Pelvic Organ Prolapse

DR BABIKIR RAJAB
MMED OBGY
 Introduction
• Prolapse is defined as the displacement of an organ from its normal
anatomical position
• Pelvic organ prolapse is descent of the anterior & posterior vaginal wall,
uterus (cervix), the apex of the vagina after hysterectomy, or the
perineum, alone or in combination.
• The terms cystocele, cystourethrocele, uterine prolapse, uterine
procidentia, rectocele, and enterocele are used to describe the structures
behind the vaginal wall thought to be prolapsed.
• Clinical description – anterior vaginal wall prolapse, apical vaginal wall
prolapse, cervical prolapse, posterior vaginal wall prolapse, perineal
descent, and rectal prolapse.
 • Two mechanical principles explain
how the pelvic floor prevents
prolapse.
• First, the uterus and vagina are
attached to the walls of the pelvis
by a series of ligaments and fascial
structures that suspend the organs
from the pelvic sidewalls.
• Second, the levator ani muscles
Anteflexion: Angle between the long axis of the constrict the lumina of these
uterus and cervix (bent of the uterus on itself) = organs, forming an occlusive layer
120–135° on which the pelvic organs may
Anteversion: Angle between the cervix and vagina = rest.
90° (remember: v for version, v for vagina) Level 1: uterosacral and cardinal ligaments
Retroversion is the first step in the development of Level 2: levator ani muscle (pelvic floor)
Level 3: perineal muscles forming perineal body
prolapse uterus.
 Introduction
• Pelvic organ prolapse to be considered a disease state in a given
individual, symptoms should be attributable to pelvic organ descent
such that surgical or nonsurgical reduction relieves the symptoms,
restores function, and improves quality of life.
• POP is the 3rd most common indication for hysterectomy.
• Estimated lifetime risk of 11% of women undergo surgery for prolapse
or incontinence
• Prolapse is defined as the displacement of an organ
from its normal anatomical position
• Pelvic organ prolapse is descent of the anterior &
posterior vaginal wall, uterus (cervix), the apex of the
vagina after hysterectomy, or the perineum, alone or
in combination.
• Signs include descent of one or more of the following:
the anterior vaginal wall,
posterior vaginal wall,
uterus and cervix,
the apex of the vagina after hysterectomy, or the perineum
• Symptoms include:
vaginal bulging,
pelvic pressure,
splinting or digitation.
 RISK FACTORs
• Etiology of POP is multifactorial and develops gradually over a span of yrs.
Etiology of pelvic organ pro lapse (pop)
 Risk Factors for Pelvic Organ Prolapse
Definite
Increased abdominal pressure
Advancing age
Occupations entailing heavy lifting
Vaginal delivery
Constipation
Probable
Obesity
Heritable issues
Race or ethnic origin
Shape or orientation of bony pelvis
Family history of pelvic organ prolapse
Previous hysterectomy
Connective tissue disorders
Hypothesized
Obstetric factors associated with
Young age at first delivery
difficult birth
Pregnancy in the absence of vaginal
Forceps delivery
delivery
Prolonged second stage of labor
Selective estrogen receptor modulators
Infant birth weight >4,500 g
 Description and Classification
• The terms cystocele, cystourethrocele, uterine prolapse, rectocele, and
enterocele used to describe the protrusion location. vaginal bulge
caused by a herniation of the bladder, bladder/urethra, uterus,
rectum, or small bowel, respectively.
• clinically described prolapse terms noted: anterior vaginal wall
prolapse, apical vaginal wall prolapse, cervical prolapse, posterior
vaginal wall prolapse, perineal prolapse, and rectal prolapse.
TYPES OF GENITAL PROLAPSE
• Cystocele is the MC type of vaginal prolapse.
 Pelvic Organ Prolapse Quantification (POP-Q)

Six points are located with reference to the plane of the hymen: two on the anterior vaginal wall (points Aa and
Ba), two in the apical vagina (points C and D), and two on the posterior vaginal wall (points Ap and Bp). All POP-Q
points, except total vaginal length (tvl),
 Assessment with POP-Q
• With the hymenal plane defined as zero
• Points above or proximal - -ves and below or distal +ves ( in cm)
• Pelvic organ prolapse quantification (POP-Q): it is a newer
classification system to grade the prolapse in which hymen is the
reference point.
Baden-Walker Halfway System for the Evaluation
of Pelvic Organ Prolapse on Physical Examination

