PELVIC ORGAN PROLAPSE

By :-
Meseret T.(RN, BScMw, MSC)
April 2013
 PELVIC ORGAN PROLAPSE
• is the descent of one or more of the genital organ
(urethra, bladder, uterus, rectum or Douglas pouch
or rectouterine pouch” and vagena) through the
fasciomuscular pelvic floor below their normal level.

• Estimates of the prevalence of symptomatic POP

range from 3 to 11 percent of women.
 Genital prolapse
• specific sites of female genital prolapse include:
1. Anterior compartment prolapse
( Anterior vaginal wall prolapse):-
a. Prolapse of the upper part of the anterior vaginal
wall with the base of the bladder is called cystocele
b. Prolapse of the lower part of the anterior vaginal
wall with the urethra is called urethrocele.
c) Complete anterior vaginal wall prolapse is called
cysto-urethrocele.
 Genital prolapse…
2. Posterior compartment prolapse –
(Posterior vaginal wall prolapse):-
a) It is called rectocele if the anterior wall of the
rectum is also prolapsed with the middle third of
the posterior vaginal wall.
b) It is called entrocele (hernia of the pouch of
Douglas) if the upper third of the posterior vaginal
wall descends lined by the peritoneum of the
Douglas pouch and containing loops of the
intestine
 Genital prolapse…
3. Apical compartment prolapse
(prolapse, vaginal vault prolapse): –
• Descent of the apex of the vagina into the
lower vagina, or beyond the vaginal
introitus. The apex can be either the
uterus and cervix, cervix alone, or vaginal
vault. Apical prolapse is often associated
with enterocele.
 Genital prolapse…
4.Procidentia — Hernia of all three
compartments through the vaginal
introitus.
 ANATOMY OF PELVIC SUPPORT
• Anatomic support of the pelvic organs in women
– is provided by an interaction between the muscles of the pelvic
floor and connective tissue attachments to the bony pelvis .
• The levator ani muscle complex, consisting of the
pubococcygeus, puborectalis and iliococcygeus muscles,
provides primary support to the pelvic organs, providing a
firm, yet elastic, base upon which the pelvic organs rest.
• The endopelvic fascial attachments, in particular
condensations of the endopelvic fascia referred to as the
uterosacral and cardinal ligaments, stabilize the pelvic
organs in the correct position so that the pelvic muscles
can provide optimal support.
 Levels of pelvic organ support
• A system of three integrated levels of vaginal
support has:-
– Level 1 – Uterosacral/cardinal ligament complex,
which suspends the uterus and upper vagina to
the sacrum and lateral pelvic side wall.
• Loss of level 1 support contributes to the prolapse of
the uterus and/or vaginal apex.
– Level 2 – Paravaginal attachments along the length
of the vagina to the superior fascia of the levator
ani muscle.
• Loss of level 2 support contributes to anterior vaginal
wall prolapse (cystocele).
 Levels of pelvic organ support …
• Level 3 – Perineal body, perineal membrane, and
superficial and deep perineal muscles, which support
the distal one third of the vagina.
– Anteriorly, loss of level 3 support can result in
urethral hypermobility.
– Posteriorly, loss of level 3 support can result in a
distal rectocele or perineal descent.
– All levels of support are connected through a
continuous supporting network of endopelvic
fascia. Defects in this network can occur at one
level or at all levels.
 II I
III

