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com

Dr. Shiralee Runwal MS

 AfraTafreeh.com

• Definition
• Pathophysiology
• Classification/quantification
• Clinical presentation
• Conservative management
• Surgical management
• Recent advances

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 POP is a condition characterized
by descent of pelvic structures
from their anatomical location.

It is defined as the descent of one or

more of the vaginal walls or cervix:
o anterior vaginal wall prolapse
(cystocele, urethrocele, paravaginal
defect),
o Posterior vaginal wall prolapse
(rectocele or enterocele),
o uterine/cervical prolapse
o vaginal vault prolapse (after
hysterectomy, often with an
enterocele)
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 SUPPORTS OF UTERUS

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 TRAMPOLINE THEORY

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 “BOAT IN THE DOCK” ANALOGY
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Imagine there is a boat tied to a dock.
The pelvic organs (i.e., bladder, uterus, and rectum) are
the boat. The ropes holding the boat to the dock are the
ligaments.
The water is the pelvic floor muscle.
■ If the water level drops (i.e. weakness of the pelvic
floor muscles), the boat (organs) hangs on the ropes
(ligaments). Eventually the
ropes stretch out and break, resulting in the boat
(organs) falling down (i.e., prolapse).
■ If you pull the boat back up by replacing the ropes (i.e.
organ suspension surgery) without raising the water level
(i.e., pelvic floor muscles strengthening) (C), the boat will
continue to hang on the ropes and eventually falls down
again (i.e., prolapse). Falling happens quicker if you jump
on the boat (i.e., increase pressure in the abdomen from
cough, sneeze, lift, or improper exercise).
THE HAMMOCK HYPOTHESIS
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 DEFECT THEORY OF POP

 This theory states that tears in different sites of the

“endopelvic fascia” surrounding the vaginal wall allow
herniation of the pelvic organs.

 Specifically, attenuation of the vaginal wall without loss

of fascial attachments is called a distention cystocele or
rectocele With distention-type prolapse, the vaginal wall
appears smooth and without rugae, due to abdominal
contents pressed against the vagina from within.

 In contrast, anterior and posterior wall defects due to

loss o the connective tissue attachment of the lateral
vaginal wall to the pelvic sidewall are described as
displacement (paravaginal) cystocele or rectocele. With
displacement-type prolapse, vaginal rugae are visible.
POP is common in multiparous women.

Pelvic support structure defects are often associated

with:
1. vaginal childbirth–related injury (either neuropathy or
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muscular injury),
2. stress and strain from heavy lifting,
3. aging process (postmenopausal state).
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 Symptoms can include vaginal bulging,

pelvic pressure, vaginal bleeding or discharge,
low backache, and the need to replace the
prolapse (splint) in order to void or defecate

 POP can be asymptomatic.

 Symptoms are more common when the

prolapse extends beyond the hymen
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Normal support of pelvic organs is provided by several

key anatomic structures:
• Level I support of the vaginal apex and cervix
is provided by the uterosacral and cardinal
ligaments and associated connective tissue

• Level II support of the mid-vagina is provided

by connective tissue attachments to the
arcus tendineus fasciae pelvis on the lateral
pelvic side walls

• Level III support of the distal (inferior) vagina

is provided by the perineal membrane and
muscles, and all of the attachments are
connected through endopelvic connective
tissue. AfraTafreeh.com
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 Asymptomatic

 The classic symptoms of prolapse include vaginal heaviness

and pressure, a vaginal bulge, pelvic pain, or vaginal
bleeding (from erosions of exposed vaginal epithelium).

 Back pain and pelvic pain, the former due to uterosacral

strain.

 If a woman with objective prolapse does not have any

symptoms or evidence of associated medical risks such as
urinary retention or renal impairment from urethral or
ureteral kinking, she does not need treatment
 Urinary symptoms: urinary incontinence,
difficulty in voiding, slow urinary stream, or
a sensation of incomplete bladder emptying.

 Bowel symptoms: constipation, straining,

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incomplete evacuation, fecal incontinence, or
splinting (reducing the prolapse) to achieve bowel
movements

 Sexual symptoms: discomfort, irritation, and

decreased sexual desire.
 SHAW’S CLASSIFICATION

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BADEN & WALKER CLASSIFICATION

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 In 1996, the International Continence Society, the American
Urogynecologic Society, and the Society of Gynecologic
Surgeons adapted a standardized terminology for the
description of female pelvic organ prolapse and pelvic floor
dysfunction.

