Notes:

OUTLINE o Why? Esp. post menopausal px due to

decrease estrogen (responsible for muscle
I. Pelvic Organ Prolapse elasticity) production (decrease normal
II. Pathophysiology-Multifactorial function of ovaries)
• Multifactorial
III. Anterior Vaginal Wall Prolapse • Patient may or may not have symptoms.
IV. Pelvic Organ Prolapse → For mild cases, patients do not have symptoms
• Treatment maybe medical, lifestyle modification,
V. Posterior Vaginal Wall Prolapse use of intravaginal devices or surgical.
VI. Enterocele
ANATOMY
VII. Uterine Prolapse (Descensus
Procidentia)
VIII. Vaginal Wall Prolapse

OBJECTIVES OF THE LECTURE

• To define what is pelvic floor disorder.

• What is pelvic organ prolapse (POP)?
• What causes POP?
• What are the symptoms of POP?
• How is POP diagnosed?
• How is POP treated?
• Can POP be prevented?

PELVIC ORGAN PROLAPSE

WHAT IS PELVIC ORGAN PROLAPSE?
• Pelvic organ prolapse or POP occurs when the
tissue and muscles of the pelvic floor and its • This is the cross-sectional view of the pelvis. The
connective tissues can no longer support the pelvic left side is the posterior side while the right side is
organs resulting in the drop (prolapse) of the pelvic the anterior side.
organs from its normal position. • From the opening of the urethra it is connected to
• From the word Prolapse – weakness of pelvic floor the urinary bladder. The vagina is connected to the
or female genital tract cervix and uterus. Behind it, is the rectum and the
• Organs include: coccyx.
→ Uterus • Anteriorly, the vagina supports the base of the
→ Cervix bladder and urethra. The rectum is located
→ Vagina posterior to the vagina behind the rectovaginal
→ Urinary bladder septum superiorly, and the perineal body is fused
→ Urethra with the vaginal muscularis inferiorly.
→ Rectum
→ Small Bowel
• Common with aging population

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 Notes:

PATHOPHYSIOLOGY-MULTIFACTORIAL RISK FACTORS FOR DEVELOPMENT OF

• Weakening of the pelvic support connective tissue PEVIC ORGAN PROLAPSE
and muscles weather by actual break or tear, or by • Vaginal childbirth (most important factor)
neuromuscular dysfunction or both. • Aging
→ most common cause. • Obesity
• Endopelvic connective tissue • Diabetes
• Pelvic Diaphragm o Neuro deficit
→ Levator Ani muscles • Genetic conditions/ connective tissue disorders
→ Coccygeus Muscles o Ehler danlos syndrome (EDS)
• Muscular Support o Provides basal tonicity and • Neurologic injury
support to the pelvic structures, pulls the rectum o Trauma, accident
(upward), vagina and the urethra anteriorly toward
the pubis (inward). POSSIBLE ASSOCIATION WITH PELVIC
ORGAN PROLAPSE
GENERAL ANATOMY OF THE FEMALE PELVIC • Prior pelvic surgery
FLOOR (SIDE VIEW) • Hysterectomy
• Constipation
• Irritable bowel syndrome
• Episiotomy
• Higher weight of the largest infant delivered
vaginally
• Chronic cough and respiratory diseases
• Exercise
• Heavy lifting
• Lower education
• Respiratory
• Anything that increase intra abdominal pressure –
increase prolapse

• The pelvic diaphragm supports the 3 structures

(bladder, uterus, rectum) to keep them stable.

ADDITIONAL NOTES
PELVIC FLOOR MUSCLES (PPD)
• Pelvic Diaphragm
→ Levator ani
▪ Pubococcygeus
▪ Iliococcygeus
▪ Puborectalis
→ Coccygeus
• Perineal membrane
• Deep perineal pouch

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 Notes:

