PELVIC ORGAN PROLAPSE slide presentation

Good notes

1. GENITAL ORGAN PROLAPSE DR.MIHAYO KAMKA MD

2. Learning tasks At the end of this session, students are expected to be able to: Define genital organ prolapse Explain aetiology /risk factors of pelvic organ prolapse Outline epidemiology of pelvic organ prolapse Explain clinical features of pelvic organ prolapse Establish diagnosis/ provisional and differential diagnosis of pelvic organ prolapse Provide pre-referral treatment of pelvic organ prolapse Provide follow-up services of pelvic organ prolapse Provide control and preventive measures of pelvic organ prolapse 2 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

3. Activity: Brainstorming What is pelvic organ prolapse ? 3 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

4. Definition P elvic organ Prolapse : Is the protrusion of the pelvic organs into or out of the vaginal canal. Is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. The entity includes descent of the vaginal wall and/or the uterus. The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), anterior vagina (cystocele), or posterior vagina (rectocele ). Is a common condition Many women with prolapse experience symptoms that impact daily activities, sexual function, and exercise. 4 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

5. Terminologies Anterior compartment prolapse – Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele) Posterior compartment prolapse – Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele) Enterocele – Hernia of the intestines to or through the vaginal wall.

6. Terminologies Apical compartment prolapse (uterine prolapse, vaginal vault prolapse) – Descent of the apex of the vagina into the lower vagina, to the hymen, or beyond the vaginal introitus Uterine procidentia — Hernia of all three compartments through the vaginal introitus

7. TYPES OF PROLAPSE

8. Epidemiology Pelvic organ prolapse (POP) affects millions of women worldwide. Genital prolapse occurs in about 10-30% of multiparous women and in 2% of nulliparous women The lifetime risk for woman undergoing surgery for genital prolapse or incontinence is 11%. Some studies show that the prevalence of pelvic organ prolapse increases steadily with age (Olsen, 1997; Swift, 2005) 9 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

9. 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

10. Anatomy of Pelvic support Levels of pelvic support 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 and the arcus tendineus fascia pelvis (also referred to as the “white line”). Loss of level 2 support contributes to anterior vaginal wall prolapse (cystocele).

11. Anatomy of Pelvic 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.  

12. Anatomy of Pelvic support 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

13. Etiology Most cases are the result of damages to the vaginal and pelvic support tissues due to childbirth or due to chronically elevated intra-abdominal pressure, , genetic predisposition, and pelvic surgery. Repeated childbirth may result into stretching and injury of: Ligaments Endopelvic fascia Levator muscle (myopathy) Perineal body Nerve (pudendal) Muscle damage 16 7/31/2024

14. Activity: Brainstorming What are risk factors for Pelvic organ prolapse? 17 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

15. Predisposing factors Prolapse occurs due to a weakness or damage that has occurred to the structures which support the pelvic organs in place . Contributing factors include pregnancy and childbirth, menopause, raised intra-abdominal pressure, genetic predisposition (Ehlers Danrose Syndrome, and Marfans Syndrome) and pelvic surgery. (anterior colporrhaphy , hysterectomy - TAH)

16. Predisposing factors Pregnancy and child birth have consequent injury to the supporting structure Pregnancy and hormonal changes Premature bear down efforts before the cervix is fully dilated Instrumental assisted delivery. Prolonged second stage of labour . Over distension of the vagina and perineum i.e macrosomia or malposition. Imperfect repair of perineal injuries. Neuromuscular damage of levator ani muscles. Subinvolution of supporting structures i.e High parity

17. Predisposing factors Advancing age - risk doubled with each decade of life. Postmenopausal atrophy - hypo estrogenic state leads their atrophy. Lifestyle and occupation - Lifting objects heavy ie weight lifting Obesity - increases the load on pelvic floor and inability to exercise. Chronic medical condition. Diabetes mellitus - neuropathy and obesity Smoking - antiestrogen properties, vascular disease, chronic hypoxic state. Corticosteroid therapy – weakening on connective tissue. Connective tissue disorders - Ehlers- Danlos syndrome. Abdominal pelvic masses/ ascites - effects the physical load on the pelvic floor.ie massive fibroids Increase in Intraabdominal pressure -constipation -Chronic cough – (COPDS) asthma , bronchitis,