 This is an objective, site-specific system for describing,

quantifying,
AfraTafreeh.com and staging pelvic support and was developed to

enhance both clinical and academic communication with

respect to individual patients and populations of patients.

 The terminology replaces such terms as cystocele, rectocele,

enterocele, and urethrovesical junctions with precise
descriptions relating to specific anatomic landmarks.
 Point Aa is a point located in the
midline of the anterior wall 3 cm
proximal to the urethral meatus and
is roughly the location of the
urethrovesical crease.

Point Ba represents the most

distal position of any part of the
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anterior vaginal wall.

Point C represents either the most

distal edge of the cervix or the
leading edge (apex) of the vagina if
a hysterectomy has been
performed.
Point D represents the location of the
posterior fornix (pouch of Douglas) in a
woman with a cervix.

Point Bp is a point most distal of any part

of the upper posterior vaginal wall,

Point Ap is a point located in the

midline of the posterior vaginal wall 3
cm proximal to the hymen.
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PB - length of the perineal body between the

posterior vagina and rectum
GH - genital hiatus measurement from the
urethra to the posterior vagina
TVL – Total vaginal length, taken after
reposition of the prolapse

• These except tvl, are measured during

straining
• The most severe prolapse measurement
on any of the vaginal walls can then be
used to assign the stage of prolapse

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  Loss of anterior vaginal wall support is the
most common site of primary POP.

 Normal support of the anterior vaginal wall

depends on level I apical support and level
II support from the endopelvic connective
tissue and its attachments to the bony
pelvis and pelvic muscles.

 Anterior vaginal wall prolapse can be

associated with stress urinary incontinence
from urethral hypermobility or urinary
retention from urethral kinking that causes
obstruction
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Cystocele is the protrusion of the bladder into
the vagina, signifying the relaxation of fascial
supports of the anterior vaginal wall.
Fascial breaks:
• Lateral breaks correspond to
paravaginal defects;

• Apical detachments from the pubocervical

fascia of the cervix or vaginal apex are
transverse cystoceles

• Distal detachments from near the pubic

symphysis appear as urethroceles or
urethral hypermobility.
 Symptoms:
1. sensation of 4. feeling that organs are falling out
fullness 5. feeling of incomplete emptying with voiding
2. pelvic pressure 6. slow urinary stream
3. vaginal bulge 7. urinary urgency.

Signs:
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 Soft, bulging mass of the anterior vaginal wall.

 In some patients this mass must be replaced manually before
the patient can void.
 Strain, cough, or prolonged standing often accentuates the
bulge.
 Often POP symptoms are less bothersome in the morning
and worsen later in the day after upright activities.
 The urethrocoele and cystocele are best demonstrated with a
patient in the lithotomy position.

 A retractor or posterior wall blade of a Graves speculum is

used to depress the posterior vaginal wall.

 The patient is then asked to strain, and the degree of

cystocele or urethrocele is noted.

 The physician should palpate the bladder neck and feel

whether it is well supported
 CLINICAL EXAMINATION

 Best performed with the bladder at least

partially filled (100 to 250 mL).

 Also perform supine stress test to

demonstrate SUI.
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 A standing exam with Valsalva often

allows the physician to see the maximal
descent of the POP.
 ESTIMATION OF STRENGTH OF THE PELVIC FLOOR

Laycock developed the Modified Oxford Grading System to

evaluate the strength of the pelvic floor muscles by using
vaginal palpation.

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 The “PERFECT” scale

Apply PERFECT scheme:--

P: power/strength
E: endurance up to 8 seconds
R: repetitions up to 10 times
F: fast 10 fast squeezes
E: elevation observe elevation of clitoris
C: co-contraction of pelvic floor
T: timed can they cough and squeeze
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 Role of Reflexes

 First, the bulbocavernosus reflex is elicited by

tapping or stroking lateral to the clitoris and
observing contraction of the bulbocavernosus
muscle bilaterally.

 Second, 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.

 Intact reflexes suggest normal sacral pathways.