SUPPORT SYSTEM FOR THE UTERUS AND

VAGINA
Comprehensive Gynecology
• Level I (suspension) and level II (attachment)
support of the vagina.
• In level I the paracolpium (uterosacral ligaments)
suspends the vagina from the lateral pelvic walls.
Fibers of level I extend both vertically and
posteriorly toward the sacrum.
• In level II support the vagina is attached to the
arcus tendineus fasciae pelvis and superior fascia
of the levator ani by condensations of the levator
fascia (e.g., endopelvic and pubocervical fascia).
• In level III support the vaginal wall is attached
directly to adjacent structures without intervening • From the top: you can see the connections of the
paracolpium (i.e., urethra anteriorly, perineal body muscles.
posteriorly, and levator ani muscles laterally). → Coccyx to pubic bone- levator ani muscles composed
of:
Berek & Novak’s ▪ pubococcygeus
▪ ilococcygeus
• The support system for the uterus and vagina has → Coccyx to ischial spine
been described as consisting of three levels. ▪ coccygeus
→ Urethra and anterior vagina lie within the
Level of Components
pubococcygeus muscle
Support

Vaginal apex ▪ Uterosacral Ligament

& Cervix ▪ Cardinal Ligament
I ▪ Connective tissue

Middle vagina ▪ Arcus tendinous

fascia and its
II connective tissues
Inferior vagina ▪ Perineal membrane
and muscles
III ▪ Endopelvic
connective tissues
▪ Urogenital
diaphragm
• From behind
Endopelvic fascia → Superficial transverse perineal muscle – high
tendency to be cut during episiotomy
▪ Collective term for the connective tissues
surrounding the vagina.
Q & A
• What is the problem in this picture?

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Notes:

Anterior Wall ▪ Cystocele

Prolapse ▪ Urethrocele
▪ Paravaginal Defect
Posterior Wall ▪ Rectocele
Prolapse ▪ Enterocele

Uterine and
Cervical Prolapse

Vaginal Vault
Prolapse

Types of Pelvic Floor Prolapse

• Red: Anterior wall prolapse

→ Cystocele is descent of the urinary bladder with the
anterior vaginal wall.
→ Usually occur when the pubocervical
musculoconnective tissue weakens midline or
detaches from its lateral or superior connecting points.
• Green: Posterior wall prolapse
→ Rectocele is a protrusion of the rectum into the vaginal
lumen resulting from weakness in the muscular wall of • Cystocele – ang bladder nanaog na
the rectum and the paravaginal musculoconnective
tissue, which holds the rectum in place posteriorly.

MODEL FOR THE DEVELOPMENT OF PELVIC

FLOOR DYSFUNCTION IN WOMEN

• Uterine prolapse – uterus na weaken na

• Rectocele – naka abot na sa dalom
ANTERIOR VAGINAL WALL PROLAPSE
• Loss of anterior vaginal wall support (connective
tissue and muscles) is the most common site of
primary POP (pelvic organ prolapse)

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Notes:

Cystocele Bladder protrudes or GENERAL SYMPTOM ASSESSMENT

descends with anterior wall 1. Vaginal heaviness
relaxation.
(more common) 2. Vaginal pressure
Enterocele Protrusion of small intestine
into the anterior wall 3. Vaginal bulge
weakness. 4. Pelvic pain
(seldom seen)
Urethrocele Descent of the urethra 5. Vaginal bleeding
through the defect.
6. Urinary symptoms
Rectocele Prolapse of rectum due to
7. Bowel symptoms
posterior wall defect.
(also common) 8. Sexual symptoms

SIGNS AND SYMPTOMS

• Urinary Symptoms – common
→ Urinary incontinence
→ Slow urinary stream
→ Incomplete bladder emptying
→ Urinary urgency
• Soft bulging mass of the anterior vaginal wall
→ Strain, cough, or prolonged standing often
accentuates the bulge Strain, cough, or prolonged
standing often accentuates the bulge.
• Sex related discomfort
→ Dyspareunia
• Often POP symptoms are less bothersome in the
morning and worsen later in the day after upright
• Posterior enterocele without eversion.
activities.
o Pouch of douglas herniation
• Anterior pelvic floor weakness
→ Cystocele

PELVIC ORGAN PROLAPSE SYMPTOM

CATEGORIES FOR CLINICAL EVALUATION

LOWER URINARY TRACT SYMPTOMS

• Urinary incontinence
• Frequency, urgency, nocturia
• Voiding difficulty
→ slow stream, incomplete emptying, obstruction
• Procidentia of the uterus and vagina. • Urinary splinting
o Total uterine prolapse – uterine descensia;
ara na sa gwa ang uterus BOWEL SYMPTOMS
o Common – home delivery
• Constipation

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Notes:

• Straining From Hiliusa:

• Incomplete evacuation
• Bowel splinting
• Anal incontinence

SEXUAL SYMPTOMS
• Interference with sexual activity
• Dyspareunia
• Decreased sexual desire

OTHER SYMPTOMS
• Pelvic pressure, heaviness, pain
• Presence of vaginal bulge or mass
• Lower back pain
• Tampon not retained
• Quality of life impacts

DIAGNOSIS
• Perform complete hx taking and pe
o When, possible factors, diin kag pano sia
nag bata, kapila na sia mag bata,
occupation
• PE – careful in diagnosing the prolapse
• POP is best diagnosed and examine while patient
is straining.
• Examine both the anterior and posterior prolapse.
• Palpate and examine the bladder and bladder neck
and note whether it is well supported.
→ Generally, if the supports of the bladder neck are
adequate, the urethra is adequately supported.
→ If a cystocele and urethrocele are present, it invariably
follows that the bladder neck is not supported.
• Perform POP – Q if possible
• Visual Inspection for presence of ulceration and
bleeding
• Bimanual Examination
→ Test the strength of muscles (Pelvic floor muscle bulk,
symmetry, and function)

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Notes:

• Be familiar with landmarks kay ga gwa sa exam • Aa is 3cm from the hymen, the point of
measurement of measuring the POP-Q is the
hymen
• Hymen is 0
• Above the hymen is +3 is the Aa
• C is the point of where the cervix is

STEPS ON HOW TO PERFORM POP -Q TEST

Step 1: Pre procedure considerations
• Empty bladder and rectum
• Standing or Lithotomy position
PELVIC ORGAN PROLAPSE • Should indicate the position on the report

PELVIC ORGAN PROLAPSE QUANTITATIVE Step 2: Measurement – all six points plus Gh, Pb and
SYSTEM (POP -Q) TVL (Total Vaginal Length)
• It is an objective, site specific system for • Measurement is done during the maximum
describing, quantifying, and staging pelvic Valsalva or cough in relation to hymen
support. To enhance both clinical and academic • All measurement is in centimeter
communication with respect to individual patients • If the point descends to the hymen, it measures
and population of patients. (BY ICS, AUGS, as 0.
SGS). • Positive → If still above the hymen
• It was intended to take the place of terminologies • Negative → If beyond the hymen
like cystocele, rectocele, and enterocele. Despite • Note, with the exception of TVL, which is
the nomenclature's ability to identify which organs measured when resting, all measures are taken
are prolapsing, we were unable to determine how while performing a Valsalva maneuver or cough.
much or where the prolapse is occurring.
Step 3: Recording the Measurements
PELVIC ORGAN PROLAPSE
QUANTIFICATIONS SYSTEM (POP -Q)
• It is a system use to assess the degree of
prolapse of pelvic organs to help standardize
diagnosing, comparing, documenting and
sharing of
clinical
findings.
• Six
defined
points in
the vagina
are Step 4: Staging of the prolapse
identified:

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Notes:

• Sample B: Posterior wall defect because the Bp and

Ap is the one outside while the anterior wall is intact.

Sample A: +3 below the hymen ang Aa, in here the point

Aa and Ba is already outside the canal. The Ba is +6. The
cervix is -2 which is decreased. The Gh and Pb is also • Same point system measurement but the
decreased. The posterior vaginal canal is almost normal. description of the drawing is different. In the first
This is an example of an anterior wall defect. figure the posterior wall is normal while the anterior
wall is bulging (anterior wall prolapse).
• Second stage anterior wall prolapse

• Figure B is an example of a posterior wall

prolapse but is still within the hymenal ring.

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Notes:

• Second stage posterior wall prolapse

• Stage 1 and 2 is still at the vaginal canal. Stage 3

ga gwa na pero partly ara pman sa sulod.
• Procidentia – totally prolapsed
• Stage I – minimal prolapse
• Stage II – pwede slightly above the hymen PREOPERATIVE PROLAPSE REDUCTION
• Stage IV – maglapaw >2cm na naka gwa STANDING STRESS TEST
• Evaluate Stress urinary incontinence full bladder

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Notes:

• At 300ml, patient is standing with the bladder in

normal position, and was ask to cough, is she
leaks, its positive.
• If positive the patient will likely to have latent or
occult urinary incontinence post operatively
• Before the operation, this test is administered to
patients who will have prolapse repair or
reconstruction surgery.
• If the test is positive, the surgeon will be able to note
that the patient may still have stress urinary
continence.