• 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
• Grade 4 Maximum possible descent for each site
• Clinical Degree of POP
• First degree: descent of cervix into the vagina (external os is at the
level of ischial spine in normal anatomical position)
• Second degree: descent of cervix up to the introitus
• Third degree: descent of cervix outside the introitus
• Fourth degree (procidentia): whole uterus (including the fundus) is
outside the introitus
 B. Stage 3. This stage is defined by C. Stage 4. This stage is
the most distal portion of the defined as complete or
prolapse being >1 cm below the near complete eversion
A. Stage 2. This stage is defined
plane of the hymen, but protruding of the vaginal wall.
by the most distal edge of the
no farther than 2 cm less than the
prolapse lying within 1 cm of the
total vaginal length in centimeters.
hymenal ring.
 Pathophysiology
• Pelvic organ support is maintained by complex interactions between:
the levator ani muscle,
vagina,
pelvic floor connective tissue.
• Mechanism of Levator Ani Damage
• Damage to the levator ani muscles follows direct muscle tissue injury
or may result from damage to its nerve supply.
• Labor and vaginal delivery and increased intra-abdominal pressure
has the potential to cause this type of damage.
• Direct Injury
occurs during second-stage labor.
↓ pelvic floor muscle strength after delivery but return of function by 10
weeks
in some cases permanent stretch injury occurs – genital hiatus widened.
• Neurologic Injury
pudendal neuropathy is associated with vaginal delivery - occurs during
second-stage labor
Excess straining and perineal descent can stretch the pudendal nerves and
result in neuropathy
 Two types of prolaps
• Distention type prolapse:
No loss of vaginal fascial attachments – distention cystocele or rectocele
• Displacement type prolapse:
anterior and posterior wall defects due to loss of the connective tissue
attachment of the lateral vaginal wall to the pelvic side wall are described as
displacement (paravaginal) cystocele or rectocele .
 Both defect types could
result from the
stretching or tearing of
support tissues during
second-stage labor.

With distention type

prolapse, the vaginal wall
appears smooth and
without rugae, due to With displacement type prolapse,
attenuation. vaginal rugae are visible.
• Smooth Muscle Dysfunction
smooth muscle fibers arising from the vaginal wall attach to the levator ani
complex.
Dysfunction of this smooth muscle may affect the attachment of the lateral vagina
to the pelvic side wall.
the fraction of smooth muscle in the muscularis of the anterior and posterior
vaginal wall apex in women with prolapse is decreased compared with women
without prolapse
• Connective Tissue Abnormalities
The connective tissue of the pelvis is comprised of collagen, elastin, smooth
muscle, and microfibers, which are anchored in an extracellular matrix of
polysaccharides.
Ehlers-Danlos or Marfan syndrome women are more likely to develop POP and
urinary incontinence
Estrogen influences collagen content by increasing synthesis or decreasing
degradation.
 Levels of Vaginal Support
• The vagina consists of a fibromuscular, flattened, cylindrical tube with
three levels of support:
Level I support suspends the upper or proximal vagina.
Level II support attaches the mid-vagina along its length to the arcus
tendineus fascia pelvis.
Level III support results from fusion of the distal vagina to adjacent structures.
• Defects in each level of support result into vaginal wall prolapse:
anterior,
apical, and
posterior.
• Level I Support:
• Consists of the cardinal and uterosacral ligaments attachment to the
cervix and upper vagina.
• Cardinal ligaments fan out laterally and attach to the parietal fascia of
the obturator internus and piriformis muscles, the anterior border of
the greater sciatic foramen, and the ischial spines.
• Uterosacral ligaments are posterior fibers that attach to the presacral
region at the level of S2 through S4.
• Defects in this support complex may lead to apical prolapse and or
with enterocele (small bowel herniation).
• Level II Support
• Consists paravaginal attachments that are contiguous with the
cardinal/uterosacral complex at the ischial spine.
• These are the connective tissue attachments of the lateral vagina
anteriorly to the arcus tendineus fascia pelvis and posteriorly to the
arcus tendineus rectovaginalis.
• Detachment of this connective tissue from the arcus tendineus fascia
pelvis leads to lateral or paravaginal anterior vaginal wall prolapse.
• Level III Support
• Comprises of perineal body, superficial and deep perineal muscles,
and fibromuscular connective tissue.
• Collectively, these support the distal one-third of the vagina and
introitus.
• The perineal body is essential for distal vaginal support as well as
proper function of the anal canal.
• Damage to level III support contributes to anterior and posterior
vaginal wall prolapse, gaping introitus, and perineal descent.
 Evaluation of the Patient with Pelvic Organ Prolapse
Symptoms Associated with Pelvic Organ Prolapse
Symptoms Other Possible Urinary symptoms
Causes Urinary incontinence Urethral sphincter incompetence