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 Differential Diagnosis

Vulval cyst and Gartner cyst tumour can be easily

differentiated from prolapse. The cyst of the
anterior vaginal wall is usually tense with well-
defined margins and cannot be reduced on
pressure.

Urethral diverticula are rare, always small and are

situated low down in the anterior vaginal wall.
Urethroscopy helps in the diagnosis.

Congenital elongation of the cervix can be

differentiated from prolapse because it is the
vaginal portion of the cervix that is elongated and
there is no accompanying vaginal prolapse. The
fornices are deep.
 Differential Diagnosis

Cervical fibroid polyps can be easily identified as

the cervix is high up in its normal anatomical
position.

Chronic inversion can be recognized because the

cervix is further up, and the uterus cannot be
defined. The uterine sound will confirm the
diagnosis. Ultrasound and laparoscopy will
identify the fundal depression and absence of
uterine fundus in the pelvis.
 Prophylaxis of Prolapse
 Antenatal physiotherapy, relaxation exercises
 Proper supervision and management of the second stage of labour is needed.
 A generous episiotomy in all complicated labour, for example, breech delivery
should be considered.
 Low forceps delivery should be readily resorted to if there is delay in the
second stage of labour.
 A perineal tear must be immediately and accurately sutured after delivery.
 Postnatal exercises and physiotherapy are beneficial.
 Early postnatal ambulation.
 Provision of adequate rest for the first 6 months after delivery.
 A reasonable inter-pregnancy interval
 Avoiding multiparity
 Prophylactic hormone replacement therapy (HRT)
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 Treatment of anterior vaginal wall prolapse may
undergo non-operative or operative
management. depending on patient preferences
and goals.

 If the patient is not bothered by the prolapse, it

is better left alone and managed expectantly
unless it is causing urinary retention or renal
hydronephrosis.

 Women with mild (e.g., Stage 2) POP may elect

for non-operative management with pelvic floor
physical therapy and Kegel exercises
Non-operative treatment
consists of supporting the
herniation of the anterior
vaginal wall with the use of :

1. Smith-Hodge ring
2. Cube
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3. inflatable pessary
4. Intermittent use of a large tampon.
5. Kegel exercises - help to strengthen the
pelvic floor musculature and thereby may
relieve some of the pressure symptoms
produced by the cystocele.
 Urethrocele & Cystocele
Management
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 Operative repair of a cystocele is generally

performed in conjunction with the repair of all
other pelvic support defects.

 Repair consists of: Anterior colporrhaphy &

Correction of uterine descensus or apical defect

 Cystoscopy should be performed to assess

bladder and ureteral integrity after the
procedure is completed.

 Buttressing of the pubovesicocervical fascia is

also known as A-repair.
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Rectocoele: signs and symptoms

 heavy pelvic pressure or “falling out” feeling in the vagina.

 May complain of constipation and occasionally may need to splint the

vagina with her fingers to affect a bowel movement.

 May also have a feeling of incomplete emptying of the rectum at the

time of the bowel movement.

 Protrusion of the prolapse may worsen later in the day and be

aggravated by prolonged standing or exertion.
  Identified by retracting the anterior vaginal wall upward with
one half of a Graves or Pederson speculum and having the
patient strain.

 The rectum will bulge into the vagina, and this bulge may
protrude through the introitus

 The physician should then place one finger in the rectum and one
in the vagina and palpate the defect (tenting).

 Often the rectovaginal septum is paper thin, and the

rectocele can be palpated to its upper margin.
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 Herniation of the pouch of Douglas (cul-desac) between
the uterosacral ligaments into the rectovaginal septum and
usually contains small bowel.

 It frequently occurs after an abdominal or

vaginal hysterectomy

 Generally is the result of a weakened support for the pouch

of Douglas and the loss of vaginal apical support by the
uterosacral ligaments.

 True hernia of the peritoneal cavity emanating from POD

between the uterosacral ligaments and into the rectovaginal
septum
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Enterocoele is noticed as a separate bulge above

the rectocele, and at times it may be large enough
to prolapse through the vagina

Transilluminate the bulge and seeing small bowel

shadows within the sac.

Gurgling sound may be appreciated

The classical “Double hump sign” in presence of

both enterocoele & rectocoele.

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 Enteroceles may be reduced transabdominally (as a primary
procedure or at the time of other abdominal procedures).