18. Clinical presentation Vaginal symptoms Sensation of a bulge or protrusion Feeling of something coming down per vagina, especially when sneezing, coughing, with physical exertion, and after long period of standing Seeing or feeling a bulge or Pressure or Heaviness Urinary symptoms Stress Incontinence , increase frequency , or urgency Weak or prolonged urinary stream Feeling of incomplete emptying Difficult in urination-Manual reduction of prolapse needed to start or complete voiding (“digitation”) Change of position needed to start or complete voiding Painful micturition (in case of cystitis)

19. Clinical presentation cont...... Bowel symptoms Incontinence of flatus, or liquid or stool Feeling of incomplete emptying Straining during defecation Digital evacuation needed to complete defecation Splinting(pushing on or around the vagina or perineum) needed to start or complete defecation (“digitation”) Sexual symptoms Dyspareunia (painful or difficult intercourse) Lack of sensation Backache or dragging pain in the pelvis . prolapsed pelvic organs Limits to the depth of penetration Spotting or bleeding from the vagina

20. Clinical evaluation General examination BMI Psychological - loss of self-esteem and a negative self image COPD Signs of neuropathy or myopathy . A pelvic examination is done in left lateral position using a Sims speculum or in a standing position in the examination chair Prolapse extent and compartments of the vagina affected. The patient should be at rest and straining or by having her stand or walk prior to examination. May require EUA

21. Clinical features cont … Physical examination: cystocele: A bulge of the anterior vaginal wall, which increases with straining protrusion of urinary bladder Has positive cough impulse Is reducible Cystourethrocele : Bulging of ant. Vaginal wall involves the lower 1/3 involving the protrusion of bladder and urethra There may be stress incontinence 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology 24

22. Clinical features cont … Physical examination cont … Rectocele and Enterocele : Often co-exist A bulge of the posterior vaginal wall with sulcus btn the protruded rectum and bowels Rectovaginal examination: enterocele is close to the cervix and cannot be reached at by the rectal finger 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology 25

23. Clinical features cont … Physical examination cont … Uterine prolapse: Cervical descent below ischial spine on straining 2 nd and 3 rd degree: Mass protruding out through the introitus leading part being external os dark pigmentation at the leading part Shallow vaginal orifices Increased length of uterine cavity on introducing uterine sound 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology 26 Third degree uterine prolapse

24. Degree of Uterine prolapse First degree: Uterus descends from its normal anatomical position but the descent is within the vagina Second degree: External OS protrudes outside the vagina introitus but the uterine body remain inside the vagina.or the descent organs remain to the introitus Third degree ( Procidentia/complete prolapse ): Uterus and cervix and body descends outside the introitus .

25. Differential diagnosis Cystocele: Gartner’s cyst Inclusion dermoid cyst Urethral diverticulum Uterine prolapse: Congenital cervical elongation Chronic uterine inversion Pedunculated Fibroid Endometrial polyp Cervical polyp 29 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

26. Investigations Mid-stream urine for urinalysis urine culture and sensitivity . Renal ultrasound in cases of complete prolapse and severe cystocele to exclude hydroureter & hydronephrosis which may occur as a result of kinking of the ureters Abdominal pelvic uss Cystometry in cases of incontinence in order to exclude urge incontinence Cystourethroscopy 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology 30

27. treatment The choice of treatment depends on the patient's wishes , level of fitness and desire to preserve coital function. Prior to specific treatment, attempts should be made to correct obesity, chronic cough or constipation.