Urinary frequency Detrusor overactivity

Bulge symptoms
Urinary urgency Hypoactive detrusor function
Sensation of vaginal Rectal prolapse Weak or prolonged urinary Bladder outlet obstruction (i.e.,
bulging or protrusion stream postsurgical)
Seeing or feeling a Vulvar or vaginal Hesitancy Excessive fluid intake
vaginal or perineal bulge cyst/mass
Feeling of incomplete emptying Interstitial cystitis
Pelvic or vaginal Pelvic mass
Manual reduction of prolapse to Urinary tract infection
pressure
start or complete voiding
Heaviness in pelvis or Hernia (inguinal or
vagina femoral) Position change to start or
complete voiding
Many women with mild to advanced prolapse lack bothersome symptoms - asymptomatic.
Bowel symptoms
Incontinence of flatus or
liquid/solid stool
Feeling of incomplete
emptying
Hard straining to defecate Rectal prolapse
Urgency to defecate
Digital evacuation to
complete defecation
Splinting vagina or
perineum to start or
complete defecation
Feeling of blockage or
obstruction during
defecation
Sexual symptoms
Anal sphincter disruption or Dyspareunia Vaginal atrophy
neuropathy Decreased lubrication Levator ani syndrome
Diarrheal disorder
Decreased sensation Vulvodynia
Decreased arousal or Other female sexual disorder
orgasm
Irritable bowel syndrome
Pain
Rectal inertia Pain in vagina, bladder, or Interstitial cystitis
rectum
Pelvic floor dyssynergia Pelvic pain Levator ani syndrome
Low back pain Vulvodynia
Hemorrhoids Lumbar disc disease
Musculoskeletal pain
Other causes of chronic
Anorectal neoplasm
pelvic pain
 Physical Examination
• Physical examination begins with a full body systems evaluation to
identify pathology outside the pelvis.
• Systemic conditions such as cardiovascular, pulmonary, renal, or
endocrinologic disease may affect treatment choices and should be
identified early.
• Perineal Examination
• In lithotomy position:
• Signs of vulvar or vaginal atrophy, lesions, or other abnormalities
identified.
• Sacral reflexes examined using a cotton swab
 First, the bulbocavernosus reflex is elicited by tapping or stroking lateral to the clitoris and
observing contraction of the bulbocavernosus bilaterally.
 Secondly, evaluation of anal sphincter innervation is completed by stroking lateral to the anus
and observing a reflexive contraction of the anus, known as the anal wink reflex.
• Asking a woman to attempt Valsalva maneuver or cough prior to placing a speculum
in the vagina
• With speculum examination, structures are artificially lifted, supported, or displaced.
• Importantly, this assessment helps answer three questions:
(1) Does the protrusion come beyond the hymen?;
(2) What is the presenting part of the prolapse (anterior, posterior, or apical)?;
(3) Does the genital hiatus significantly widen with increased intra-abdominal pressure?

Stage 2. This stage is defined
by the most distal edge of
the prolapse lying within 1
cm of the hymenal ring.
Stage 3. This stage is defined by
Stage 4. This stage is
the most distal portion of the
prolapse being >1 cm below the defined as complete or
plane of the hymen, but near complete eversion
protruding no farther than 2 cm of the vaginal wall.
less than the total vaginal length
in centimeters.
• Standing
• Bimanual
 DECUBITUS ULCER
• Decubitus ulcer is the ulceration of the prolapsed tissue due to
friction, congestion, and circulatory changes in the dependant part of
the prolapse.
• Reduction of the prolapse into the vagina and daily packing (glycerin
acriflavine tampon) heals the ulcer in a week or two.
• Glycerin = hygroscopic agent and acriflavine = yellow colored dye that
helps in epithelization.
 Approach to Treatment
• Asymptomatic or mildly symptomatic, expectant management is
appropriate
• INDICATIONS OF RING PESSARY
• Early pregnancy (up to 18 weeks)
• Puerperium
• Women either unfit or unwilling to undergo surgery.
• It is never curative, only palliative.
Nonsurgical Treatment
Pessary Use in Pelvic Organ Prolapse
• Pessaries are the standard nonsurgical
treatment for POP – made of silicone or inert
plastic

