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1. Genital Prolapse
Dr. Ala’aShallalFarhan
M.B.Ch.B/F.I.C.O.G/C.A.B.O.G

2. Pelvicorganprolapse(POP)isdefinedasthedownwarddisplacementofpelvic
organsfromtheiroriginalpositionintoorbeyondthevagina.
Urogenitalprolapseoccurswhenthereisaweaknessinthesupportingstructures
ofthepelvicfloorallowingthepelvicvisceratodescendandultimatelyfallthrough
theanatomicaldefect.Whileusuallynotlifethreatening,prolapseisoften
symptomaticandisassociatedwithadeteriorationinqualityoflifeandmaybethe
causeofbladderandboweldysfunction.
POPwillaffectasubstantialnumberofwomen.Skillfulassessmentand
managementisrequiredtoensureappropriatetreatmentandimprovedoutcome.
Inappropriatetreatmentcanleavewomenworseoffthanwhentheystarted.

3. Increasedlifeexpectancyandanexpandingelderlypopulationmean
thatprolapseremainsanimportantcondition,especiallysincethe
majorityofwomenmaynowspendathirdoftheirlivesinthepost-
menopausalstate.Surgeryforurogenitalprolapseaccountsfor
approximately20percentofelectivemajorgynaecologicalsurgeryand
thisincreasesto59percentinelderlywomen.Thelifetimeriskof
havingsurgeryforprolapseis11percent;athirdoftheseprocedures
areoperationsforrecurrentprolapse.

4. Relevant anatomy
Uterovaginalprolapseiscausedbyfailureoftheinteractionbetween
thelevatoranimusclesandtheligamentsandfasciathatsupportthe
pelvicorgans.Thelevatoranimusclesarepuborectalis,pubococcygeus
andiliococcygeus.Theyareattachedoneachsideofthepelvicside
wallfromthepubicramusanteriorly(pubococcygeus),overthe
obturatorinternusfasciatotheischialspinetoformabowl-shaped
musclefillingthepelvicoutletandsupportingthepelvicorgans.There
isagapbetweenthefibersofthepuborectalisoneachsidetoallow
passageoftheurethra,vaginaandrectum,calledtheurogenitalhiatus.
Thelevatormusclessupportthepelvicorgansandpreventexcessive
loadingoftheligamentsandfascia.

5. The levatoranimuscles

6. Incidence
ThelifetimeriskofsurgeryforPOPis12–19%,withmorethan300000
womenundergoingsurgeryayearintheUSA.Approximately8%of
womenintheUKreportsymptomsofprolapse.
Onroutineexamination,lossofvaginaloruterinesupportwillbeseen
inupto30–70%ofwomenwhopresentforroutinegynecologicalcare.
However,onlyasmallproportionofthesewillreportsymptoms.Ofthis
cohort,onlyabout3–6%willhavedescentbeyondthehymenalmargin
anditisthisgroupthatwilltendtobesymptomatic.

7. EPIDEMIOLOGY
Age:
Theincidenceofurogenitalprolapseincreaseswithincreasingage,withapproximately60
percentofelderlywomenhavingsomedegreeofprolapseanduptohalfofallwomenover
theageof50yearscomplainingofsymptomaticprolapse.Inastudyofwomenwithsevere
vaginalvaultprolapsefollowinghysterectomy,60percentwereovertheageof60years.
Parity:
Urogenitalprolapseismorecommonfollowingchildbirth,althoughitmaybeasymptomatic.
Studieshaveestimatedthat50percentofparouswomenhavesomedegreeofurogenital
prolapseand,ofthese,10–20percentaresymptomatic.Only2percentofnulliparous
womenarereportedtohaveprolapse.
Race:
ProlapseisgenerallythoughttobemorecommoninCaucasianwomenandlesscommon
inwomenofAfro-Caribbeanorigin.However,astudyexaminingracialdifferencesinNorth
Americahasshownthatthismaynotbethecase,astherewaslittleracialvariationnoted,
althoughthismaysimplyreflectculturaldifferencesinreporting.

8. Themostcommonformofprolapseisthatoftheanteriorwallofthe
vagina(cystocele).Prolapseoftheposteriorwall(rectocele)isfarless
frequentandapicalprolapse(descentoftheuterusorvaginalvaultif
thepatienthashadahysterectomy)theleastcommon.
Patientscanpresentwithoneormoreoftheformsandinany
combination.

