Pelvic organ prolapse

PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.

1. PELVIC ORGAN PROLAPSE Dr. M. GOKUL RESHMI.

2. INTRODUCTION DEFINITION: Descent of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy),or other pelvic viscera alone or in combination. 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.

3. ANATOMY The support system : Level I – The uterosacral/cardinal ligament complex, - apical defect. Level II – Endopelvic fibromuscular connective tissue to the arcus tendineus and levator fascia. – anterior (upper 2/3 rd )/ posterior( lower 2/3 rd ) wall defect . Level III - The muscles and connective tissue surrounding the distal vagina and perineum. – anterior wall ( lower 1/3 rd ), perineal body, genital hiatus defect.

4. 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. 

5. DEFECTS AND ITS EFFECTS Level I : Suspension defect – Descent of the cervix, enterocele, apical/ vault prolapse. Level II : attachment defect – cystocele, rectocele. Level III : fusion defect – gaping introitus, deficient perineum, urethrocele.

6. DEFECTS AND ITS EFFECTS APICAL COMPARTMENT: Level I 1. The loss of cardinal/uterosacral support with resultant cervical/uterine or vaginal cuff descent 2. fibromuscular vagina : anterior rectum -enterocele or, at times, sigmoidocele . 3. Tears or attenuation - post hysterectomy, -central apical descent as a ballooning defect.

7. DEFECTS AND ITS EFFECTS ANTERIOR COMPARTMENT: Level II 1. Central defect or distension cystocele – Rugae absent – Lateral vaginal sulci present 2. Lateral (paravaginal) defect or displacement cystocele. – Rugae present – Lateral vaginal sulci absent 3. The presence or absence of sulci lateral detachment to the arcus is maintained or lost.

8. DEFECTS AND ITS EFFECTS ANTERIOR COMPARTMENT: Classification of Cystocele: Paravaginal defect (central, displacement), Midline defect (central, distention) or Transverse defect (apical) depending on whether the pubocervical fascia is separated from the vaginal cuff, separated from the uterosacral ligament, or mixed.

9. DEFECTS AND ITS EFFECTS POSTERIOR COMPARTMENT: Level II Perineal detachment of Denonvillier (pararectal) fascia - perineal rectocele, associated with defecation difficulty .

10. EPIDEMIOLOGY 11% life time risk. Common Problem in Women – 50% of parous women have some prolapse, 10-20% have symptoms. 1% Lifetime Risk for Surgery – Of these, 29% require repeat surgery. 5-7% Develop Post-Hysterectomy Vault Prolapse. The risk of POP increased 1.2 times with each vaginal delivery.

11. ETIOLOGY Weakness of the structures supporting the organs in position. Anatomical factors Clinical factors Aggravating factors Predisposing factors: • Acquired • Congenital Anterior inclination of pelvis. Gravitational stress. Stress of parturition. Pelvic floor weakness due to urogenital hiatus and the direction of obstetric axis through the hiatus. Inherent weakness of the supporting structures.

12. Cont … AGGRAVATING FACTORS: Postmenopausal atrophy. Poor collagen tissue repair with age. Increased intra-abdominal pressure as in COPD and constipation. Occupation (weight lifting). Asthenia and undernutrition. Obesity. Increased weight of the uterus as in fibroid or myohyperplasia .

13. Cont … PREDISPOSING FACTORS Acquired: vaginal delivery causing injury (tear or break) to: (1) Ligaments (2) Endopelvic fascia (3)  Levator muscle (myopathy) (4) Perineal body (5)  Nerve (pudendal) and muscle damage due to repeated child birth Congenital: Inborn weakness of supporting structures.

14. Risk Factors Associated with Pelvic Organ Prolapse Pregnancy - Vaginal childbirth, Menopause – Aging – Hypoestrogenism. Chronically increased intraabdominal pressure – COPD, Constipation, Obesity, Pelvic floor trauma, Genetic factors - Race, Connective tissue disorders, Spina bifida.