• III
Uterosacral/
• III
cardinal ligament complex • LLE LEVEL I

Levator ani LEVEL II

LEVEL III

Pubocervical fascia
Rectovaginal fascia
 Nerve supply
• The innervation of the pelvic region derives
from the S2, S3, and S4 segments of the spinal
cord, which fuse to form the pudendal nerve.
• The pudendal nerve innervates the external
anal sphincter, whereas the levators,
coccygeus muscles, and urogenital diaphragm
appear to be innervated by a direct
connection of S2, S3, and S4 nerve fibers .
 RISK FACTORS for POP
Established risk factors for POP include parity,
advancing age, and obesity.
1. Parity —
• The risk of POP increases with increasing parity.
compared with nulliparity, the risk of hospital
admission for POP increased markedly after the first
(4-fold) and second birth (8-fold), and then increased
less rapidly for subsequent births (third: 9-fold; fourth:
10-fold).
• Among parous women, it has been estimated that 75
percent of prolapse can be attributed to pregnancy
and childbirth.
 RISK FACTORS …
2. Obstetric factors
– Vaginal delivery is associated with a higher
incidence of POP than cesarean.
3. Advancing age —
– Older women are at an increased risk for POP.
4. Obesity —
– Overweight and obese women (body mass index
>25) have a two-fold higher risk of having prolapse
than other women. While weight gain is a risk
factor for developing prolapse, it is controversial
whether weight loss results in prolapse regression.
 RISK FACTORS …
5. Hysterectomy
– Hysterectomy is associated with an increased risk of
apical prolapse.
* Vault prolapse is more likely to occur after subtotal
than after total hysterectomy.
6. Other risk factors —
– Chronic constipation is a risk factor for POP, likely due
to repetitive increases in intraabdominal pressure.
– Some connective tissue disorders (eg, Ehlers-Danlos
syndrome) or congenital abnormalities (eg, bladder
exstrophy) contribute to POP . There are few data
regarding a genetic component of prolapse.
 CLINICAL MANIFESTATIONS
• This depends on the types and the severity
of the prolapse.
• Generally, most women are not aware of
the presence of mild prolapse.
• When prolapse is moderate or severe,
symptoms may include sensation of a lump
inside the vagina or disturbance in the
function of the affected organs, such as:
 Bladder
• stress incontinence
• urgency
• frequency
• incomplete emptying
• dribbling
• recurrent urine infections
 Bowel
• low back pain or discomfort
• incomplete emptying
• constipation
• manual decompression
• incontinence of flatus
 Sexual problems
• looseness and lack of sensation
• difficult entry and expulsion
• discomfort or painful intercourse
• vaginal bleeding in neglected cases
 Other
• can see and feel it
• back ache
• dragging sensation
• increased discharge
• skin irritation
 CLINICAL MANIFESTATIONS …
• Symptoms are often related to position;
• they are often less noticeable in the morning
or while supine and worsen as the day
progresses.
DIAGNOSIS AND CLASSIFICATION
• POP is diagnosed using
– pelvic examination.
– A medical history - prolapse-associated symptoms.
 Pelvic examination
• Patient positioning —
– The examination is performed in each position with the
woman relaxed and then straining (to demonstrate the
maximum degree of prolapse).
– The patient is examined initially in the dorsal lithotomy
position. The examination is then repeated with the
patient standing.
– In the standing position, the patient places one foot on
a well-supported footstool. The examining gown is
lifted slightly to expose the genital area during the
examination.
 VISUAL INSPECTION
• visual inspection of the vulvar, perineal, and perianal
areas with the patient in the dorsal lithotomy position.
• should be performed initially with the patient relaxed
and then while straining.
• Findings that should be noted during this component of
the examination include:-
– Transverse diameter of the genital hiatus (eg, the space
between the labia majora)
– Protrusion of the vaginal walls or cervix to or beyond the
introitus (procidentia)
– Length and condition of the perineum
– Rectal prolapsed
– In patients with prolapse examined for ulceration.
 SPECULUM AND BIMANUAL
EXAMINATION
• The speculum and bimanual examinations are
the principal components used to evaluate
POP.
• Prolapse of each anatomic compartment is
evaluated as follows:
– Apical prolapse (prolapse of the cervix or vaginal
vault) –
• A bivalve speculum is inserted into the vagina and then
slowly withdrawn; any descent of the apex is noted.
 SPECULUM AND BIMANUAL…
– Anterior vaginal wall – A Sims retractor or the
posterior blade of a bivalve speculum is inserted
into the vagina with gentle pressure on the
posterior vaginal wall to isolate visualization of the
anterior vaginal wall.
– Posterior vaginal wall – A Sims retractor or the
posterior blade of a bivalve speculum into the
vagina with gentle pressure on the anterior
vaginal wall to isolate visualization of the posterior
vaginal wall.
 RECTOVAGINAL EXAMINATION
• A rectovaginal examination is performed to:
– Diagnose an enterocele
– Differentiate between a high rectocele and an enterocele
– Assess the integrity of the perineal body
– Detect rectal prolapse
– The best method for detecting an enterocele is to perform
the rectovaginal exam with the patient standing; the small
bowel can be palpated in the cul-de-sac between thumb
and forefinger
 UTEROVAGINAL PROLAPSE

-Is measured in relation to the degree of prolapse of the

cervix below the level of the ischial spines.
Grades:-
G-I. descent of the cervix below the ischial spines as
far as, but not beyond the introitus.
G-II. Descent of the cervix beyond the introitus(but not
all uterus, the fundus is Inside.
G- III. The whole uterus is outside the introitus
G-IV. complete eversion, not replaced manually,
keratinized, edematous, Infected some times and is
called prosidentia.
1st degree-2nd degree-3rd degree uterine prolapse
 APPROACH TO MANAGEMENT

• Indications for treatment —

– symptoms of prolapse or associated conditions
(urinary, bowel, or sexual dysfunction). Obstructed
urination or defecation or hydronephrosis from
chronic ureteral kinking are all indications for
treatment, regardless of degree of prolapse.
• Management options —
– Women with symptomatic prolapse can be managed
expectantly, or treated with surgical therapy.
• The choice of therapy depends upon the patient’s
preferences, as well as the ability to comply with
conservative therapy or tolerate surgery.
• Vaginal pessary -non-surgical treatment for
POP.
• Pessaries are silicone devices in a variety of
shapes and sizes, which support the pelvic
organs.
• Vaginal Pessaries - many choices but regular
checks and changes needed and best
combined with oestragen creams
• Pelvic floor muscle exercises — (PFME)
appear to result in improvements in POP stage
and POP-associated symptoms.
 What are pelvic muscle exercises?
• Pelvic muscle exercises are exercises that strengthen the
muscles that control the flow of urine and bowel movements.
These exercises are also known as “Kegel” exercises.
Patent information
• A woman might learn to do Kegel exercises by:1st need to learn
which muscles to tighten. It is sometimes hard to figure out the
right muscles.
• Putting a finger inside her vagina and squeezing the muscles
around her finger;
• A man might learn to do Kegels by tightening his butt muscles as
if he were holding back gas.
• do the exercises— 2 to 3 times a day, every day. Each time, flex
your muscles about 10 times, and hold them tight for a few
seconds each time tighten. Keep up this routine for at least 4 or 5
months.
 Surgical management

• goal
– To relieve symptoms
– Restoring anatomic position
– Allowing satisfactory coital function
– Obtain durable result
• Indications
– Age/menopause/
– For definitive correction
– Presence of genuine stress incontinence
– No future fertility
• These include
– Anterior colporraphy(cystocele)
– Posterior colporraphy(rectocele)
– Vaginal hysterectomy + Anterior / posterior
colporraphy(UVP)
– Manchester’s operation- is amputation of the cervix
and approximation of the cardinal ligaments in front of
the cervix + Anterior colporraphy
– Vento suspension is suspending round ligament to
abdominal wall facia and is done for patients who need
future fertility.
– Lefort’s partial colpocleisis is a partial suturing of
anterior and posterior vaginal walls together.
 Prevention ??
• Reading assignment