Types of pessaries. A. Cube pessary. B. Gehrung

pessary. C. Hodge with knob pessary. D. Regula
pessary. E. Gellhorn pessary. F. Shaatz pessary.
G. Incontinence dish pessary. H. Ring pessary. I.
Donut pessary.
 Ring pessary with support

• Support pessaries, such as the ring pessary:

 In the posterior fornix and against the posterior aspect
of the symphysis pubis.
 Elevates the superior vagina
 Effective in women with first- and second-degree
prolapse
 Useful in women with accompanying anterior vaginal
wall prolapse.
• When properly fitted, the device should lie behind
the pubic symphysis anteriorly and behind the
• space-filling pessaries maintain their position by:
creating suction between the pessary and vaginal walls (cube),
creating a diameter larger than the genital hiatus (donut), or
both mechanisms (Gellhorn).
• Gellhorn is often used for moderate to severe prolapse and for complete
procidentia
• contains a concave disk that fits against the cervix or vaginal cuff and has a
stem (useful for device removal) that is positioned just cephalad to the
introitus
• the two most commonly used pessaries and studied devices are the ring
and Gellhorn pessaries
Technique for placement and removal of a Gellhorn pessary
To remove a
Vaginal atrophy should be treated before or Gellhorn pessary, an
concomitantly with pessary initiation. index finger is
The type of device selected may be affected by placed behind the
patient factors such as: disk and suction is
hormonal status, prior hysterectomy, broken prior to
sexual activity, stage and site of POP. removal.
Insertion of Hodge-type pessary
• in the lithotomy position with empty bladder and rectum, digital
examination done for vaginal length and width, and an initial
estimation of pessary size is made.
• Introduce a Lubricanted ring pessary, against the posterior vaginal
wall.
• Next, an index finger is directed into the posterior vaginal fornix to
ensure that the cervix is resting above the pessary.
• Pessary is removed nightly to weekly, washed in soap and water, and
replaced the next morning.
 Complications with Pessary Use
• Pessary erosions, abrasions, ulcerations, or granulation tissue – Rx change
pessary type or size, treat before replacement.
• Vaginal bleeding is usually an early sign
• Prolapse ulcers from rubbing on a patient's clothes – Rx insert pessary
• Rx of vaginal atrophy with local or systemic estrogen or with water-based
lubricants.
• Pelvic pain with pessary - indication for substituting a smaller-sized pessary.
• The resultant odor – Rx nighttime device removal, washing, and re-insertion the
next day. Or use Trimo-San gel (helps restore and maintain normal vaginal
acidity that aids in reducing odor-causing bacteria) once or twice weekly or
douche with warm water. Lawash, v-wash gels
 Pelvic Floor Muscle Exercise
• Kegel exercises - muscle-strengthening techniques.
• two hypotheses that describe the benefits:
• prevents organ descent
• builds permanent muscle volume and structural support
 Surgical Treatment
• Factors determining the choice of surgery are:
• Patient’s age, parity,
• degree of prolapse,
• any prior surgery for prolapse,
• type of prolapse (cystocele, enterocele) and
• Associated factors (urinary/fecal incontinence, PID),
• Any associated comorbid condition (cardiac disease).
• The two approaches to prolapse surgery are obliterative and reconstructive
• Obliterative Procedures
• includes Lefort colpocleisis and complete colpocleisis
• These procedures involve:
removing extensive vaginal epithelium,
suturing anterior and posterior vaginal walls together,
obliterating the vaginal vault, and effectively closing the vagina.
• Obliterative procedures are only appropriate for elderly or medically compromised
patients, who have no future desire for coital activity.
• Obliterative procedures are technically easier, require less operative time, and offer
superior success rates compared with reconstructive procedures. Success rates for
colpocleisis range from 91 to 100 percent
 Reconstructive Procedures