15. THE BADEN-WALKER HALFWAY SYSTEM - SYMPTOMS Urethral - Urinary incontinence, Falling out Vesical - Voiding difficulties, Falling out Uterine - Falling out, Heaviness and so forth Cul-de-sac - Pelvic pressure (standing), Falling out Rectal - True bowel pocket, Falling out Perineal - Anal incontinence, Too loose (gas/ feces )

16. Shaw's System Anterior wall Upper 2/3 cystocele Lower 1/3 urethrocele Posterior wall Upper 1/3 enterocele Middle 1/3 rectocele Lower 1/3 deficient perenium Uterine prolapse Grade 0 Normal position Grade 1 descent into vagina not reaching introitus Grade 2 descent up to the introitus Grade 3 descent outside the introitus Grade 4 Procidentia

17. Comparison of systems used to quantify pelvic organ prolapse –

18. PELVIC ORGAN PROLAPSE

19. PELVIC ORGAN PROLAPSE QUANTIFICATION (POP-Q).

20. PELVIC ORGAN PROLAPSE QUANTIFICATION (POP-Q).

21. PELVIC ORGAN PROLAPSE QUANTIFICATION (POP-Q).

22. LEVATOR TONE Grade 0 –no discernible pelvic floor contraction Grade 1 –a flicker under finger. Grade 2 – a weak contraction or increase in tension without any discernible lift or squeeze Grade 3 – a moderate contraction with partial lifting of postvaginal wall and squeezing of finger, contraction > grade 3 is visible. Grade 4 –good pelvic contraction causing elevation of postvaginal wall against resistance and indrawing of perineum. Grade 5 – strong contraction of pelvic floor against strong resistance.

23. SYMPTOMS Asymptomatic Fullness in the vagina Mass descending per vaginum – On straining – At rest Urinary symptoms – Sensation of incomplete emptying – Frequency/urgency – Dysuria – Stress incontinence – Need to manually reduce to void – Urinary retention Bowel symptoms – Constipation – Incomplete emptying – Splinting and straining Sexual symptoms – Sexual dissatisfaction – Dyspareunia. Vaginal discharge Bleeding Low backache

24. DIFFERENTIAL DIAGNOSIS Cervical/endometrial polyps. Chronic inversion of uterus. Hypertrophic elongation of cervix. Gartner cyst, vaginal cyst. Urethral diverticula are rare, always small and are situated low down in the anterior vaginal wall. Congenital elongation of the cervix.

25. Complications of Prolapse 1. Kinking of ureter with resulting renal damage. 2. Urinary tract infection (chronic) in a large cystocele with residual urine can lead to upper renal tract infection and renal damage. 3. In rare cases, cancer of the vagina is reported over the decubitus ulcer and if the ring pessary is left in over a long period.

26. MANAGEMENT INVESTIGATIONS: Fitness for surgery – Haemoglobin – Blood sugar – Serum creatinine Urine culture Pap smear Evaluate decubitus ulcer – Cytology – Colposcopy and biopsy, if required Ultrasonogram – If pelvic pathology suspected Pessary test – To rule out occult stress incontinence Urodynamic evaluation Proctography MRI

27. Radiological classification of cystoceles Originally proposed by Green , Based on: Descent of the bladder neck , retrovesical angle (the angle between the proximal urethra and the trigonal surface of the bladder ) and the degree of urethral rotation .

28. Radiological classification of cystoceles Green type I is described as cystocele with open retrovesical angle (≥ 140°) and urethral rotation < 45°. Green type II describes a cystocele with open retrovesical angle (≥ 140°) and urethral rotation between 45 and 120°, also called cystourethrocele . A cystocele with intact retrovesical angle (< 140°) is defined as Green type III

29. Urodynamic Abnormalities Bladder obstruction is among the most common reasons to order urodynamic testing for POP. Bladder outlet obstruction can be defined as a low maximum free flow rate of less than 12 mL/s that persists for the patient in combination with high detrusor pressure greater than 20 cm H 2 O during a pressure-uroflow study. This test looks for bladder obstruction, muscle weakness, stress induced incontinence, urethra strength, and other disorders that affect the pelvic organs, muscles, and tissues .

30. Apical cystocele  is located upper third of the vagina. The structures involved are the  endopelvic fascia  and  ligaments . The  cardinal ligaments  and the  uterosacral ligaments  suspend the upper vaginal-dome. The cystocele in this region of the vagina is thought to be due to a cardinal ligament defect. Medial cystocele  forms in the mid-vagina and is related to a defect in the suspension provided by to a sagittal suspension system defect in the uterosacral ligaments and  pubocervical fascia . The pubocervical fascia may thin or tear and create the cystocele. An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This defect can be assessed by  MRI . Lateral cystocele  forms when both the pelviperineal muscle and its ligamentous–fascial develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and support for the lateral sides of the vagina. Defects in this lateral support system results in a lack of bladder support. Cystocele that develops laterally is associated with an anatomic imbalance between anterior vaginal wall and the  arcus tendineus fasciae  pelvis – the essential ligament structure.

