Pelvic organ prolapse

peer review

1. PELVIC ORGAN PROLAPSE DR. Okechukwu A. Ugwu

2. OUTLINE INTRODUCTION EPIDEMIOLOGY RELEVANT ANATOMY/SUPPORT OF PELVIC ORGANS RISK FACTORS AETIOPATHOGENESIS CLASSIFICATION CLINICAL FEATURES MANAGEMENT

3. DEFINITION Descent of one or more of the genital organs below their normal anatomical position . Prolapse is a condition in which organs, which are normally supported by the pelvic floor, namely the bladder, bowel and uterus, herniate or protrude into the vagina due to weakness in their supporting structures.

4. Epidemiology Common Problem in Women 50% of parous women have some prolapse, 10-20% have symptoms 11% Lifetime Risk for Surgery Of these, 29% require repeat surgery 5-7% Develop Post-Hysterectomy Vault Prolapse

5. ANATOMY- SUPPORTS OF THE UTERUS AND VAGINA The normal position of the uterus is maintained mainly by 3 factors: 1. The cervical ligaments: consist of 3 pairs: The Mackenrodt’s / tranverse cervical/cardinal ligament; the most important part The uterosacral ligaments The Pubocervical ligaments 2. The pelvic floor muscles : The levator ani muscles is the most important & consists of 3 parts : The ischio-coccygeus muscle The ilio-coccygeus muscle The pubo-coccygeus muscle; the most important part Others include obturator internus , coccygeus . 3. The anteverted position of the uterus/ posterio Angulation of the vagina.

6. ANATOMY- contd

7. Supports of the Uterus-The Cervical Ligaments

8. Supports of the Uterus -The Cervical Ligaments- contd

9. Supports of the Uterus- PELVIC FLOOR MUSCLES

10. ANATOMY – posterior angulation of the vagina

11. Posterior Angulation of the vagina-2

12. Supports of the vagina Three Levels of Support: ( DeLancey ) Level I (upper level): Cardinal/ Uterosacral ligaments Level II (middle level): Pubocervical fascia anteriorly Rectovaginal fascia posteriorly Levator ani muscles (through the arcus tendineus fasciae pelvis) Level III (lower level): Perineal membrane Urogenital Diaphragm

13. RISK FACTORS Increased intra-abdominal pressure. Chronic cough. Chronic constipation. Weight lifting. Presence of abdominal tumors e.g fibroid & ovarian cysts. High impact exercises Age/Menopause Obesity Smoking Multiparity Congenital Weakness-rare, due to deficiency in collagen metabolism Injury to pelvic floor muscles Iatrogenic/Pelvic surgery- Hysterectomy

14. AETIOPATHOGENESIS 1-Congenital weakness of the pelvic supports is associated with- short vagina, spina bifida & deep utero -vaginal & utero -sacral pouches It leads to the appearance of prolapse at an early age, the so-called “ nulliparous ” or even “virginal” prolapse . 2-Acquired weakness of pelvic supports; This is assoc with direct injury to pelvic musculature and fasciae as well as partial denervation of pelvic floor muscles

15. AETIOPATHOGENESIS- contd Acquired weakness of the cervical ligaments and pelvic connective tissue A) Obstetric childbirth trauma: Straining during the first stage of labour. Wrong forceps application before full cervical dilatation. Prolongation of the 2 nd stage of labour leads to pressure & stretching of levator ani Rapid succession of pregnancies; before involution of the pelvic structures . unsutured or badly repaired perineal tear B ) Postmenopausal atrophy: Oestrogen deficiency & ageing may lead to loss of collagen and weakness in CT & fascia, particularly in patients predisposed to by obstetric trauma.

16. GENITAL PROLAPSE IN A NEONATE

17. Diagram showing prolapse due to weakness of pelvic lig .

18. CLASSIFICATION OF PELVIC ORGAN PROLAPSE 1. Uterine prolapse: 1st, 2nd, or 3rd, degree 2. Vaginal prolapse: which may be; A) Anterior vaginal wall prolapse Cystocele (bladder descent) Urethrocele (urethral descent) Cystourethrocele (both bladder and urethral descent) B) Posterior vaginal wall prolapse Rectocele (rectal descent) Enterocele (small bowel descent through the Pouch of Douglas) 3. Combined Uterovaginal prolapse: 4. Vault prolapse:

19. Degrees of uterine prolapse

20. Degrees of uterine prolapse-contd

21. Degrees of uterine prolapse-contd

22. Types and Degrees of Genital Prolapse

23. DIFFERENT TYPES OF PROLAPSE

24. DIFFERENT TYPES OF PROLAPSE- Contd

25. TYPES OF PROPLASE- contd

26. TYPES OF PROPLASE- contd

27. TYPES OF PROPLASE- contd

28. TYPES OF PROPLASE- contd

29. TYPES OF PROPLASE- contd

30. BADEN-WALKER HALF-WAY SYSTEM GRADE POSITION OF PROLAPSE SITE No prolapse 1 Half-way to hymen 2 To hymen 3 Half-way past hymen 4 Maximum descent