• Attempts to restore normal pelvic anatomy

• Approaches – Vaginal, abdominal, and laparoscopic.
• Type of approach depends on the patient's unique characteristics and
surgeon's expertise.
• Abdominal approach best for women with:
prior failure of a vaginal approach,
a shortened vagina, or
those believed to be at higher risk for recurrence, such as young women with severe
prolapse.
• vaginal approach – shorter operative time and a quicker return to daily
activities.
 Laparoscopy
• A laparoscopic approach to prolapse include procedures as:
sacrocolpopexy,
uterosacral ligament vaginal vault suspension,
paravaginal repair,
enterocele repair, and
rectocele repair.
• In addition, robotic laparoscopic sacrocolpopexy is currently
performed in centers with the da Vinci Robot
 Surgical Plan
• Asymptomatic areas of prolapse do not always warrant repair, and in
fact, correction can lead to de novo symptoms
• Surgery should be designed to relieve current symptoms.
 Anterior Compartment
• Three anterior colporrhaphy techniques:
 traditional midline plication,
 ultralateral repair,
 traditional plication plus lateral reinforcement with synthetic mesh
• The mesh is used to reinforce the vaginal wall and is sutured in place laterally – its use should
be considered experimental (ACOG 2007).
• anterior vaginal wall prolapse results from fibromuscular defects at the anterior apical segment
or transverse detachment of the anterior apical segment from the vaginal apex.
• Apical suspension procedure such as an abdominal sacrocolpopexy or uterosacral ligament
vaginal vault suspension will resuspend the anterior vaginal wall to the apex and reduce
anterior wall prolapse.
• lateral defect – paravaginal repair can be performed through the vaginal, abdominal, or
laparoscopic route. Paravaginal repair is performed by re-attaching the fibromuscular layer of
the vaginal wall to the arcus tendineus fascia pelvis.
 Anterior colporrhaphy
• This operation is designed to correct cystocele and urethrocele.
• The underlying principles are to excise a portion of the relaxed
anterior vaginal wall, to mobilize the bladder and push it upwards
after cutting the vesicocervical ligament.
• The bladder is then permanently supported by plicating the
endopelvic fascia and the pubocervical fascia under the bladder neck
in the midline.
• Preliminaries
• The operation is done under general or epidural anesthesia.
• The patient is placed in lithotomy position.
• Vulva and vagina are to be swabbed with antiseptic solution.
• The perineum is to be draped with sterile towel and legs with
leggings.
• Bladder is to be emptied by metal catheter.
• Vaginal examination is done to assess the type and degree of
prolapse.
• Actual steps
• Sims’ posterior vaginal speculum is introduced and the anterior lip of the cervix is held
by multiple teethed vulsellum
• A metal catheter is introduced to know the lower limit of the bladder.
• An inverted ‘T’ incision is made on the anterior vaginal wall.
• The horizontal incision is made below the bladder and the vertical incision is made
starting from the midpoint of the transverse incision up to a point about 1.5 cm below
the external urethral meatus
• triangular vaginal flaps on either sides are separated from the endopelvic fascia covering
the bladder by knife and gauze dissection. The line of cleavage is vesicovaginal space,
• The bladder with the covering endopelvic fascia (pubocervical) is now exposed as the
edges of the vaginal wall are retracted laterally.
Steps of anterior colporrhaphy
•The vesicocervical ligament is held up with Allis tissue or toothed dissecting forceps and
divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the
uterovesical pouch is visible. The vesicocervical space is now exposed (Figs 15.15.3 and
15.15.4).
•The pubocervical fascia is plicated by interrupted sutures with No ‘O’ chromic catgut using
round body needle. The lower one or two stitches include a bite on the cervix, thus closing
the hiatus through which the bladder herniates (Fig. 15.15.5).
•The redundant portion of the vaginal mucosa is cut on either side (Fig. 15.15.6).
•The cut margins of the vagina are apposed by interrupted sutures with No. ‘O’ chromic
catgut using cutting needle
•(Figs 15.15.7 and 15.15.8).
•The catheter is reintroduced once more to be sure that the bladder is not injured.
•Toileting of the vagina is done.
•Vagina is tightly packed with roller gauze smeared with antiseptic cream.
•A self-retaining catheter is introduced.
•The last two formalities are optional.
 Vaginal Apex
• support of the vaginal apex provides the cornerstone for a successful
prolapse repair.
• The vaginal apex resuspention procedures including:
abdominal sacrocolpopexy,
sacrospinous ligament fixation, or
uterosacral ligament vaginal vault suspension.
 Abdominal Sacrocolpopexy
• suspends the vaginal vault to the sacrum using synthetic mesh.
• Primary advantages include:
durability and conservation of normal vaginal anatomy
offers greater vaginal apex mobility and avoids vaginal shortening.
provides enduring correction of apical prolapse, and long-term success rates
approximate 90 percent.
• Sacrocolpopexy used primarily or as a second surgery for women with
recurrences after failure of otherprolapse repairs.
 Sacrospinous Ligament Fixation (SSLF)