TREATMENT OF PROLAPSE
• The choice of treatment for genital prolapse
depends on several factors including
• The type and degree of prolapse.
OPERATIVE REPAIR
→ The type and degree of prolapse.
• specific to the site of problem
→ Her desire to preserve coital function
→ Her desire to preserve fertility. Anterior Colporrhaphy
→ The patient’s acceptance for surgical treatment
• anterior wall repair
→ Her level of fitness for a surgical approach
• accomplished via plication of the anterior wall's
• Treatment option is divided into:
connective tissue and fibromuscular fascia
→ Conservative
→ Surgical Posterior Colporrhaphy
• posterior wall repair
BEHAVIORAL TREATMENTS
• Physical therapy Colposcopy
→ designed to strengthen Pelvic Floor Muscles Kegel • done after surgery to assess bladder and urethral
Exercise integrity
• Behavioral Modification
• Refrain from lifting heavy objects, bawal na mag jog Hysterectomy
• removal of the uterus
MECHANICAL TREATMENT
• Pessary Insertion (inserted into the vaginal canal to Perineorrhaphy
prevent prolapse) • repair to rebuild the perineal body
• Radiofrequency stimulation – may nasulod sa • Anterior wall prolapse are defects from Level I and
vagina then introduce pila ka radiofrequency para or Level II support
mag tone ang vaginal canal
→ Lateral Breaks – Paravaginal Defects
• Pressary – prevent uterus from collapsing
→ Distal Breaks near the symphysis pubis
o For bedridden, damo comorbidities, elderly
na indi na mayo ka function

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Notes:

→ Urethrocele and Urethral Hypermobility, or Kinking. • Sexual activity disruption

• Constipation and difficulty in bowel movement
• Rectocele or enterocele

DIAGNOSIS
• Descent of the posterior vaginal wall (one or both)
→ Enterocele - small bowel
→ Rectocele - rectum
• Physical examination with patient straining
• Rectovaginal examination, POP –Q

MANAGEMENT
NON- OPERATIVE
• Pessaries
• Kegel Exercise
• Estrogen
• Lifestyle modification
→ Usually for stage I and II, we don’t encourage surgical
repair, only lifestyle modification or sometimes
Pessary.

OPERATIVE
• Posterior colporrhaphy- site specific repair
• Perineorrhaphy- Repair to build perineal body

• Perineorrhaphy. Following the completion of the

POSTERIOR VAGINAL WALL PROLAPSE repair of the rectocele, the perineal body may need
SIGNS AND SYMPTOMS to be reconstructed. The bulbospongiosus and the
superficial transverse peroneus muscles are
• Pelvic Pressure
plicated in the midline with absorbable sutures.
→ a falling out feeling, a bulge in the vagina
→ Hiliusa: Protrusion of the prolapse may worsen later in
the day and be aggravated by prolonged standing or Perineorrhaphy (Posterior repair)
exertion

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Notes:

• The surgeon should estimate the degree or the

extent of damage and the area to repair
• Hymen should be use as landmark
• The vaginal epithelium is separated from the
underlying fibromuscular epithelium using a scalpel
laterally and proximally towards the apex of the
vagina above the limit of rectocele.
• Site specific repair
• Repair is done layer by layer
• Success rate
→ 96% for posterior colporrhaphy
→ 89% for site specific repair