9. Anterior vaginal(compartment) wall prolapse (cystocele)

10. Posterior vaginal(compartment) wall prolapse(rectocele)

11. Apical compartment prolapse (descent of the uterus,procidentia)

12. Apical compartment prolapse(vaginal vault prolapse)

13. Classification and grading of urogenital system
Therearearangeofmethodsthathavebeendescribedto
classifyprolapse.Ofthese,thePOP‐Qmethodisthe
internationallyacceptedstandard.Ithasproveninter‐observer
andintra‐observerreliabilityandisthemostcommonlycited
systeminthemedicalliterature.
Alternatively,theBaden–WalkerHalfwayScoringSystem,which
hasfivedegrees/grades,isanothercommonlyusedPOPstaging
system.Thedegree,orgrade,ofeachprolapsedstructureis
describedindividually(e.g.grade1anteriorvaginalwallprolapse
orgrade3uterineprolapse).Thegrade/degreeisdefinedasthe
extentofprolapseforeachstructurenotedonexaminationwhile
thepatientisstraining.

14. Aetiology
Pregnancyandchildbirth:
Theincreasedincidenceofprolapseinmultiparouswomenwouldsuggest
thatpregnancyandchildbirthhaveanimportantimpactonthesupporting
functionofthepelvicfloor.Damagetothemuscularandfascialsupportsof
thepelvicfloorandchangesininnervationcontributetothedevelopmentof
prolapse.Thepelvicfloormaybedamagedduringchildbirth,causingthe
axisofthelevatormusclestobecomemoreobliqueandcreatingafunnel
thatallowstheuterus,vaginaandrectumtofallthroughtheurogenital
hiatus.Inaddition,theproportionoffasciatomusclewithinthepelvicfloor
tendstoincreasewithincreasingage,andthusoncedamagedbychildbirth,
musclemayneverregainitsfullstrength.
Mechanicalchangeswithinthepelvicfasciahavealsobeenimplicatedin
thecausationofurogenitalprolapse.Duringpregnancy,thefasciabecomes
moreelasticandthusmorelikelytofail.Thismayexplaintheincreased
incidenceofstressincontinenceobservedinpregnancyandtheincreased
incidenceofprolapsewithmultiparity.Denervationofthepelvicmusculature
hasbeenshowntooccurfollowingchildbirth,althoughgradualdenervation
hasalsobeendemonstratedinnulliparouswomenwithincreasingage.
However,theeffectsweregreatestinthosewomenwhohaddocumented
stressincontinenceorprolapse.

15. Hormonalfactors:
Theeffectsofageingandthoseofoestrogenwithdrawalatthetimeofthemenopauseareoften
difficulttoseparate.Rectusmusclefasciahasbeenshowntobecomelesselasticwith
increasingage,andlessenergyisrequiredtoproduceirreversibledamage.Furthermore,there
isalsoareductioninskincollagencontentfollowingthemenopause.Bothofthesefactorslead
toareductioninthestrengthofthepelvicconnectivetissue.
Constipation:
Chronicallyincreasedintra-abdominalpressurecausedbyrepetitivestrainingwillexacerbate
anypotentialweaknessesinthepelvicfloorandisalsoassociatedwithanincreasedriskof
prolapse.
Obesity:
Althoughobesityhasbeenlinkedtourogenitalprolapseduetoapotentialincreaseinintra-
abdominalpressure,therehasbeennogoodevidencetosupportthistheory.
Exercise:
Increasedstressplacedonthemusculatureofthepelvicfloorwillexacerbatepelvicfloordefects
andweakness,thusincreasingtheincidenceofprolapse.Consequently,heavyliftingand
exercise,aswellassportssuchasweightlifting,high-impactaerobicsandlong-distance
running,increasetheriskofurogenitalprolapse.

16. Surgery:
Pelvicsurgerymayalsohaveaneffectontheoccurrenceof
urogenitalprolapse.Continenceprocedures,whileelevatingthe
bladderneck,mayleadtodefectsinotherpelviccompartments.
AtBurchcolposuspension,thefixingofthelateralvaginal
fornicestotheipsilateralileopectinealligamentsleavesa
potentialdefectintheposteriorvaginalwallthatpredisposesto
rectoceleandenteroceleformation.
Prolapseofthevaginalvaultmaypresentfollowingeithervaginal
orabdominalhysterectomy,althoughtheincidenceislow,with
only0.5percentofwomenwhohavehadahysterectomy
requiringfurthersurgicalinterventionforvaginalvaultprolapse.