• This is one of the most popular procedures for apical suspension.

• The vaginal apex is suspended to the sacrospinous ligament
unilaterally or bilaterally using a vaginal extraperitoneal approach.
• Complications associated with SSLF include buttock pain in 3 percent
of patients and vascular injury in, 1%
• Although uncommon, significant and life-threatening hemorrhage can
follow injury to blood vessels located behind the sacrospinous
ligament
 Uterosacral Ligament Vaginal Vault Suspension
• the vaginal apex is attached to remnants of the uterosacral ligament
at the level of the ischial spines or higher.
• Performed vaginally or abdominally replacing the vaginal apex to a
more anatomic position than SSLF,
• attempts to reduce the rates of anterior vaginal prolapse recurrence
following SSLF
 Hysterectomy at the Time of Prolapse Repair
• Hysterectomy is often performed concurrently with prolapse surgery.
• If apical or uterine prolapse is present, hysterectomy will more readily
allow the vaginal apex to be resuspended with the previously
described apical suspension procedures.
• if apical or cervical prolapse is not present, hysterectomy need not be
incorporated into prolapse repair.
 Posterior Compartment
• Posterior vaginal wall prolapse may be due to enterocele or rectocele.
• Enterocele Repair
small bowel harniation through the vaginal fibromuscular layer, usually at the
vaginal apex.
repair of this defect should reduce the posterior wall prolapse.
• Rectocele Repair
several techniques involved.
posterior colporrhaphy aims to rebuild the fibromuscular layer between the
rectum and vagina by performing a midline fibromuscular plication
• Anatomic cure rate is 76 to 96%
 Steps of enterocele repair operation with cervix still present

1. Dissection to expose the enterocele.

2. To open the sac and reduce the contents if any.
3. A purse string sutureis placed at the neck of the sac and
tied.
4. The excess peritoneum is resected
Steps of perineorrhaphy
• Site-Specific Posterior Repair
• This repair is based on the assumption that specific tears exist in the
fibromuscular layer, which can be identified and repaired in a discrete
fashion.
• Defects may be midline, lateral, distal, or superior.

Posterior vaginal wall defects.

• Mesh Reinforcement
• To reduce prolapse recurrence, graft augmentation with allograft,
xenograft, or synthetic mesh, has been used in conjunction with
posterior colporrhaphy and site-specific repair.
• the graft is placed after colporrhaphy or site-specific repair is completed
• Graft augmentation may be the only surgical option in situations in
which the fibromuscular layer cannot be identified to perform a midline
plication or site-specific repair.
• The graft is attached to the vaginal apex and the uterosacral ligament.
Distally, the graft is attached to the perineal body.
• Sacrocolpoperineopexy
• This modification of sacrocolpopexy may be selected for correction of
posterior vaginal wall descent when an abdominal approach is
employed for other prolapse procedures or if treatment of perineal
descent is necessary
• The posterior sacrocolpopexy mesh is extended down the posterior
vaginal wall to the perineal body
 Perineum
• The perineum provides distal support to the posterior vaginal wall and anterior
rectal wall and anchors these structures to the pelvic floor.
• A disrupted perineal body will allow descent of the distal vagina and rectum and
will contribute to a widened levator hiatus.
• Perineorrhaphy is often done in conjunction with posterior repair to recreate
normal anatomy (see Section 42-16, Perineorrhaphy).
• During surgery, the perineum is rebuilt through midline plication of the perineal
muscles and connective tissue.
• Importantly, overly aggressive plication can narrow the introitus, create a
posterior vaginal wall ridge, and lead to entry dyspareunia.
• However, in a woman who is not sexually active, high perineorrhaphy with
intentional introital narrowing is believed to decrease the risk of posterior wall
prolapse recurrence
The Use of Mesh and Materials in Reconstructive Pelvic Surgery

