PELIVIC ORGAN PROLAPSE

Symptoms from pelvic organ prolapse

• Pelvic organ prolapse can cause symptoms directly due to the • Pa7ents may experience vaginal bleeding from a prolapse that is
prolapsed organ or indirectly due to organ dysfunc7on external and becomes ulcerated or abraded, but in women with
secondary to displacement from the anatomical posi7on. a uterus, one must remember to exclude endometrial carcinoma
• Prolapse symptoms include a sensa7on of vaginal bulge, by biopsy and ultrasound.
heaviness or a visible protrusion at or beyond the introitus. • Risk factors predisposing to prolapse are very much similar to
Pa7ents may also describe lower abdominal or back pain, or a those predisposing to stress incon7nence. Research has shown
dragging discomfort relieved by lying or si=ng. the pudendal nerves to be damaged aGer childbirth, with
• Indirect symptoms will depend on which other organs are increased nerve conduc7on 7mes, and ultrasound studies of the
involved in the prolapse but may include difficulty in voiding pelvic anatomy of women with prolapse have demonstrated
urine or emptying the bowel (termed obstruc7ve defaeca7on), thinning or avulsion of the puborectalis muscle from its inser7on
and sensa7ons of incomplete emptying of bladder or rectum. on the pubic ramus, on either one or both sides in a high
• Pa7ents may have to support or reduce the prolapse with their propor7on of cases.
fingers to be able to void or evacuate stool completely (termed
digita7on, dis7nct from manual evacua7on of the rectum).
• Urinary or faecal incon7nence may also be present.
• It is important to ask about sexual ac7vity, even in the older
pa7ent, and to enquire about difficulty achieving penetra7on,
pain or discomfort during intercourse and loss of sensa7on and
difficulty achieving orgasm due to vaginal or introital laxity.

Fascial supports of the pelvic organs.

• Level 1 support is provided by the uterosacral ligaments, suspending the uterus and a<ached vaginal vault.
• Level 2 (midvagina) support is provided by the fascia lying between the vagina and the bladder or rectum that fuses laterally and
runs to a<ach on the pelvic side wall.
• Level 3 support is provided by the perineal body, which has the posterior vaginal fascia fused to its upper surface.
Relevant anatomy

• Uterovaginal prolapse is caused by failure of the interac7on (ii) Level 2 support

between the levator ani muscles and the ligaments and fascia - Provided by the fascia that surrounds the vagina, both
that support the pelvic organs. anteriorly and posteriorly, lying between the vagina and
• The levator ani muscles are puborectalis, pubococcygeus and the bladder (pubocervical fascia) or rectum (rectovaginal
iliococcygeus. They are aIached on each side of the pelvic side fascia).
wall from the pubic ramus anteriorly (pubococcygeus), over the - These fascial sheets fuse together at the vaginal edge and
obturator internus fascia to the ischial spine to form a bowl- then are aIached to the pelvic side wall, fusing to the
shaped muscle filling the pelvic outlet and suppor7ng the pelvic fascia overlying obturator internus.
organs. - These fascial aIachments result in the vagina lying as a
• There is a gap between the fibres of the puborectalis on each flaIened tube (laterally) at rest.
side to allow passage of the urethra, vagina and rectum, called - Defects in the fascia providing level 2 support will lead to
the urogenital hiatus. prolapse of the vaginal wall into the vaginal lumen
• The levator muscles support the pelvic organs and prevent (causing anterior or posterior vaginal prolapse).
excessive loading of the ligaments and fascia. - The bladder or rectum will prolapse behind the vaginal
• There are three levels of suppor7ng ligaments and fascia, which wall due to the fascial aIachment to it.
work together to provide a global and dynamic system to - On examina7on, the affected vaginal wall will be seen
support the uterus, vagina and associated organs. bulging into the vagina.
(i) Level 1 (apical) support: (iii) Level 3 support
- Provided by the uterosacral ligaments, which aIach - Provided by the fascia of the posterior vagina, which is
the cervix to the sacrum. aIached at its caudal end to the perineal body.
- Obviously, support at this level is crucial in - The perineal body is a dense connec7ve 7ssue mass
contribu7ng to support of the vaginal walls that are underneath the lower third of the posterior vaginal wall
aIached to the cervix. and is the inser7on of the posterior vaginal fascia, fibres
- Defects in level 1 support can be seen on examina7on of levator ani and the transverse perineal muscles.
by the descent of the uterus within the vagina. - It is the perineal body that is torn or cut (by episiotomy)
- Level 1 support remains cri7cal even aGer during childbirth.
hysterectomy, so it is important during that procedure - Defects of the perineal body usually cause the
to reaIach the uterosacral ligaments to the vaginal development of lower posterior vaginal wall prolapse, but
vault. the loss of the perineal body increases the size of vaginal
- In women who have previously undergone opening and therefore predisposes to anterior vaginal
hysterectomy, level 1 support defects will manifest as prolapse as well.
vaginal vault prolapse.
Clinical assessment of prolapse

