd RECURRENCE

 PATHOPHYSIOLOGY
ATTENUATION OF THE SUPPORTIVE STRUCTURES
 BY ACTUAL TEARS
 BY NEUROMUSCULAR DYSFUNCTION OR BOTH
SUPPORT OF PELVIC ORGANS

 PERITONEUM
 VISCERA & ENDOPELVIC FASCIA
 LEVATOR ANI MUSCLE
 PERINEAL MEMBRANE
 EXTERNAL GENITAL MUSCLE
 The vaginal axis
 Normally
 vertical distal 1/3
 Horizontal proximal 2/3
 Maintained by
 Cardinal uterosacral complex
 RVS
 Perineal body
 Levator plate
FIG 35A.2 (TELINDE 930)
PELVIC ORGAN PROLAPSE
 ETIOLOGY
 CONGENITAL
 VAGINAL DELIVERY
 INCREASED INTRAABDOMINAL
PRESSURE
 AGEING
 LIFESTYLE
 MEDICAL CONDITIONS
 POSTOPERATIVE
 SYMPTOMS

 VOIDING DYSFUNCTION
 URINARY INCONTINENCE
 OBSTRUCTIVE VOIDING SYMPTOMS
 URINARY URGENCY & FREQUENCY
 URINARY RETENTION
 UPPER RENAL COMPROMISE WITH
RESULTANT PAIN & ANURIA
 SYMPTOMS
 OTHER SYMPTOMS
 PELVIC PAIN
 DEFECATORY PROBLEMS
 CONSTIPATION
 DIARRHOEA
 TENESMUS
 FECAL INCONTINENCE
 BACK & FLANK PAIN
 OVERALL PELVIC DISCOMFORT
 DYSPAREUNIA
 CLINICAL EVALUATION
 HISTORY
 PATIENT’S PERCEPTION
 MICTURITION , DEFECATION & SEXUAL
HISTORY
 PAST SURGICAL HISTORY
 MEDICAL HISTORY
 PROPER PHYSICAL EXAMINATION
 BADEN WALKER HALFAY SYSTEM
 POP-Q SYSTEM
 PELVIC MUSCLE FUNCTION
ASSESSMENT
 BIMANUAL EXAMINATION
 RECTOVAGINAL EXAMINATION
 Urethral mobility measurement
 Urethral hypermobility-
 resting urethral algle >30 degrees
 Maximal strain angle >30 degrees
 Urethral mobility + SUI-
 Incontinence procedure to be done

 Pudendal nerve motor latency studies

 For neuropathies
 Test for urinary incontinence
 Assessment made with prolapse in reduced state
 may be masked by
 Hypotonic bladder
 Reverse kinking of the urethra if cystocele is large

 Examination under anaesthesia

 BLADDER EVALUATION
 To obtain objective information about bladder
& urethral functions
 Basic office bladder testing with the prolapse
reduction
 Urine culture ; PVR volume ; office
cystometrics
 Reduction stress testing
 IMAGING
 Fluoroscopic evaluation of bladder function
 Ultrasound of pelvis
 Defecography
 MRI-
 Reveals advanced muscle atrophy & muscular
detachments
 Clinical evaluation
 POP map
 Identify
 Rugae
 Anterior lateral sulci
 Dominant prolapse
Potential sites of fascial defects
 Colpoperineorrhaphy
 Dissection f posterior vaginal wall from
RVF
 2nd rectal examination for verification of
site of defect
 Interrupted stitches over RVS
(monofilament)
Vaginal hysterectomy with
repair of enterocele,
cystocele , & rectocele
 VAGINAL VAULT PROLAPSE
 VAGINAL PROCEDURES
 McCALL’ culdoplasty
 Sacrospinous ligament fixation
 High uterosacral ligament suspension with
fascial reconstruction
 Illiococcygeus fascia suspension
 Abdominal sacral colpopexy
 High uterosacral ligament suspension
 VAGINAL VAULT PROLAPSE
 Obliterative procedures
 Le fort partial colpocleisis
 Colpectomy & colpocleisis
 Complex prolapse
 Recurrent prolapse
 Use of supportive tissue-inorganic type 1
mesh
 Prolapse with urinary or fecal incontinence
 Nulliparous prolapse
 Prolapse in afrail patient
 Vaginal & rectal prolapse