 Moschowitz or Halban repair is made use of.

 In the primary procedure the sac should be reduced upward if

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possible and dissected free from the bladder and rectum. If the
uterosacral ligaments are present, these may be brought together in
the midline and attached to the vaginal cuff after closing the
anterior and posterior fascia of the vaginal apex.

 Concentric purse-string sutures/multiple A-P sutures in the

endopelvic fascia may obliterate the cul-de-sac.
 McCall’s Culdoplasty

In 1957, Milton McCall, MD, described a technique to

manage the cul-de-sac at the time of vaginal
hysterectomy.

The McCall technique of posterior culdoplasty differs from

other approaches by omitting dissection and excision of
the hernia sac, or excess cul-de-sac peritoneum.

The original McCall culdoplasty begins with the placement

of several rows (average of 3) of non-absorbable suture
(“internal” McCall sutures), starting at the left uterosacral
ligament about 2 cm above its cut edge, and proceeding
across the redundant cul-de-sac to terminate in the right
uterosacral ligament.

Each subsequent row is placed superior to the first, by

applying traction to the previously placed sutures.
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 McCall’s Culdoplasty
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Prior to the tying of these sutures, 3 “external” absorbable

sutures are placed.

These sutures incorporate posterior vaginal epithelium, each

uterosacral ligament, and the contralateral vaginal epithelium
in a mirror image of the first pass through the vagina.

Again, several rows are placed, each more superior to the

last, to move the newly created vaginal apex to the highest
point on the uterosacral ligaments once all the sutures are
tied.

Tying the internal sutures not only creates a firm, shelf-like

midline structure, but obliterates the redundant cul-de-sac.

The external sutures move the vaginal apex to the uterosacral

bridge and are tied at the conclusion of the procedure.
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 Associated with injuries of the
endopelvic fascia, including the
cardinal and uterosacral ligaments,
as well as injury to the
neuromuscular unit with relaxation
of the pelvic floor muscles,
particularly the levator ani muscles

 Occasionally, prolapse is the result of

increased intraabdominal pressure
(acites or large pelvic or intraabdominal
tumors) superimposed on poor pelvic
supports
 Stage I uterine prolapse does not require
therapy unless the patient is very
uncomfortable

 For stages 2-4, operative repair for

prolapse of the uterus and cervix generally
involves a vaginal hysterectomy with pelvic
floor repair (Ward Mayo operation)
accompanied by a vaginal vault suspension.
 NON-SURGICAL MANANGEMENT

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 Pessaries in play !
Pessaries are divided into two broad categories: support
and space-filling.

Support pessaries, such as the ring pessary, use a spring

mechanism that rests in the posterior fornix and against
the posterior aspect of the symphysis pubis

In contrast, space-filling pessaries maintain their

position by creating suction between the pessary and
vaginal walls (cube), by creating a diameter larger than
the genital hiatus (donut), or by both mechanisms
(Gellhorn).

Ideal in pregnancy, puerperium & moribund patients.

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 Procedure & Mechanism
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Generally, a patient is fitted with a pessary

while in the lithotomy position after she has
emptied both her bladder and rectum.

A digital examination is performed to assess

vaginal length and width, and an initial
estimation of pessary size is made.

Lubricant is placed on either the vaginal

introitus or the pessary’s leading edge. While
holding the labia apart, the pessary is inserted
by pushing in a cephalad direction and against
the posterior vaginal wall.
 Procedure & Mechanism
Next an index finger is directed into the posterior
vaginal fornix to ensure that the cervix is resting
above the pessary.

The pessary should fit snugly but not tightly against

the symphysis pubis and the posterior and lateral
vaginal walls.

Following pessary placement, a woman is prompted

to perform a Valsalva maneuver, which might
dislodge an improperly fitted pessary. She should be
able to stand, walk, cough, and urinate without
difficulty or discomfort.
 In some women the cervix is hypertrophied and
elongated to the area of the introitus, but the
supports of the uterus itself are intact.
 A cystocele and rectocele may be present, and
operative repair can consist of a Manchester (Donald
or Fothergill) operation.

 Combines an anterior and posterior colporrhaphy with the

amputation of the cervix and the use of the cardinal ligaments
to support the anterior vaginal wall and bladder (Sturmdorf
suture).