28. treatment Conservative treatment Pre-referral treatment: Treat underlying cause as appropriate Treat complications such as UTI as appropriate Pelvic floor exercises in an attempt to strengthen the muscles (Kegel exercises). For 2nd and 3rd degree genital prolapse; Cover with gauze soaked with normal saline for safe transfer/referral

29. Conservative treatment ...... For a mild prolapse, simple measures such as losing weight (if overweight), avoiding lifting heavy objects and treating conditions like chronic coughing and constipation may alleviate some symptoms and help toprevent the prolapse from worsening

30. Conservative treatment ...... Pelvic floor exercises ( Kegels exercise) are useful but not a cure for pelvic prolapse. o These exercises are designed to strengthen the pelvic floor muscles through actively tightening and lifting them at intervals o They can be performed while patient is sitting, standing or lying down

31. Kegels exercise

32. Treatment cont… Specific treatment: Estrogen replacement therapy may improve minor degree prolapse in postmenopausal women Pessary Surgery 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology 36

33. Pessary Treatment Devices which are inserted into the upper part of the vagina to provide support to the pelvic structures Vaginal device made of silicone, rubber, or plastic to support the walls and related pelvic organs. First-line management option for women with pelvic organ prolapse . A pessary can be kept in place for three to four months. Indications Early pregnancy up to 18 weeks Puerperium to facilitate involution Unfit or unwillingness and waiting for surgery Improvements of symptoms

34. Pessary Treatment

35. Surgical management For symptomatic or advanced stages of prolapse where conservative has failed or not indicated. Vaginal repair - involves a repair to the tissues supporting the vaginal wall. Anterior colporrhaphy - to correct cystocele or urethrocele . Posterior colporrhaphy - to correct a rectocele or enterocele . Hysterectomy with either anterior or posterior colporrhaphy Vaginal vault repair – to correct vaginal vault prolapse by anchoring the vault to the sacrospinous ligament.

36. Complications Morbid changes Decubitus ulcer Infection-Urinary tract infection: Cystis and pyelonephritis Incarceration-Incarceration: At times, infection of the para-vaginal and cervical tissues makes the entire prolapsed mass edematous and congested. As a result, the mass may be irreducible. Hemorrhage Urinary Urinary retention Obstructive uropathy -hydronephrosis Infection

37. Complications Gastrointestinal Constipation Sexual functions Dyspareunia Use of pessary Vaginal irritation is another possible side effect. Vaginal discharge or bleeding

38. Surgical Complications Operative Hemorrhage Trauma Postoperative Urinary retation Infection Secondary hemorrhage Late Dyspareunia Recurrence of prolapse VVF/ RVF

39. Prevention Perform pelvic floor exercises regularly, particularly during pregnancy, after childbirth and into menopause. Avoid constipation and straining during a bladder and bowel movement. Eating an adequate diet and drinking 1.5-2 liters of water daily will help prevent constipation . Treat the cause of any chronic cough Maintain a healthy weight. Avoid lifting heavy objects frequently Family planning to increase pregnancy interval.

40. Prevention Control of chronic diseases. - Diabetic complications Adequate antenatal and intranatal care Avoiding of: prolonged labour , bearing down before full cervical dilatation and difficult instrumental delivery

41. Key points Pelvic organ prolapse is the protrusion of the pelvic organs into or out of the vaginal canal It is a result of injury to the pelvic support by conditions such as childbirth or increased intra-abdominal pressure. Other factors includes obesity, menopause and undernutrition Common presentation includes sensation of something in the vagina and lower back pain both which tend to be relieved on lying down Treatment involves correction of underlying causes/factors, use of pessaries and surgery 47 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

42. Key points cont … Treatment involves correction of underlying causes/factors, use of pessaries and surgery POP can be prevented by avoiding the risk factors, proper antenatal, intranatal and postnatal care 48 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

43. Review questions What is Pelvic organ prolapse? Outline the risk factors for Pelvic organ prolapse. What are the clinical presentation of Pelvic organ prolapse? Outline the management of Pelvic organ prolapse. 49 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

44. References D.C Dutta . Textbook of Gynecology. 6 th edition https://emedicine.medscape.com//article/954252 Williams textbook of Gynaecology ( Mc Graw 2008) Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology , Second Edition.  Informa HealthCare; 2006. Progetto Menopausa Italia Study Group. Risk factors for genital prolapse in non- hysterectomized women around menopause. Results from a large cross-sectional study in menopausal clinics in Italy.  Eur J Obstet Gynecol Reprod Biol. Dec 2000;93(2):135-40.  50 7/31/2024 CMT 06210: Apprenticeship in Obstetrics and Gynaecology

45. Thank you!!