31. MANAGEMENT - TREATMENT: Conservative management: Lifestyle modification. Pelvic floor exercises / pelvic floor muscle training (PFMT). Vaginal pessary. Indications: Mild or moderate degree of prolapse Asymptomatic women Unfit for surgery Old women Prolapse in pregnancy While awaiting surgery

32. GOALS OF CONSERVATIVE MANAGEMENT: Prevent worsening prolaps , Decrease the severity of symptoms Increase the strength, endurance, and support of the pelvic floor musculature Avoid or delay surgical intervention

33. CONSERVATIVE MANAGEMENT MECHANICAL DEVICES - PESSARIES Types : Support and space filling. M/C used: support pessary - ring pessary for stage I and II prolapse, Gelhorn pessary is a commonly used space-filling pessary for stage III and IV prolapse.

34. PESSARIES

35. Cont … Placement and Management: T he patient’s desire and motivation to use this type of device. In hypoestrogenic women, treatment of the vagina with estrogen and maintenance of intravaginal estrogen treatment is recommended. Fitting a Pessary: Examined in the lithotomy position after emptying her bladder. Size of the pessary is estimated after a digital examination. When fitted, the patient is asked to stand, perform Valsalva, and cough to ensure the pessary is retained. should be able to void with the pessary in place before leaving .

36. Cont … Follow-Up Recommendations: Initially in 1 to 2 weeks and then at 4 to 6 weeks, Proper placement of the pessary, support of the prolapse and continence efficacy should be ensured. The pessary’s integrity should be checked, and the tissues should be evaluated for irritation, pressure sores, ulceration, and lubrication

37. CONSERVATIVE MANAGEMENT Complications : vaginal discharge and odor, Failure to retain the pessary too large pessary could lead to excoriation or irritation. With reduction of vaginal prolapse, de novo or increased stress incontinence may occur, More severe complications: vesicovaginal or rectovaginal fistula, small bowel entrapment, hydronephrosis, and urosepsis.

38. MANAGEMENT - TREATMENT : Surgical management: Vaginal Abdominal Laparoscopically Combined approach Robotic Type: Reconstructive procedures Compensatory (augmentation) Obliterative procedures

39. Factors determining the choice of surgical treatment. Age Parity stage of prolapse Prior surgery for prolapse Intra-abdominal adhesions – Endometriosis – PID Type of prolapse – Anterior vaginal wall – Posterior vaginal wall – Apical/vault Associated stress incontinence

40. Surgical management Primary aims To relieve symptoms, To restore vaginal anatomy so that sexual function may be maintained or improved without significant adverse effects or complications.

41. RESTORATIVE VAGINAL REPAIRS NATIVE TISSUE: No biological graft or synthetic mesh. No risk of mesh related complications. Slightly higher recurrence rates. GRAFT REPAIR: Biological graft – human cadaveric dermal tissue, bovine collagen. MESH REPAIR: Mono-filament(polypropylene) No longer FDA approved.

42. Surgical management - Vaginal Procedures: LEVEL I The Apical Compartment: Apical support is the key to a successful prolapse repair. Transvaginal repairs (extraperitoneal procedures) Sacrospinous suspensions, Iliococcygeal suspensions, and High paravaginal suspensions of the apical vaginal fornices to the arcus tendineus at the level of the ischial spine or to the endopelvic fascia, Transvaginal repairs (intraperitoneal suspensions) Uterosacral suspensions and Mc Call culdoplasties .

43. Surgical management - Vaginal Procedures: LEVEL I Sacrospinous Ligament Fixation: Extraperitoneal via the rectovaginal space with penetration of the pararectal ( Denonvillier fascia) at the level of the ischial spine to expose the muscle and ligament. Variations in this approach to the ligament include entrances through an anterior lateral access, an apical passage posterior to the uterosacral ligament, and a laparoscopic approach.