• The history should elicit the presen7ng symptom(s) and severity, • In women who have undergone hysterectomy, the vaginal vault
and include ques7ons to ascertain if the pa7ent has any can prolapse.
coexis7ng urinary, faecal or sexual symptoms as discussed above • Vaginal prolapse of the anterior vagina (the anterior
for the incon7nent pa7ent. compartment) is also known as cystocele in the upper half or
• One should be sensi7ve to the emo7onal aspect of the problem, urethrocele in the lower half.
but specific ques7ons should be asked about sexual discomfort • Posterior vaginal prolapse (the posterior compartment) is also
and difficulty achieving orgasm. known as enterocele in the upper third, or rectocele below this.
• For women who are not sexually ac7ve, it should be discussed • Vaginal prolapse is formally staged using the methods
whether this is due to the prolapse symptoms or other personal men7oned above, but the most important assessment is
or social issues (e.g. health of the partner). For some women, whether the vaginal prolapse reaches to, or beyond, the hymen.
intercourse is avoided because of anxie7es or embarrassment Finally, it is important to assess whether the perineal body is
over the appearance of the genitalia and a loss of perceived intact or has become aIenuated, resul7ng in an enlarged vaginal
aIrac7veness. opening.
• Clinical examina7on should ideally be done in the lithotomy • For women with symptoms of pressure or vaginal bulge only,
posi7on with a Sims speculum. This allows retrac7on of the there is rarely a need to arrange any inves7ga7ons, other than
anterior and posterior vaginal wall in turn, to allow full those rela7ng to anaesthe7c preassessment.
assessment of the degree of prolapse and to assess how much • In view of the complex rela7onship between prolapse and
descent of the cervix and uterus is present. bladder or bowel func7ons, if women have addi7onal indirect
• Prolapse is described in three stages of descent, and note should symptoms, then it is prudent to arrange urodynamic assessment
be made of whether it occurs at pa7ent straining or at rest and or func7onal tests of the lower bowel, which may include
whether trac7on has been applied: endoanal ultrasound to check for anal a sphincter defects, rectal
(i) Stage I where the prolapse does not reach the hymen. manometry, flexible sigmoidoscopy and a defaeca7ng
(ii) Stage II where the prolapse reaches the hymen. proctogram.
(iii) Stage III when the prolapse is mostly or wholly outside the • Ideally, such pa7ents should be reviewed with the completed
hymen. When the uterus prolapses wholly outside this is inves7ga7ons in a MDT mee7ng including a gynaecologist,
termed prociden7a. colorectal surgeon, con7nence nurse and physiotherapist.
Treatment for prolapse

ConservaCve treatment Surgery for pelvic organ prolapse

• Conserva7ve treatment for prolapse includes pelvic floor muscle • Surgical treatment for prolapse is common, and can be offered if
exercises and the use of suppor7ve vaginal pessaries. conserva7ve treatments have failed or if the pa7ent chooses
• For women with urinary or bowel symptoms as well, surgery from the outset.
conserva7ve treatment for these symptoms can be commenced • The procedure chosen depends on which compartment is
at the same 7me as for the prolapse. affected, whether the woman wishes to retain her uterus and
• A course of supervised pelvic floor exercises will reduce the whether the vaginal or abdominal route of surgery is chosen.
symptoms of prolapse and for women who are keen to avoid • The essen7al principles of prolapse surgery apply for all
surgical treatment, this can be an effec7ve first step, although procedures.
there is less evidence that pelvic floor exercise will reduce the • Prolapse surgery is performed through the vagina to restore the
anatomical extent of the prolapse and it is unlikely to be helpful ligamentous 7ssue supports to the apex, anterior and posterior
for women whose prolapse is beyond the vaginal introitus. vagina (anterior repair, posterior repair) and repair of the
• An alterna7ve to this is to insert a vaginal support pessary to perineal body.
reduce the prolapse, which leads to resolu7on of many of the • The vaginal route can also be used for posthysterectomy vault
symptoms. prolapse, aIaching the vaginal vault to the right sacrospinous
• Pessary use can be very effec7ve at relieving symptoms and has ligament with non-absorbable or slowly absorbable sutures, but
the advantage of avoiding surgery and the associated risks, here an abdominal approach to perform a sacrocolpopexy is an
which can be extremely useful in the medically unfit and elderly. op7on that will provide excellent, durable long-term cure.
• Ring pessaries are usually tried first, but an intact perineal body • In the last 3–5 years, there has been an increasing number of
is necessary for these to be retained. Shelf pessaries, Gelhorn women wishing to avoid hysterectomy during prolapse surgery,
pessaries and others are useful for women with deficient so both sacrospinous fixa7on and sacrocolpopexy can be
perineal bodies. performed by aIaching a mesh or sutures to the cervix rather
• It is usual prac7ce to replace a pessary every 6 months and to than the vaginal vault.
examine the pa7ent for signs of vaginal ulcera7on, although this • Principles of prolapse surgery:
frequency is tradi7onal and not based on any evidence. - Remove/reduce the vaginal bulge.
• Complica7ons are uncommon and usually minor (bleeding, - Restore the ligament/7ssue supports to the apex, anterior
discharge), although rarely the pessary can become and posterior vagina.
incarcerated, requiring general anaesthesia to remove, and rare - Replace associated organs in their correct posi7ons.
cases of rectovaginal or vesicovaginal fistula forma7on have - Retain sufficient vaginal length and width to allow
been reported. intercourse.
• Sexual intercourse remains theore7cally possible with a well- - Restore the perineal body.
placed ring pessary, but not with the others, so would not - Correct or prevent urinary incon7nence.
generally be suitable for women who are sexually ac7ve. -
Correct or prevent faecal incon7nence.
• Mo7vated pa7ents can be taught to insert and remove their -
Correct obstructed defaeca7on.
own pessaries if they do wish to remain sexually ac7ve. • Vaginal repair using mesh improves the anatomical outcome and
reduces the risk of recurrent prolapse. However, the available
long-term data do not demonstrate a difference in symptom
relief between standard repair and mesh repair.
• Mesh repair carries the risk of later erosion and need for
removal, which is challenging surgery. Therefore, many surgeons
will only consider mesh repair for women with recurrent vaginal
prolapse, and only proceed aGer careful and full counselling of
the woman about the rela7ve benefits and poten7al risks of
surgery.