UVP is a common gynecology problem in developing countries

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1. Management of POP Updates Dr Fekade Ayenachew

2. Objective Discuss main clinical and surgical anatomical considerations for POP Describe the POP-Q staging system and compare it with other systems Describe approach to the patients with and the defect specific reconstructive surgery for POP

3. What is uterovaginal Prolapse ? (UVP) Herniation of various pelvic structures (POP) adjacent to the vagina (including the uterus –UVP) Arises from abnormality in PF architecture (cellular or gross morphological levels) leading to mechanical failure of this support. UVP can be in the form of : Anterior compartment – cystocele Apical / central / vault – enterocele/uterine prolapse Posterior compartment – rectocele Perineum – perineal descent

4. Description – pelvis & perineum

5. The pelvic diaphragm – levator ani Oblique viewed Viewed from above

6. The pelvic lateral walls Sagittal view Covering fasciae

7. Pelvic fascia and peritoneum Pelvic ‘visceral’ fascia Pelvic peritoneum

8. Anatomical support for the GT Anatomical support of the vagina is reliant on three main mechanisms: Closure of the vagina at its introitus (by pelvic floor muscular contraction) The flap-valve effect created by the near horizontal position of the vagina on the pelvic floor Vertical suspension of the vagina by the endopelvic fascia (uterosacral ligaments) Similar and additional factors for continence

9. Pelvic viscerae and fasciae Components of the deep endopelvic connective tissue Cardinal ligaments Pubocervical septum or fascia Pubocervical ligaments Rectovaginal septum of fascia Pericervical ring

10. The ‘Endopelvic fascia’

11. Level 1: The cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the bony sacrum. Level 2: The arcus tendineous fascia pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina. Level 3: The urogenital diaphragm and the perineal body provide support to the lower part of the vagina. 3-D view of the endopelvic fascia with DeLancey’s biomechanical levels of support

12. Vaginal attachments & surrounding spaces AVASCULAR SPACES OF THE PELVIS Prevesical Paravesical Vesicovaginal Vesicocervical Rectovaginal Pararectal Retrorectal

13. Site specific defects

14. Causes

15. Symptoms Depends on the types and the severity Mostly and mild prolapse is asymptomatic Moderate or severe degrees, symptoms may include sensation of a lump inside the vagina or disturbance in the function of the affected organs, including

16. Symptoms … Bladder – stress incontinence, urgency, frequency, incomplete emptying, dribbling, recurrent urine infections Bowel – low back pain/discomfort, incomplete emptying, constipation, manual decompression, incontinence of flatus Sexual problems – lack of sensation, dyspareunia, bleeding, Others – dragging pain, backache, discharge

17. Differential diagnoses

18. Differential diagnoses

19. Classification systems

20. Baden–Walker Halfway scoring/grading system POP–Q Staging system

21. Graphic descriptions of POP POP map Grid for POP-Q measurements

22. Treatment 1. Nonsurgical treatment Observation Estrogens Pessaries Symptom directed therapy: weight loss, exercise Pelvic floor muscle rehabilitation: Kegel exercises

23. Treatment … 2 . The Surgical Management of Prolapses Main goal of the defect-specific pelvic reconstructive surgeon is the restitution of the anatomical connections of the pericervical ring Restoration of pelvic structures to normal anatomical relationship Restore and maintain urinary and fecal continence Maintain coital function Correct co-existing pelvic pathology Obtain a durable result

24. Treatment … 2. surgical Reconstructive – site specific defect repair Abdominal / vaginal sacrocolpopexy Uterosacral /sacrospinous ligament fixation by vaginal approach Sacral hysteropexy by abdominal approach Transvaginal posterior colporrhaphy Obliterative Colpocleisis / Colpectomy  Hysterectomy

25. FOR APICAL SUPPORT ( UTERINE OR VAULT PROLAPSE) Sacrocolpopexy Fixation of vagina with suspension material to the anterior longitudinal ligament of sacrum. Sacrocolpoperineopexy Same technique plus the posterior arm of mesh extends to the perineal body. Levator myorrhaphy Wide midline plication of the levator with fixation of the vaginal cuff with apical plication Mayo culdeplasty A modification of the McCall’s culdoplasty attaches the apex to plicated uterosacral ligaments. Sacrospinous ligament suspension/fixation Suspends the vaginal apex to the sacrospinous ligament extraperitoneal The enterocele, anterior and posterior walls are repaired as needed. Uterosacral ligament suspension/fixation Intraperitoneal vaginal procedure, suspension the vaginal apex to uterosacral ligaments to the level of the ischial spines

26. Anterior compartment Anterior colporrhaphy with plication of the pubourethral and vaginal fascia Anterior colporrhaphy with more vigorous plication of subpubic fascia Paravaginal repair (either vaginal or abdominal approach) Use of mesh to reinforce the anterior colporrhaphy

27. Posterior compartment Posterior colporrhaphy Midline plication of endopelvic fascia of posterior vagina Posterior site-specific repair Identification and repair of specific defects in recto-vaginal fascia With or without herniorrhaphy Trans-anal repair Rectal mucosa separated and the rectovaginal septum is plicated from rectal side.

28. Others operations Obliterative surgeries Colpocleisis Colpectomy Concomitant surgeries Hysterectomy (total, SO) Continence surgeries (sling, Burch, tapes) Rectal prolapse Perineal or abdominal procedures Cystoscopy