31. PELVIC ORGAN PROLAPSE QUANTIFICATION (POPQ) SYSTEM

32. CLINICAL FEATURES OF PROLAPSE Symptomatic or asymptomatic: Exaggerated by effort and straining, and disappear by lying down & reduction 1. Sensation of pelvic heaviness 2. Backache; especially in uterine prolapse , due to stretch on uterosacral ligaments 3. A mass filling the vagina or protruding from the vulva ; on straining or squatting, and disappears by lying down on the back. 4. Urinary symptoms: Frequency of micturition by day due to mechanical irritation of the trigone . Stress ( urodynamic ) Incontinence. Inability to complete the act of micturition unless the anterior vaginal wall is pushed upwards and supported by the finger .- Features of UTI Acute urinary retention mostly in 1 st trimester 5 . Bowel symptoms ; heaviness in the rectum and a constant desire to defecate. 6. Decubitus ulcer . 8. Vaginal discharge 9. Dyspareunia 10. others- cough

33. DIFFERENTIAL DIAGNOSIS OF PROLAPSE VAGINAL CYST CERVICAL POLYP ELONGATION OF THE CERVIX Tumors of the urethra/Bladder Large urethral Diverticulum Skene’s and Bartholin’s gland cysts/abscess

34. MANAGEMENT History- (age, risk factors and complications) Physical examination- Examine in either the Sims position[left lateral] or dorsal position- Use a speculum to depress post vaginal wall to view anterior wall and vice versa. Urinary stress incontinence also tested for. Rectal examination to differentiate between rectocele and enterocele . Rectovaginal examination She can stand/ squart and then cough/strain

35. Investigations in a case of prolapse 1. Urine analysis , microscopy, culture and sensitivity in cases with urinary symptoms. 2. Urodynamic studies in cases associated with stress incontinence. 3. IVU and cystography to delineate course of ureters and detect vesical pouch 4. Pelvic and abdominal US if suspected pelvic or pelviabdominal swellings. 5. Routine preoperative Investigations; blood chemistry, CBC, kidney and liver function tests. 6. Wound swab mcs 7. Others depend on history and finding- CXR in elderly,

36. TREATMENT OF PROLAPSE The choice of treatment for genital prolapse depends on several factors including The type and degree of prolapse Her desire to preserve coital function. Her desire to preserve fertility. The patient’s acceptance for surgical treatment. Her level of fitness for a surgical approach . Treatment options is divided into a)Conservative b)Surgical

37. CONSERVATIVE METHOD OF TREATMENT While treating underlying conditions Life style modification Pelvic floor physiotherapy Estrogen replacement therapy Vaginal pessary

38. Pessary treatment of prolapse Indications of pessary treatment Temporary measure to allow for treatment of underlying conditions e.g.Promote healing of decubital ulcers prior to surgery Patients who refuse surgery During pregnancy Medically unfit patients , as very old age, morbid obesity, cerebrovascular accidents, etc. Therapeutic test to confirm that presenting symptoms are due to prolapse

39. Different types of pessaries

40. CARE OF PESSARY The patient should be shown how to withdraw the pessary if it becomes displaced. Inform her not to use contraceptive diaphragm while vaginal pessary is in place Tell her to report any discomfort – (bleeding, disturbance in defecation or urinary function) immediately. The patient should be examined 1-2weeks after insertion, a repeat exam can be done in 4 weeks after which visits should be 3-6month interval. The pessary should be maintained with an acidic gel.

41. COMPLICATIONS OF PESSARIES 1-Ulceration of vaginal vault. 2-Impaction of pessary. 3-Constipation. 4-Stress incontinence when large type is used. 5- Fistula 6-Carcinoma of the vaginal wall in neglected cases. 7-Dyspareunia

42. OESTROGEN REPLACEMENT THERAPY Important in postmenopausal women with atrophy of vaginal wall. Mild degrees of prolapse may improve remarkably. Oestrogen helps improve quality of vaginal mucosa and improves blood flow.

43. Surgical treatment for genital prolapse Indications for Surgery a) Failed conservative treatment b)Severe degree of Prolapse c) Patient who has completed her family size and doesn't desire to preserve fertility Surgical treatment is divided into: a) Conservative surgical methods b) Radical method c)Others- mgt of Vault prolapse

44. Conservative surgical methods 1-Pelvic floor repair Anterior colpo-perineorrhaphy . Posterior colpo-perineorrhaphy . Combination of ant & post types. 2-Manchester Fothergill operation. 3-Sacrohysteropexy and sacrospinous fixation 4-Vaginal colpocleisis – complete or incomplete. -Le Forts operation/complete-postmenopausal & surgically poor risk pxs .

45. Radical Surgery for Treatment of Prolapse Vaginal hysterectomy & pelvic floor repair: in older women when future pregnancy is not con­templated, or after menopause. It can be Abdominal, Vaginal or Laparoscopic Hysterectomy Other surgical method include: Vaginal Vault Prolapse repair Abdominal approach (abdominal sacro-colpopexy ) Vaginal approach (sacrospinous ligament fixation)

46. Complications of Surgical Treatment Anaesthetic complication Haemorrhage Damage to surrounding structures Wound breakdown Recurrence Vault Prolapse Cervical stenosis/Incompetence Preterm Labour miscarriage = FROM CERVICAL AMPUTATION Cervical dystocia Precipitate labour Dyspareunia

47. Prevention of prolapse Family planning/Child spacing to avoid repeated child birth Proper selection of patients for instrumental delivery Weight reduction/prevention of Obesity Stop smoking Partographic management of labour - good repair of episiotomy and perineal tears after labour - Avoid constipation in pueperium . -Encourage postnatal exercises

48. Surgery

49. Surgery- contd

50. Surgery- contd

51. Surgery- contd

52. Surgery- contd

53. Sacrospinous Ligament Suspension Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle

54. All references & acknowledgements are in accompanying resource materials 56 Sacrocolpopexy and paravaginal repair for total pelvic floor prolapse

55. REFERENCES

56. END THANK YOU