PELVIC ORGAN

PROLAPSE
Dr. Hazem Al-Mandeel
481 GYN
Department of Obstetrics & Gynecology
 Objectives
• To define pelvic organ prolapse
• Recognize pelvic anatomy
• Determine the Pathophysiology
• Discuss the predisposing factors
• Understand the grading systems
• Be aware of the options of management
 Pelvic Organ Prolapse
• Is the descent of the pelvic organs as a
result of the loss of muscular and fascial
structural support .
 Anatomic Supports
• Muscular : Levator Ani (Pelvic Floor Ms.)
• Ligaments : Uterosacral-Cardinal Complex
• Fascial : Endopelvic (Pubocervical &
Rectovaginal)
 Levator Ani
• Major structure of pelvic floor
• Anterior/posterior orientation
• Perforated by urogenital hiatus
• Consists of : Pubococcygeus
Iliococygeus
Puborectalis
Coccygeus
 Endopelvic Fascia
• Fibromuscular layer
• Local condensations are ligaments
• Principal ligaments are Uterosacral
Cardinal
• Pubocervical and Rectovaginal Fascia
important in specific surgical correction
 Pathophysiology

• Direct Trauma to pelvic soft tissues

• Neurological injury

• Connective tissue disorders

 Predisposing Factors
• Hereditary (genetic) predisposition
• Race: White > Black > Asian
• Pregnancy and Vaginal Childbirth
• Age and Menopause
• Raised intra-abdominal pressure (e.g.:
obesity, cough, constipation, lifting, etc)
• Iatrogenic: surgical procedure
 Types of Pelvic Organ Prolaopse

1. Urethra
2. Bladder
3. Uterus/ Vaginal Vault
4. Small Bowel
5. Rectum
6. Perineum
 Compartments
• Anterior : Cystocele
Urethrocele
• Middle : Uterine prolapse
Enterocele/vault prolapse
• Posterior : Rectocele
Rectal prolapse
 Classification of Prolapse
• Baden Walker (1972)
• Each site graded from 1 – 4

• POPQ: quantifies using specific points

• Measured relation to the hymenal ring
• More widely used
 Symptoms of Prolapse
• Pelvic pressure
• Pelvic pain
• Feeling of a “lump”
• Back pain
• Urinary dysfunction
• Bowel dysfunction
 Complications of Prolapse
• Bleeding
• Infection
• Recurrent UTI’s
• Urinary obstruction
• Renal failure
 Associated conditions
• Urinary Incontinence : Stress
Urge
Mixed
• Fecal Incontinence : sphincter injury
 Options of Management
• No Treatment ( pelvic floor exercise)

• Conservative: such as
Physiotherapy or Pessary

• Surgical Treatment
 Aims of prolapse surgery
• Alleviate symptoms

• Restore normal anatomy

• Restore normal visceral function

• Avoid new bladder or bowel symptoms

• Preserve sexual function

• Avoid surgical complications

 Classisfication of prolapse
surgery
• Vaginal • Abdominal • Laparoscopic

Primary Primary All of the Abdominal

Vaginal hysterectomy procedures +/-
Paravaginal repair
Anterior/Posterior repair reinforcement
Hysteropexy

Secondary
Sacrospinous fixation Secondary +- reinforcement
Iliococcygeus fixation Sacrocolpopexy
Uterosacral fixation Uterosacral/Sacrospinous
fixation
Recurrent+/- reinforcement
Synthetic mesh/autologous/
donor/Xenograft
 Conclusions
• Pelvic organ prolapse is common
• Results from injury to soft tissue and nerves
• Childbirth most significant association
• Treatment requires understanding of anatomic
relationships
• Treated with a combination of physio/pessary
and often complex surgery