• Mesh Indications
• (1) the need to bridge a space,
• (2) weak or absent connective tissue,
• (3) connective tissue disease,
• (4) high risk for recurrence (obesity, chronically increased intra-
abdominal pressure, and young age), and
• (5) shortened vagina. High-quality scientific data are lacking to support
the use of grafts for augmentation of transvaginal prolapse repairs.
• ACOG (2007) considers this practice experimental,
• Mesh Material
• Surgeons using grafts should be familiar with the different types and their
characteristics. Biologic grafts may be autologous, allograft, or xenograft.
Autologous grafts are harvested from another part of the body such as rectus
abdominis fascia or fascia lata. Morbidity is low, but may include increased
operative time, pain, hematoma, or weakened fascia at the harvest site. Allografts
come from a human source other than the patient and include cadaveric fascia or
cadaveric dermis. Xenografts are biologic tissue obtained from a source or species
foreign to the patient such as porcine dermis, porcine small intestinal submucosa,
or bovine pericardium. Biologic materials have varying biomechanical properties
and, as noted earlier, are associated with high rates of prolapse recurrence. Thus,
recommendations on the appropriate clinical situations for biologic material are
limited.
• Synthetic grafts are classified as types I to IV, based on pore size
SURGICAL TREATMENT FOR
PROLAPSE
• Age, parity status, and /type of prolapse are the factors that decide the type of
surgery.
• Conservative Treatment (Uterus-preserving Surgeries)
• It is done for young patients desirous of further childbearing/menstrual function
• Transvaginal
Fothergill’s operation
Shirodkar’s uterosacral ligament advancement
• Abdominal (Sling Surgery/Cervicopexy)
• Purandare
• Shirodkar
• Khanna
• Virkud (composite sling)
Different types of surgical mesh