44. Surgical management - Vaginal Procedures: LEVEL I Sacrospinous Ligament Fixation - Advantages : (1)Its transvaginal extraperitoneal approach; (2) Resultant posterior vaginal deflection; and (3) It is a durable repair if performed correctly. Reported success for apical support has been good (89% to 97%)

45. Surgical management - Vaginal Procedures: LEVEL I Sacrospinous Ligament Fixation - Disadvantages : (1) relative difficulty in adequately exposing the ligament; (2) an unnatural lateral vaginal deflection toward the fixation site; (3) an inability to perform without excessive tension when the vaginal length is compromised, as may be the case in repeat procedures; (4) potential risk for injury to the sciatic nerve or pudendal nerve or vessel; and (5) occasional need to shorten or narrow the upper vagina when a fibromuscular defect involves much of the apical area.

46. Surgical management - Vaginal Procedures: Iliococcygeal Vaginal Suspension: The attachment, usually bilaterally, of the vaginal apex to the iliococcygeus muscle and fascia. Extraperitoneal access is achieved via the posterior vagina

47. Surgical management - Vaginal Procedures: LEVEL I Enterocele repairs : 1. Removal of the peritoneal sac with closure of the peritoneal defect, followed by closure of the fascial or fibromuscular defect or both below it 2. Dissection and reduction of the peritoneal sac and closure of the defect 3. Obliteration of the peritoneal sac from within with transabdominal Halban or Moschcowitz type procedures or transvaginal McCall or Halban procedures 4. If the posterior vaginal wall is significantly elongated and enlarged, excision of that area to establish an acceptable vaginal length and to eliminate redundancy

48. Surgical management – Abdominal Procedures: LEVEL I Moschcowitz Culdoplasty : cul-de-sac - at the base and are directed upward at level of the vaginal apex, through the posterior vaginal wall -right uterosacral ligament - the rectosigmoid colon muscularis, and finally the left uterosacral. 3-4 concentric rings, 1-2 cm apart.

49. Surgical management – Abdominal Procedures: LEVEL I Halban Culdoplasty : Several rows of 2-0 gauge permanent sutures are placed longitudinally through the serosa and muscularis of the rectosigmoid 1 cm apart - through the deep cul-de-sac and up toward the apex of the posterior vaginal wall. As much of the cul-de-sac as possible is obliterated, but to avoid ureteral injury, sutures are not placed lateral to the uterosacral ligament.

50. Surgical management - Vaginal Procedures: LEVEL I Uterine Preservation: when the uterus or cervix is to be kept in place, additional apical support procedures include Manchester and Gilliam procedures and fixation of the cervix to the sacrospinous ligament.

51. Surgical management - Vaginal Procedures: LEVEL I Uterosacral Ligament Suspension: The vaginal apex is suspended to the uterosacral ligaments above the level of the ischial spines. Excellent success rates. Most common serious complication - ureteral obstruction secondary to ureteral kinking 11% or incorporation of a ureter in a suspension stitch 2% to 3% . Cystoscopy is performed to document ureteral patency.

52. The two most commonly performed transvaginal native tissue apical prolapse repairs are the sacrospinous ligament suspension and uterosacral ligament suspension. vaginal apical descent to more than one-third of the total vaginal length; (2) anterior or posterior vaginal wall descent beyond the hymen; (3) bothersome vaginal bulge symptoms; and (4) retreatment of prolapse. The 2-year success rate was 59% versus 61% for uterosacral and sacrospinous ligament suspension, respectively.

53. Surgical management - Vaginal Procedures: The Anterior Compartment - LEVEL II Anterior Vaginal Colporrhaphy: Anatomic correction of an anterior defect or cystocele will relieve symptoms of protrusion and pressure. Improve micturition function when abnormal micturition is associated temporally with the defect. If the patient has significant stress incontinence an appropriate incontinence procedure may be performed simultaneously with the anterior repair. Mid urethral sling procedure is done with a separate incision for the sling.

54. Surgical management - Vaginal Procedures: The Anterior Compartment - LEVEL II Paravaginal Repair: The paravaginal or “lateral defect” repair involves reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia and, in some cases, muscle at the level of the arcus tendineus pelvis (“white line”).

55. OPERATIVE GOALS OF ANTERIOR VAGINAL RECONSTRUCTION Central: Reconstruct the pubocervical septum or repair of distention cystocele. Proximal: Reattach the proximal pubocervical septum to the suspensory support of the paracolpium . Rebuild the pericervical ring and compensate for the defect left by the absence of the cervix ( DeLancey Level I ). Lateral: Reattach the pubocervical septum to the arcus tendineus fasciae pelvis (white line) or paravaginal repair ( DeLancey Level II ). Distal: Urethropexy ( DeLancey Level III ).