 Ideal for women who have an elongated cervix and well-

supported uterus because it is technically easier and has a
shorter operative time than the vaginal hysterectomy
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 In elderly women who are no longer sexually
active, a simple procedure for reducing prolapse
is an obliterative procedure called a colpocleisis
(Le Fort procedure)

 The classic partial colpocleisis procedure was

described by Le Fort in 1877

 It involves the removal of a strip of anterior

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and posterior vaginal wall, with closure of the

margins of the anterior and posterior wall to
each other.

 The vaginal cavity is nearly completely closed,

with small vaginal canals on either side of the
opposed vaginal walls to allow drainage of any
fluid from the cuff or uterus.
 Goodall-Power modification of the Le Fort operation
allows for the removal of a triangular piece of vaginal
wall beginning at the cervical reflection or 1 cm above
the vaginal scar at the base of the triangle, with the
apex of the triangle just beneath the bladder neck
anteriorly and just at the introitus posteriorly.

 The cut edge of vaginal wall making up the base of the

triangle anteriorly is sutured to the similar wall
posteriorly, and the vaginal incision is then closed with a
row of interrupted sutures beginning beneath the
bladder neck and carried side to side to the area of the
introitus.

 Ideal for relatively small prolapses, whereas the Le Fort is

best for larger ones.
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 How to manage apical defects ?

 One of the most widely performed transvaginal suspension

procedures is the sacrospinous fixation in which the coccygeus
sacrospinous ligament is attached to the vaginal apex.

 Advantages include avoiding the morbidity of an abdominal

incision, achieving a functional vagina, and the ability to
repair coexisting anterior and posterior compartment defects
using a single surgical site.

 However, because the technique displaces the vaginal axis

posteriorly, it can often lead to the development of new
anterior compartment defects.

 Associated complications that have been reported include

intraoperative hemorrhage due to laceration of the pudendal
artery, vaginal shortening, sexual dysfunction, and injury to
the pudendal nerve
 How to manage apical defects ?

The uterosacral suspension is an alternative transvaginal

approach in which the plication of the uterosacral ligaments
across the midline is preformed and attached to the vaginal
cuff. Disadvantages to consider in this approach is the
proximity of the uterosacral ligaments to the ureters.

In recent years, the procedure of choice has become the

abdominal sacrocolpopexy, which can be done by either
laparotomy, laparoscopy, or robotic-assisted. Since the initial
delineation of the procedure by Lane in 1962, the procedure
has gone through many modifications. Birnbaum has
advocated anchoring the suspensory mesh to the sacrum.
However, there is a high risk of hemorrhage from laceration
of the presacral vessels.

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 MESH -- A miracle or mess ?
The use of biologic grafts or synthetic mesh has expanded rapidly and
in the absence of supporting long-term safety and efficacy data.

Selective use may include:

(1) the need to bridge space
(2) weak or absent connective tissue
(3) connective tissue disease
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(4) high risk or recurrence (obesity, chronically increased intra-
abdominal pressure, and young age)
(5) shortened vagina

Type I Macroporous mesh is ideal.

Mesh erosion, extrusion & scarring are known complications.

 APOGEE/PERIGEE/PROLIFT REPAIR

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 NULLIPAROUS PROLAPSE

Since India has the largest prevalence of nulliparous prolapse, it is no

surprise that Indian gynecologists have devised most of the
conservative operations for genital prolapse.

The various conservative sling operations for genital prolapse in young

women who want to preserve fertility are:--

•Shirodkar sling
•Purandare cervicopexy
•Khanna sling
•Soonawalla sling
•Joshi sling
•Virkud sling
•Mangeshkar’s laparoscopic technique
•Neeta Warty’s laparoscopic modification of Shirodkar’s operation
 Shirodkar’s Sling Operation
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 VN Shirodkar was the first to describe a conservative sling
operation.

 His aim was to recreate the uterosacral ligaments because he

realized that they have a more important role in prevention
of genital prolapse that the cardinal ligaments.

 In his sling operation one end of tape is attached to the

anterior longitudinal ligament and then passed
subperitoneally along the right pelvic wall between the two
leaves of broad ligament and transfixed to isthmus
posteriorly.