A. Marlex.
B. Mersilene.
C. Prolene.
D. Gore-Tex.
E. Gynemesh-PS.
F. IVS (intravaginal slingplasty) mesh.
Concomitant Prolapse and Incontinence
Surgery
 Radical Surgery
• For old patients, family complete, postmenopausal women who are
medically fit for surgery
• Vaginal hysterectomy with or without anterior and posterior
colporrhaphy is the best surgery:
Anterior colporrhaphy: repair of cystocele and cystourethrocele
Posterior colporrhaphy: repair of rectocele and lax perineum
• Operative Repairs
• The aims of surgical management of POP are to:
 Reduce the prolapse
 Improve symptoms of POP, the lower urinary tract, and bowel
 Restore or improve sexual functioning (except after colpocleisis), and correct coexisting pelvic
pathology.
• The surgical approach for POP includes vaginal, abdominal, and laparoscopic
routes.
• Anatomic studies have demonstrated different levels of support, and POP
may result from a single or combination of support defects
• Surgical management may therefore involve a combination of repairs
including the anterior vaginal wall, vaginal apex, and posterior vaginal wall.
KEY POINTS OF VARIOUS SURGERIES
• 1. Fothergill’s repair (Manchester operation): Main step is amputation of
cervix.
○ Initially, the operation was thought to preserve the fertility status of the patient.
○ But as it is associated with a lot of complications, it is not a preferred option
nowadays.
○ Various complications include:
a. Primary hemorrhage/secondary hemorrhage
b. Repeated second trimester abortions due to cervical incompetence
c. Preterm labor/PROM
d. Cervical stenosis
e. Cervical dystocia
f. Infertility due to cervical factor
• 2. Shirodkar’s uterosacral ligament advancement surgery (modification of Fothergill’s
operation):
• There is no amputation of cervix, and so the complications of Fothergill’s operation
are not there. It is preferred in young women desirous of further childbearing.
• 3. Purandare’s cervicopexy (dynamic sling and open sling): Central part of Mersilene
tape is fixed anteriorly over the exposed isthmus. The two ends of tape are attached
to the posterior rectus sheath.
• Good abdominal muscle tone is prerequisite for this surgery. If the anterior
abdominal tone is poor, this surgery should not be done. Postsurgery, the uterus
becomes retroverted and the POD becomes deep. Hence, enterocele is a long-term
complication of this surgery. Enterocele formation can be prevented by Moschowit’s/
• Halban’s surgery in which POD is obliterated.
4. Shirodkar sling (static sling): Mersilene tape is placed posteriorly on the
cervix and anchored to sacral promontory (anterior longitudinal ligament).
• On the left side, the tape has to pass below the mesentery of sigmoid colon
to reach sacral promontory. On the left side, a loop is created over the psoas
muscle to avoid obstruction to the rectosigmoid.
• Complications:
 Injury to sigmoid colon, mesentery, and ureters
 Hemorrhage from pre-sacral/mesenteric vessels
 Intestinal obstruction
 Injury to genitofemoral nerve (present in psoas muscle)
5. Khanna sling: Mersilene tape is anchored to anterior superior iliac spine.
• 6. Composite sling (Virkud): As the complications of Shirodkar sling are mainly on
the left side in this surgery, on right side the tape is attached to sacral
promontory and on left side the tape is attached to rectus sheath (left-sided
Purandhare + right-sided Shirodkar).
• 7. Vaginal hysterectomy with pelvic floor repair: Women above 40 years who
have advanced uterine prolapse with cystorectocele, have completed their
families, and are not interested in further childbearing or menstruation are fit for
surgery.
• 8. Le Fort’s repair (complete colpocleisis): It is done in very elderly
postmenopausal women who are unfit for major surgery (with medical
complications such as heart failure, past history of myocardial infarction, severe
hyper tension, etc.).
• This procedure can be performed under local anesthesia and sedation. Prior to
the procedure, PAP smear and pelvic USG should be done to rule out cervical
dysplasia and pelvic pathology. Vaginal sexual activity is not possible after this
surgery. If sexual function is desired, Goodell-Powel surgery (partial colpocleisis)
is done (modification of Le Fort’s repair).
• VAULT PROLAPSE
• It is a long-term complication of any hysterectomy and occurs more
frequently after vaginal as compared to abdominal. It can be
prevented by vault suspension at the time of primary surgery.
• Management
Transvaginal sacrospinous ligament fixation
Transabdominal sacrocolpopexy: mesh is attached to vault and sacral
promontory
• Sacrocolpopexy is considered the gold standard operation for vault
prolapse.
• Complications of genital prolapse in pregnancy are increased risk of:
• 1. Abortions
• 2. Cervical and intra-uterine infection
• 3. PROM
• 4. Cervical dystocia
• 5. Prolonged labor
• 6. Operative interference
• 7. Urinary retention and UTI
• 8. Subinvolution
• 9. Sepsis
 Urinary Incontinence
• Types
• Stress urinary incontinence (SUI) is the loss of urine that occurs with
increased abdominal pressure, such as coughing or straining. SUI is the
result of loss of anatomic support of the urethrovesical junction or
urethra. It most commonly occurs following pelvic floor muscle and nerve
damage that resulted from childbearing.
• Urethral hypermobility is the most common form of SUI and usually follows child
birth injury to urethral support. The SUI occurs because the urethra can no longer
be compressed against the vagina during raised intra-abdominal pressure.
• Intrinsic urethral sphincteric deficiency is less common and is caused by a
weakened urethral sphincter. Severe SUI develops even with minimal exertion.
Risk factors are scarification from prior anti-incontinence surgery and aging.
• Urge incontinence is defined by the symptom of urine loss that occurs
when the patient experiences urgency, or a strong desire to void. This
type of incontinence is often accompanied by symptoms of urinary
frequency, urgency, and nocturia. Urge incontinence includes the
following subtypes:
• Detrusor overactivity (DO) (previously called detrusor instability), or
overactive bladder, is caused by involuntary detrusor contractions. Its cause is
usually unknown.
• Neurogenic DO is involuntary detrusor contractions associated with a
neurologic disorder (e.g., stroke, spinal cord injury, or multiple sclerosis). It is
a common cause of incontinence in elderly and institutionalized women.
• Overflow incontinence occurs because of underactivity of the
detrusor muscle. This form of incontinence is associated with
retention of urine. The bladder does not empty completely, and
“dribbling” of urine occurs.
• Extraurethral sources of urine include genitourinary fistulas, which
may be congenital or follow pelvic surgery or radiation. These
typically cause continuous leaking of urine.