ENTEROCELE
• Herniation in the Pouch of Douglas (Posterior Cul-
de-Sac)
• Between the uterosacral ligaments into the
rectovaginal septum containing the small bowel
• Usually follows after abdominal surgery or Vaginal
Hysterectomy weakness or loss of support by
apical uterosacral ligaments
• May be a separate bulge above the rectocele
• May be diagnosed by trans-illuminating the bulge
• Upper left: Enterocele and uterine prolapse
and seeing small bowel shadow within the sac
• Upper right: Elderly patient with stage IV apical
• Prolapse of small bowel
eversion and enterocele with vaginal ulcers.
• Also called true herniation of Pouch of douglas (at
• Lower left: Sagittal imaging though the midline of
the back of uterus)
the pelvis in a female patient during magnetic
• Weakness of posterior wall will create enterocele resonance imaging proctography. A loop of small
bowel has descended anterior to the rectum to
SURGICAL REPAIR form a large enterocele (black arrows). Note the
MCCALL STITCH OR MACCALL coexistent cystocele (white arrows) and small
CULDOPLASTY collapsed rectocele (arrowhead).
• Repair of enterocele by attaching the apex of the • Lower right: Enterocele with Vaginal Apical
vagina attached to its respective uterosacral Prolapse. Split speculum exam and digital exam
ligaments. Obliterating it will shorten the cul de sac with palpation of bowel in the sac helped define
and supporting the entercele neck. this defect
• From the word “plasty” meaning there’s no cutting, • common - ulceration
only repair
• Apex of posteriovaginal canal will be stitched to UTERINE PROLAPSE (DESCENSUS PROCIDENTIA)
uterosacral ligaments above para indi manaog and • Prolapse of the uterus and cervix through the barrel
gin pakipot imo nga posterior fornix or pouch of of the vagina.
douglas. Gin saradhan kag gin balabagan sang • All supporting structures including cardinal and
stitch so it won’t go down uterosacral ligaments
• Levator ani and pelvic floor weakness
• Total prolapse
• Bilog mo nga uterus nag gwa sa dalom.

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 Notes:

• There is weakness in 3 layers gid. All 3 levels of repair, ga butang sila mesh to prevent further
support nag prolapse tanan. prolapse

SIGNS AND SYMPTOMS

Sacrohysteropexy
• Pelvic pressure, heaviness, fullness, bulge or
• fixed prolapse of the uterus, using a mesh
falling out in the perineal area
• Success rate for reconstructive and mesh surgeries
• Mass or protrusion into the vaginal canal
is between 80-90%.
• Discharges, pain, bleeding
• Recovery takes about 6 weeks or more for
→ due to secondary infection or ulceration because of abdominal surgeries.
exposure sa sagwa
• Post-surgical complications – pain during sex,
pelvic pain, urinary incontinence.
MANAGEMENT
NON -SURGICAL Manchester (Donald or Forthergill) operation
• Pelvic floor muscle strengthening • Combination of anterior and posterior colporrhaphy
• Pessary – for women who are poor surgical risk, with amputation of cervix and use of cardinal
planning for another pregnancy ligaments to support anterior vaginal wall and
→ Ring pessary – are the most commonly used. bladder.
• Not 100% effective • Use if there is a combined cystocele and rectocele,
• Can help but not restore with intact uterine support.
o Bedridden etc… • Operation has advantage to elderly because it is
easier and shorter to perform.
SURGICAL • Gin utod mo ang cervix kag ang vaginal canal na
(OBLITERATIVE OR RECONSTRUCTIVE) lang gn attach mo sa cardinal ligament.
• Transabdominal or transvaginal repair • Steps of operation:
• Vaginal hysterectomy with vault suspension to the → A. D and C
uterosacral or sacrospinous ligaments. → B. Amputation of the cervix
• Abdominal supracervical hysterectomy with → C. Plication of Mackenrodt’s Ligaments (Cardinal) in
sacrocolpopexy and colpocleisis front of the vagina
• Vaginal hysterectomy in general had better ▪ Attach the cardinal ligament in front of the cervix sa
outcome. imo nga gn cut na area in front of the vagina.
• Same with other prolapse. 1st and 2nd degree we → D. Anterior Colporrhaphy
don’t mind. We just prescribe behavioral
management and exercise. For stage 3 and 4, we
encourage px to undergo surgical repair.

Sacrocolpopexy
• these procedure uses surgical mesh to fix and
anchor the prolapsed vaginal vault to the
sacrospinous ligament (uterosacral ligament)
• In post hysterectomy woman
• kay wala ka man da inug kwaon. Remember,
hysterectomy is not the end point. Sometimes, a px
after hysterectomy will still go into prolapse. Once
may prolapse after surgery, wala kana tissue inug

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 Notes:

