Pelvic Organ Prolaspe

Define POP

a form of ‘hernia’ involving the weakness of the support of the midline structures of the pelvis resulting in the herniation of these organs into the vagina.

Upper tier support of pelvic floor

What do they do?

• Endopelvic fascia

• Round ligaments

• Broad ligaments

Maintain uterine anteversion and anteflexion(tilted forward)

Middle tier supports

And what they prevent

Which is the strongest support

Pericervical ring consists of:

1. Pubocervical ligament: supports anterior vagina wall and bladder, damage causes cystocele or urethrocele

2. Cardinal ligament/transverse cervical Ligament: one of the strongest supports of the uterus: weakness caused by uterine prolapse

3. Uterosacral ligaments: weakness causes uterine prolapse and vaginal vault Prolaspe

4. rectovaginal septum: weakness causes rectocele

• Pelvic cellular tissues

Lower tier supports

Pelvic floor muscles : levator Ani

• Endopelvic fascia

Anatomical Risk factors

Anatomical

• Gravitational stress

• Anterior inclination of the pelvis

• Stress of parturition

• Pelvic floor weakness due to urogenital hiatus

• Inherent (genetic) weakness of the pelvic floor

Acquired & Congenital RFs for POP

Acquired

1. Trauma during vaginal delivery • Ligaments• Endopelvic fascia • Levator muscle• Perineal body • nerves

2. Congenital

• Connective tissue disorders – Marfan’s Syndrome, Ehlers-Danlos Syndrome. • Spina bifida

Aggravating factors for POP

•Postmenopausal Atrophy

• Advanced age

• Chronic increased intra-abdominal pressure • Weight lifting

• Obesity

• Smoking

• Aesthenia

• Large uterus

Types of vaginal Prolaspe (anterior and posterior)

Anterior

1. Urethrocele: prolaspe of urethra into anterior vaginal wall

2. Cystocele: prolaspe of bladder into anterior vaginal wall(pubocervical ligament)

Posterior

Rectocele: prolaspe of the rectum into the posterior vaginal wall(rectovaginal Ligament)

enterocele: herniation of small bowel int upper posterior vaginal wall

Classify Uterine Prolaspe using

Braden-Walker Halfway System

•Grade 0 – normal position

•Grade 1 – Descent halfway to the hymen

• Grade 2 – Descent to the hymen

• Grade 3 – Descent halfway past the hymen

• Grade 4 – Maximum Prolapse

Clinical features

• Feeling of something coming down from the vagina

• Back pain or dragging pain in the pelvis

• Excessive white or blood stained vaginal discharged

•Feeling of fullness in vagina

• Urinary symptoms – urgency, frequency, feeling of incomplete voiding, dysuria, stress incontinence, Urinary retention

• Bowel – constipation, difficulty in passing stool

Management modalities

• Preventive

• Conservative

• Surgery

Prevention of POP

• Adequate antenatal and intrapartum care

• Adequate postnatal care – early ambulation, pelvic exercises

• Family planning with restriction of parity

• Avoid heavy weight lifting, chronic cough, constipation

Indications for pessaries

•Early pregnancy

• Puerperium

• Patients unfit for surgery

• Unwillingness for surgery

• For improvement of urinary symptoms • Mild POP

Indications for pessaries

•Early pregnancy

• Puerperium

• Patients unfit for surgery

• Unwillingness for surgery

• For improvement of urinary symptoms • Mild POP

Image of rectocele

Image of urethrocele

Treatment for cytocele or urethrocele

And what happens in it

Anterior colporrhaphy

Dissection of anterior vagina wall to free it from the bladder

Repair of pubocervical fascia

Vaginal wall is reconstructed

Treatment of rectocele

Posterior colpoperineorrhaphy

Uterine preserving surgery for POP

Describe it

Fothergill’s operation or Manchester operation/Manchester repair)

It corrects prolapse by shortening and reattaching the supporting ligaments around the cervix and repairing associated vaginal wall defects using anterior colporrhaphy, posterior colpoperineorrhaphy.

Ideal operation for procidentia in postmenopausal women

Vaginal hysterectomy and pelvic floor repair

Other surgical operations

1. Colpocleisis: vaginal canal is closed/obliterated

2. Le Fort operation: partial colpocleisis

3. Sacrospinous Colpoplexy:This is a reconstructive procedure in which the vaginal apex (vault) or cervix is attached to the sacrospinous ligament to restore pelvic support

Uterine preserving surgeries

Manchester/Forthergills operation

Hysteropexy: suspends uterus w/o removing it