 It passes posteriorly through left broad ligament; it is then

passed through a psoas loop, through the sigmoid mesentery
back to the sacral promontory where it is fixed.
 Shirodkar’s Sling Operation
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Shirodkar sling has following advantages:

•Anatomically it is the most correct

operation as it maintains the uterus in its
correct anatomical position.

•It provides a strong static bony support.

•No tendency to enterocele formation

 Shirodkar’s Sling Operation
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Disadvantages of the sling operation are:

 Technically very difficult to perform

 The degree of difficulty is more on the left side
where the sling has to pass through the Psoas
loop and then under the sigmoid mesentery
 There is risk of injuring the nerves passing
through the psoas muscle while making the Psoas
loop.
 Since it is a closed loop sling, should it become
tight, there is a risk of bowel obstruction.
 Purandare’s Sling Operation

Purandare cervicopexy was first described

by Dr. B. N. Purandare in 1965.

He used rectus sheath strips as sling

material. Purandare cervicopexy was later
modified by Dr. V. N. Purandare and
Pravin Mhatre; they used Mersilene tape
and attached the tape to the isthmus
posteriorly instead of anteriorly.

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 Purandare’s Sling Operation

Advantages of Purandare’s sling are:

•Technically very easy to perform
•Provides dynamic support to uterus

Disadvantages are:
•The uterus becomes retroverted
•There is a tendency to enterocele
•Since the tape is anchored to the isthmus anteriorly, it may
be damaged at subsequent cesarean section (LSCS) operation.
•Advancement of bladder on uterus may make exposure of
lower uterine segment difficult.
•Since it is a closed loop sling, should it become tight, there is
a risk of bowel loops being trapped between uterus and
anterior abdominal wall
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 Khanna’s Sling Operation
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Brigadier SD Khanna propounded this technique

for conservative treatment of nulliparous prolapse.
The principle aim of the sling is to strengthen the
cardinal ligaments. The ends of the tape are
attached to the anterior superior iliac spines.

Disadvantages are:
If the tape is very superficial, it can be very easily
felt by the patient
If skin wound gets infected, periosteitis results
which is very painful and there is a risk of the tape
getting detached.
 Virkud’s Sling Operation
Here the tape is fixed to anterior longitudinal ligament,
passed subperitoneally along right side, and then
transfixed to isthmus posteriorly at the level of the
uterosacral ligaments.

The tape is then passed between two leaves of left broad

ligament, it then pierces the transversals fascia in the
internal inguinal ring and passes medially between the
anterior rectus sheath and rectus muscle where it is
fixed to the rectus compartment.

This operation has the advantages of Shirodkar and

Purandare sling operations, and at the same time, it
avoids the disadvantages of both these operations
 Virkud’s Sling Operation

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 Virkud’s Sling Operation

Advantages are:
•Provides double support: Bony (sacral
promontory) + Dynamic (rectus sheath)
•Uterus remains anteverted
•No tendency to enterocele formation
•No risk of injury to sigmoid mesentery/colon or the
genitofemoral nerve
•No risk of bowel obstruction (open sling)
•No difficulty in subsequent LSCS: as tape is posterior

Only disadvantage is that it tends to dextrortoate the

uterus: This is the reason why it is advised to do
plication of the left uterosacral ligament.
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 Soonawala’s Sling Operation

Dr. RP Soonawala advises only a right sided

posterior sling as in Shirodkar’s sling operation
to avoid the risks of passing the sling on the
left side.

Advantages of Soonawala sling are:

No risk of bowel obstruction (open sling)
No risk of injury to sigmoid mesentery/colon
or the genitofemoral nerve

Disadvantages are:
Position of uterus may be distorted

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 Joshi’s Sling Operation
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A technique described by Dr. Vivek Joshi from Pune is

an extraperitoneal sling operation where the uterus is
suspended from the pectineal ligaments on either side
with Mersilene tape.

Advantages of Joshi sling are:

Gives good static support.
No risk of injuring the ureters, rectosigmoid, median
sacral vessels.

Disadvantages are:
Operating in the retropubic space requires experience
Risk injury to vessels in the retropubic space
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 “Rule of 11”

11% lifetime risk of POP surgery

11% risk of re-operation after primary surgery

Within next 11 years, it tends to recur at a different site

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