17. Clinical presentation
CLINICALSYMPTOMS:
Mostwomencomplainofafeelingofdiscomfortorheavinesswithinthepelvisinadditionto
a‘lumpcomingdown’.Symptomstendtobecomeworsewithprolongedstandingand
towardstheendoftheday.Womenmayalsocomplainofdyspareunia,difficultyininserting
tamponsandchroniclowerbackache.Incasesofthird-degreeprolapse,theremaybe
mucosalulcerationandlichenification,whichresultsinasymptomaticvaginaldischargeor
bleeding.AcystocelemaybeassociatedwithLUTSofurgencyandfrequencyofmicturition
inadditiontoasensationofincompleteemptying,whichmayberelievedbydigitally
reducingtheprolapse.RecurrentUTIsmayalsobeassociatedwithachronicurinary
residual.Whilelessthan2percentofmildcystocelesareassociatedwithureteric
obstruction,severeprolapsemayleadtohydronephrosisandchronicrenaldamage.
Between33and92percentofcasesofcompleteprocidentiaareassociatedwithsome
degreeofuretericobstruction.Arectocelemaybeassociatedwithdifficultyindefecation,
somewomencomplainingoftenesmusandhavingtodigitatetodefaecate.Bowelsymptoms
includethesensationofincompleteemptyingandtheneedtomanuallyassistdefecation.

18. Differential diagnosis
Differentialdiagnosisincludes:
1.vaginalcysts.
2.pendunculatedfibroidpolyp.
3.urethraldiverticulum.
4.chronicuterineinversion.

19. INVESTIGATION
InwomenwhoalsocomplainofconcomitantLUTS,urodynamicstudiesorapost-
micturitionbladderultrasoundshouldbeperformedinordertoexcludeachronic
residualduetoassociatedvoidingdifficulties.Insuchcases,amidstreamspecimenof
urineshouldbesentforcultureandsensitivity.Subtractedcystometry,withorwithout
videocystourethrography,willallowtheidentificationofunderlyingdetrusoroveractivity,
whichisimportanttoexcludepriortosurgicalrepair.Incasesofsignificantcystocele,
stresstestingshouldbecarriedoutbyaskingthepatienttocoughwhilestanding.Since
occulturodynamicstressincontinencemaybeunmaskedbystraighteningtheurethra
followinganteriorcolporrhaphy,thisshouldbesimulatedbytheinsertionofaring
pessaryortampontoreducethecystocele.
Ifstressincontinenceisdemonstrated,acontinenceproceduresuchas
colposuspensionorinsertionoftension-freevaginaltapemaybeamoreappropriate
procedure.Incasesofsevereprolapseinwhichtheremaybeadegreeofureteric
obstruction,itisimportanttoevaluatetheupperurinarytractwitheitherarenaltract
ultrasoundoranintravenousurogram.Althoughacystoceleitselfmayberesponsible
forirritativeurinarysymptoms,cystoscopyshouldbeperformedtoexcludeachronic
follicularorinterstitialcystitis.

20. Evaluation
PatientspresentingwithacomplaintofPOPneedtohaveacomprehensive
historytaken.Thisshouldincludeafullurinary,bowelandsexualhistory.Itis
alsoessentialtoestablishwhicharethemostworrisomesymptomsandto
clarifywhichsymptomsthepatienthopeswillbecorrected.
BecauseofthehighincidenceofasymptomaticPOP,patientspresentingto
theirpractitionerwithprimarybladderorboweldysfunctionareoftenthen
referredonformanagementoftheprolapseduetothemistakenbeliefthat
theirbladderorbowelsymptomsaretheresultoftheprolapsenoticed
duringtheroutinephysicalexamination.Treatmentoftheprolapsein
isolationwillveryoftenleadtodisappointmentwiththeoutcomesachieved.
OthersymptomsmisappropriatedtoPOParebackacheandpelvicpain
syndrome.

21. AllwomenpresentingwithsymptomsofPOPshouldhaveathorough
examination.Thisshouldbeginwithpalpationoftheabdomenbefore
proceedingtothepelvicexaminationtoexcludeanabdominalmassor
ascites.Forthepelvicexaminationthewomenshouldideallybe
examinedinthedorsallithotomypositionwithValsalva.
Thishasbeenshowntobeaseffectiveasanexaminationinthe
standingposition.Incaseswherethesymptomsdonotcorrelatewith
thephysicalfindingsitmaybeworthwhilebringingthepatientbackfor
alateafternoonclinicandtoperformtheexaminationinthestanding
position.