→ E. Colpoperineorrhaphy

• So the cardinal ligament is located on the lateral

side of the cervix, both right and left.
▪ Removal of triangular tissue starting at the vaginal
• You cut the entire cervix. Ang vaginal canal ang
scar at the base of the triangle 1 cm above the
mabilin. Then your anterior portion or apex of the
vaginal scar, the apex is just beneath the bladder
vaginal canal is sutured to the cardinal ligament.
neck.
Because originally imo cardinal ligament naga
▪ This works well with small prolapse while le fort
attach sa cervix. So because you cut the cervix, imo
works with larger ones.
canal na shorten mo and attach sa ligament.
▪ Prognosis is usually excellent 91-100%.
▪ Simpler compare to classic
Colpocleisis
• Obliteration of the vaginal canal – usually done in
elderly, who are no longer sexually active and
medically compromised.
• Example:
→ A. Le Fort Procedure
▪ classic partial colpocleisis
▪ Removal of rectangular strip of anterior and
posterior wall. With or without the uterus. Only a
small canal on either side of the vagina is left to
allow drainage of fluid.
▪ Makwa ka d rectangular tissue sa anterior and
posterior and suture from anterior dason magwa sa
cervix, to the posterior dason masara.ibutongan
mo pra magsulod or push in. then leave a little hole
open pra may drainage. Siradhan mo lg pra ang
prolapse ara lg sa sulod, ndi na mgwa. Para lg ni A. Representation of vaginal incision on anterior and
sa mga tigulang. posterior wall.
B. Early placement of sutures
→ B. Goodall-Power modification C. Later placement of sutures.
▪ Modification of Le fort operation.

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 Notes:

D. Vaginal incision completely closed; perineorrhaphy • Pelvic organ prolapse is defined as the descent of
being performed. one or more compartments of the vagina: the
E. Appearance at completion of procedure. Repair of anterior vaginal wall, posterior vaginal wall, uterus
Rectocele (cervix), or apex (vaginal vault or cuff scar after
hysterectomy).
• Pelvic organ prolapse is more likely to be
A. Placement of Allis clamps at margins of perineal symptomatic when the leading edge protrudes past
incision; perineal incision is being made. the hymen; it can be managed expectantly if
B. Reflected vaginal epithelium with rectum bulging. asymptomatic.
C. Depression of rectum identifying margins of levator ani
• Renal function should be evaluated in women with
muscle.
advanced pelvic organ prolapse if the patient
D. Placement of sutures in perirectal tissue and levator ani
declines treatment to reduce the prolapse.
bundles.
• Vaginal delivery is a major risk factor for the
development of pelvic organ prolapse.
VAGINAL WALL PROLAPSE
• The cardinal and uterosacral ligaments hold the
• Apical prolapse after hysterectomy
uterus and upper vagina in the proper location.
• 0.1-18.2 % rate
• Pessaries should be offered to all women with
• 5% on post-hysterectomy POP
symptomatic pelvic organ prolapse.
• POP-Q test utilize for diagnosis
• Pelvic organ prolapse often includes a mixture of
• Rectovaginal examination is helpful. anterior, posterior, and apical prolapse, and each
compartment should be evaluated under strain
MANAGEMENT prior to determining the appropriate operative
• Non-surgical treatment.
• Surgical – 3 guiding principles • Surgery for pelvic organ prolapse is usually
→ Normal position of the vagina while in standing effective at decreasing a vaginal bulge, but the
position against the rectum is no more than 30 effects on urinary, bowel, and sexual function can
degrees from the horizontal plane. vary. It is important to elicit a patient’s goals before
→ Pelvic relaxation is part of the problem. surgery.
→ Acknowledges that the perineal body is almost always • Vaginal vault prolapse can be repaired abdominally
severely damage. or vaginally. An abdominal sacral colpopexy with
synthetic mesh appears to have a higher long-term
SACROSPINOUS LIGAMENT SUSPENSION success rate for the vaginal apex, but at the risk of
(UTEROSACRAL) more surgical complications.
• The apex of the vagina is anchored to the
LEGENDS
sacrospinous ligament.
• The incision is deep and tight. Red – Doc’s Verbatim
• Avoid pudendal nerve injury, inferior gluteal arteries Purple – Past Trans (Batch CAM)
and sciatic nerve.
REFERENCES
KEYPOINTS: • William's Obstetrics (26th Edition)
• In the female, large hernias, hernias that • Batch CAM Trans (2022)
continuously have intraabdominal contents, • Dr. Rivera’s PPT (2024)
hernias that cause continuing discomfort, and • Trans Group Audio Recordings (2024)
hernias that have been incarcerated should be
operatively repaired.

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