56. Surgical management - Vaginal Procedures: The posterior Compartment Traditional Posterior Colporrhaphy: The Denonvillier fascia is mobilized from the vaginal epithelium. After defects in the rectal muscularis are repaired, the fascia is plicated in the midline with interrupted or continuous sutures. Perineal body or perineal membrane reconstruction is performed after posterior colporrhaphy for PB defect. Dyspareunia is reported in 8% to 26% of sexually active patients who have traditional posterior colporrhaphy.

57. Surgical management – Vaginal Procedures: Transvaginal Mesh Procedures “bridging material to reinforce native structures” (1) nonantigenic; (2) exhibit a low infection rate; (3) decrease or negate recurrence of anatomic defects; (4) cause no harm with respect to bowel or renal function; and (5) relatively inexpensive. Graft exposure/erosion may produce bothersome discharge, pain, and sexual dysfunction with vaginal scarring. Monofilament and large pore size grafts (type 1) mesh is used.

58. Surgical management – Vaginal Procedures: Transvaginal Mesh Procedures

59. Corrective surgery for vaginal vault prolapse Laparoscopic approach: Laparoscopic sacrocolpopexy - Vaginal vault to anterior sacral ligaments

60. Surgical procedures for anterior and posterior vaginal wall prolapse Anterior vaginal wall Anterior colporrhaphy - Plication of pubovesicocervical fascia Posterior vaginal wall Posterior colporrhaphy - Plication of rectovaginal fascia Site-specific repair – Perirectal fascial repair at the site of defect Perineorrhaphy - Approximation of pubovaginalis; repair of perineal body McCall culdoplasty - Plication of uterosacrals ; attaching uterosacrals to vaginal vault Moskowitz procedure (abdominal) - Purse-string plication of peritoneum of POD

61. Uterus-preserving surgeries in pelvic organ prolaps Fothergill / Manchester surgery Suspension/sling procedures Apogee and perigee Abdominal sacrohysteropexy Purandare sling procedure Shirodkar sling procedure Khanna sling procedure

62. APOGEE AND PERIGEE

63. UTERUS - PRESERVING SURGERIES Sacral hysteropexy: Open laparotomy or laparoscopy Mesh is attached to sacrum at one end and posterior or both anteroposterior suface of uterine isthmus on other. Burch operation may be performed concomitantly.

64. Corrective surgery for vaginal vault prolapse Vaginal approach: Sacrospinous colpopexy (unilateral or bilateral) Vaginal vault to sacrospinous ligament. Mc Call culdoplasty Approximation of uterosacral ligaments; vaginal vault to uterosacral ligaments. Iliococcygeus colpopexy Vaginal vault to iliococcygeus muscle. Bilateral high uterosacral ligament suspension Vaginal vault to uterosacral ligaments

65. Corrective surgery for vaginal vault prolapse Abdominal approach: Abdominal sacrocolpopexy Vaginal vault to anterior sacral ligament Abdominal uterosacral suspension Vaginal vault to uterosacral ligament

66. Colpocleisis Consider  colpocleisis  for women with vault or uterine prolapse who do not intend to coitus and who have a physical condition that may put them at increased risk of operative and postoperative complications.

67. Complications of surgical procedures Haemorrhage – primary, reactionary, secondary haemorrhage. Sepsis Trauma to the bladder, urethra and rectum mainly in repeat surgery. Urinary infection. Thrombo-embolism. Late sequelae: Narrow scarred vagina and dyspareunia. Granulation tissue. Recurrence of vault prolapse Fistula

68. Postoperative care postoperative fluid management, adequate analgesia and monitoring for vital signs and bleeding. The prophylactic antibiotics should include broad spectrum antibiotics covering anaerobic organisms also. The most commonly used regimen is amoxicillin + clavulanic acid 1.2 gm and metronidazole 500 mg perioperatively in prophylactic doses. The duration of postoperative catheterization should be minimum depending on extent of bladder dissection and type of surgery performed. Woman should be ambulated after effect of anesthesia wears off. The perineal hygiene should be taken care of.

69. Reasons for failure or recurrence of prolapse Wrong choice of surgical procedure Poor surgical technique Omission to recognise and treat enterocele Shortening of anterior vaginal wall Inherent weakness of supports Pregnancy and delivery following operation.

70. Reference Williams Gynecology Berek and Novaks Gynaecology Campbell Urology TeLindes Operative Gynecology DC Dutta Gynaecology Lakshmi Seshadri Gynecology

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