22. WomenaregenerallyexaminedintheleftlateralpositionusingaSims’
speculum,althoughdigitalexaminationwhenstandingallowsmoreaccurate
assessmentofthedegreeofurogenitalprolapseand,inparticular,vaginal
vaultsupport.ASim’sspeculumisusedtosystematicallyidentifyeach
componentoftheprolapse.Toassessforanteriorprolapsethebladeisused
toretracttheposteriorwallwhileinspectingthedegreeofprolapseofthe
anteriorwall.Conversely,fortheposteriorwallthebladeisusedtoretract
theanteriorwallwhileassessingthedegreeofprolapseoftheposteriorwall.
Duringthisexaminationthepositionofthecervix,orinapost‐hysterectomy
patientthevault,isdetermined.Thefinalpartoftheassessmentisa
bimanualpelvicexamination.Anabdominalexaminationshouldalsobe
performedtoexcludethepresenceofanabdominalorpelvictumourthat
mayberesponsibleforthevaginalfindings.

23. Management
Prevention:
Ingeneral,anyfactorthatleadstochronicincreasesinintra-abdominal
pressureshouldbeavoided.Consequently,careshouldbetakentoavoid
constipation,whichhasbeenimplicatedasamajorcontributingfactorto
urogenitalprolapseinWesternsociety.Inaddition,theriskofprolapsein
patientswithchronicchestpathology,suchasobstructiveairwaysdisease
andasthma,shouldbereducedbyeffectivemanagementofthese
conditions.Hormonereplacementtherapymayalsodecreasetheincidence
ofprolapse,althoughtodatetherearenostudiesthathavetestedthis
effect.MaintaininganidealBMIduringpregnancy,smallerfamilysizeand
improvementsinantenatalandintrapartumcarehavealsobeenimplicated
intheprimarypreventionofurogenitalprolapse
InfantbirthweightandcurrentBMIwereimplicatedasriskfactorsfor
prolapseaftervaginaldelivery.Equally,antenatalandpostnatalpelvicfloor
exerciseshavenotyetbeenshownconclusivelytoreducetheincidenceof
prolapse,althoughtheymaybeprotective.

24. Physiotherapy:
Pelvicfloorexercisesmayhavearoleinthetreatmentofwomenwithsymptomatic
prolapse,althoughtherearenoobjectiveevidence-basedstudiestosupportthis.Education
aboutpelvicfloorexercisesmaybesupplementedwiththeuseofaperineometerand
biofeedback,allowingquantificationofpelvicfloorcontractions.Inaddition,vaginalcones
andelectricalstimulationmayalsobeused,althoughagain,whiletheyhavebeenshownto
beeffectiveinthetreatmentofurodynamicstressincontinence,therearenodatatosupport
theiruseinthemanagementofurogenitalprolapse.
Insummary,physiotherapyprobablyhasaroleincasesofmildprolapseinyoungerwomen
whofindanintravaginaldeviceunacceptableandarenotyetwillingtoconsiderdefinitive
surgicaltreatment,especiallyiftheyhavenotyetcompletedtheirfamily.

25. Intravaginal devices:
Theuseofintravaginaldevicesoffersafurtherconservativelineoftherapyforthosewomen
whoarenotcandidatesforsurgery.Consequently,theymaybeusedinyoungerwomen
whohavenotyetcompletedtheirfamily,duringpregnancyandthepuerperium,andalsofor
thosewomenwhomaybeunfitforsurgery.Clearly,thislastgroupofwomenmayinclude
theelderly,althoughagealoneshouldnotbeseenasacontraindicationtosurgery.In
addition,apessarymayoffersymptomaticreliefwhileawaitingsurgery.Ringpessaries
madeofsiliconeorpolythenearecurrentlymostfrequentlyused.Theyareavailableina
numberofdifferentsizes(52–120mm)andaredesignedtoliehorizontallyinthepelviswith
onesideintheposteriorfornixandtheotherjustbehindthepubis,henceprovidingsupport
totheuterusanduppervagina.
Pessariesshouldbechangedeverysixmonths;long-termusemaybecomplicatedby
vaginalulcerationandthereforealow-dosetopicaloestrogenmaybehelpfulinpost-
menopausalwomen.Ringpessariesmaybeusefulinthemanagementofminordegreesof
urogenitalprolapse,althoughinseverecases,andforvaginalvaultprolapse,ashelf
pessarymaybemoreappropriate.

26. Types of vaginal pessary

27. Surgery:
Surgeryoffersdefinitivetreatmentofurogenitalprolapse.Asinotherforms
ofpelvicsurgery,patientsshouldreceiveprophylacticantibioticstocover
bothGram-negativeandGrampositiveorganisms,aswellas
thromboembolicprophylaxisintheformoflow-doseheparin,and
thromboembolic deterrent (TED) stockings.
Allpatientsshouldalsohaveaurethralcatheterinsertedatthetimeofthe
procedureunlessthereisaparticularhistoryofvoidingdysfunction,in
whichcaseasuprapubiccathetermaybemoreappropriate.Thisallowsthe
residualurinevolumetobecheckedfollowingavoidwithouttheneedfor
recatheterisation.Patientshavingpelvicsurgeryarepositionedinlithotomy
withthehipsabductedandflexed.Tominimisebloodloss,localinfiltrationof
thevaginalepitheliumisperformedusing0.5percentxylocaineand
1/200,000adrenaline,althoughcareshouldbetakeninpatientswith
coexistentcardiacdisease.Avaginalpackmaybeinsertedattheendofthe
procedure,andremoved onthefirstpostoperativeday.

28. Anterior compartment defects
AnteriorcolporrhaphyIndication:
Anteriorcolporrhaphyisindicatedforthecorrectionofcystourethrocele.
Procedure:

29. Posterior compartment defects:
PosteriorcolporrhaphyIndication:
Posteriorcolporrhaphyisindicatedforthecorrectionofrectoceleanddeficientperineum.
Procedure:

30. Enterocelerepair
EnterocelerepairIndication:
Enterocelerepairisindicatedforthecorrectionofenterocele.
Uterovaginalprolapse:
VaginalhysterectomyIndication:
Vaginalhysterectomyisindicatedforuterovaginalprolapse.
Thisproceduremaybecombinedwithanteriorandposteriorcolporrhaphy.
Contraindications(relative).
1.Uterinesize>14weeks’gestation,althoughmorcellationoruterine
bisectionmaybeused.
2.Twoormorecaesareansections.
3.Endometriosis.
4.PID.
5.Suspectedmalignancy(uterineorovarian).

31. Uterine preserving surgery
Uterineprolapsecanalsobetreatedwith‘uterussparing’procedureswherean
attemptismadetosuspendtheuterusratherthanremoveitthrougha
hysterectomy.
Theindicationstopreservetheuterusmaybeasfollows:
1.Preservationoffertility.
2.Lackofuterinepathology.
Routes:
Abdominal:Sacrospinoushysteropexy,pectinealligamentsuspension.
Vaginal:sacrospinoushysteropexyanduterosacralligamentplicationhavebeen
described.
Laparoscopic:Roundligamentplication,sacrohysteropexy,uterosacralplication.

32. Vaginal vault prolapse
Vaginalvaultprolapseoccursequallycommonlyfollowingvaginalorabdominalhysterectomy,
withanincidenceofapproximately5percent,althoughonly0.5percentofwomenrequire
furthersurgery.
Abdominalsacrocolpopexy
Indication:
Abdominalsacrocolpopexyisindicatedforvaginalvaultprolapse.
Procedure:

33. Sacrospinous ligament fixation
Indication:Sacrospinousligamentfixationisindicatedforvaginalvault
prolapse.
Procedure:

34. Obliterative surgical procedures
Obliterativeproceduresarereservedforwomenwhohavefailed
conservativetherapybutwhohavesignificantcomorbiditiesandare
thereforenotcandidatesforextensivesurgery.Themostcommon
procedureisacolpocleisis.
Thiscanbedoneinwomenwhohavehadahysterectomyandthose
whohavenot.Theprocedureinvolvesremovalofstripsofvaginafrom
theanteriorandposteriorvaginalepithelium,leavingasmallstripof
lateralepitheliumoneachside.Theanteriorandposteriorwallsare
thensuturedtogether.Themainpurposeofthesidestripsistoallow
forvaginaloruterinesecretionstobedischarged.Theprocedureis
associatedwithexcellentresultsandverylowcomplications.

35. LeFortColpocleisis

36. THANK YOU