1. Pelvic Organ Prolapse : Overview of Causes and Surgical Options
Vincent Tse MB BS ( Hons ) MS ( Syd ) FRACS
Male and Female Incontinence Urodynamics Neuro-urology Pelvic Floor Reconstructive Surgery
Department of Urology, Concord Hospital, Sydney, NSW

2. “Pelvic Floor Reconstructive Surgery”
Recent time becoming a cross-disciplinary field
Gynaecologist
Urologist the PELVIC FLOOR SURGEON
Colorectal surgeon
Common interest and training in pelvic floor dysfunction
Various national and international societies collaborating research in this growing area

3. What is POP ?
Herniation of adjacent structures into vagina

4. What is Pelvic Organ Prolapse ? (POP)
Herniation of various pelvic structures adjacent to the vagina
Can be in the form of :
anterior compartment – cystocele
vault – enterocele/uterine prolapse
posterior compartment – rectocele
perineum – perineal descent

6. POP Prevalence 20-30% in multiparous 2% in nulliparous
20% in post-gynaecological surgery
10% in requiring POP surgery in lifetime

7. Pathophysiology of POP
Central is genetic predispositon
Age
Childbirth ( pudendal nerve injury denerevates levators)
One birth doubles POP risk
10-15% increase every subsequent birth
Nerves
Collagen
Abdo pressure
BMI > 30 increases risk by 40-75%
Surgery
Burch
Hysterectomy

8. Pathophysiology of POP
... Leading to herniation of various pelvic structures adjacent to the vagina
from
DETACHMENT or DISRUPTION

9. Types of Defects Detachment Disruption
vagina is broken away from the pelvis and needs to be reattached
Disruption
vaginal structure is torn and needs to be patched or repaired

10. Normal Pelvic Support Muscle Ligaments Nerves Blood Supply
Levator ani ( ‘pelvic floor muscle’)
Obturator muscles
Ligaments
Endopelvic fascia
Pubourethral, urethropelvic, vesicopelvic, cardinal, uterosacral, rectovaginal septum …
Nerves
Blood Supply

11. Level 1 support – vault/uterine prolapse
Level 2 Support – cystocele, enterocele,rectocele
Level 3 Support –Perineal descent,low rectocele

13. LEVEL 2 and LEVEL 3 SUPPORTS

15. Level 2 Support Defects - Anterior Compartment : The Cystocele
2 types :
CENTRAL DEFECT
Defect in fascia between vagina and bladder
Loss of central rugae
Looks like a round bulge on Valsalva
LATERAL DEFECT
Defect in fascia supporting lateral bladder to pelvic side wall
Central rugae intact
Flat sagging anterior vagina
>80% are mixed

18. Anterior Compartment Prolapse : Cystocele
Patient may present with :
Asymptomatic
‘bulge’ or pressure in vagina
Often worse at end of day
Back ache
Irritation from contact with underwear
Voiding difficulty and Recurrent UTIs
Obstructive uropathy
Cystocele are often accompanied by :
Prolapse of other compartments prolapse ( eg. vault or rectocele )
STRESS incontinence

20. Grading of Pelvic Organ Prolapse ( POP )
Baden-Walker ( older, more clinically useful )
Grade 1: minimal displacement with straining
Grade 2: towards introitus with straining
Grade 3: to and beyond level of introitus with straining
Grade 4 : outside introitus at rest
POP-Q ( newer … )
Cumbersome and questionable clinical utility other than for research ( standardisation ) purposes

21. POP-Q System

22. POPQ

23. Management Conservative Surgical Simply observe Vaginal ring pessary
Topical estrogen cream if indicated
Surgical
Most pts need pre-operative urodynamics to exclude occult stress incontinence
Anterior colporraphy ( central defect )
Paravaginal repair ( lateral defect )
+/- TVT or fascial pubovaginal sling

24. Type of Surgery Depends on …
Detachment
vagina is broken away from the pelvis and needs to be reattached
Disruption
vaginal structure is torn and needs to be patched or repaired

26. Anterior Compartment
To Replace
Add mesh/biologic
(graft augmentation)

27. Mesh Use in PRIMARY Cystocele Repair
Author
Year
Mesh N
F- up mths
Anatom.
success %
Infection%
Vaginal erosion %
Julian
1996
Marlex 12 24
100
8.3
Flood
1998
142 36
94.4
3.5
2.1
Adhoute
2004
Gynemesh 52 27 95
3.8
Shah
Prolene 29 25
93.3
6.7
Dwyer
Atrium 47 94 7
Milani 63 17 13
de Tayrac
2007
Polypropylene
132
92.3
6.3
Hiltunin
104
(vs 61.5 AR)
Sivaslioglu
2008 90 91
(vs 72% AR)
6.9
Nieminen
105 89
(vs 59% AR)
8.0

28. Level 2 Support Defects - Posterior Compartment: The Rectocele
May present with :
Asymptomatic
Defecatory difficulty/constipation
Digital manipulation of posterior vaginal wall
Deep pelvic pain
Back pain
Urinary difficulty

29. Entero-Rectocele

30. Management Conservative Surgical Bowel softeners
Exclude other possible low rectal conditions (eg. cancer)
Ring Pessary
Surgical
Pre-operative defecatory rectoproctography
Posterior colporraphy
Transanal Delorme repair
Perineorraphy if perineal descent present

31. Level 1 Support Defects : Vault / Uterine Prolapse
Presentation often similar to cystocele
Often co-exist with cystocele/rectocele
Beware of the little old lady with unexplained back pain, recurrent UTIs, or renal failure – exclude PROLAPSE

32. Procidentia

33. Management Conservative Surgical In general, Observe Ring pessary
Topical Estrogen if required
Surgical
In general,
YOUNGER and SEXUALLY ACTIVE
Suspend to the sacrum
OLDER and NON-SEXUALLY ACTIVE
Suspend to the sacrospinous ligament

34. Surgical Management : Level 1
FUNCTIONAL
To sacrum
Sacrocolpopexy/hysteropexy
Open, laparoscopic, robotic
Uterosacral ligament
To other level 1 sites
Sacrospinous ligament
Iliococcygeal fascia, etc
NON-FUNCTIONAL
colpocleisis

36. Open Sacrocolpopexy
sigmoid
Sacral promontory
rectum
vault
bladder

37. CLOSURE OF CUL-de-SAC prevents ENTEROCELE FORMATION

38. Transvaginal Sacrospinous Ligament Fixation

39. Open vs Transvaginal Sacrocolpopexy
Level 1 evidence – most durable and effective
Preserves vaginal axis hence less dyspareunia
Lower complication profile
Rx of choice for recurrence
Longer stay and return to activity
Transvaginal
Equally effective but …
Alters vaginal axis, hence higher dyspareunia rate ( 15%)
May be more appropriate for the older, less sexually active
Shorter stay and less invasive

40. CONCLUSION

41. Conclusion Causes of POP Level 1 and 2 support defects
Overview of conservative and operative management of cystocele, rectocele and vault prolapse

42. Take Home Messages Aetiology is multifactorial
CAVEAT : pelvic examination in the elderly female with confusion, recurrent UTIs, unexplained renal impairment !
Conservative management with pessary
Pelvic floor exercises may retard the progression of POP, but will not reverse any existing POP
Management of pelvic prolapse are now managed by pelvic floor reconstructive surgeons who have had special training and may be a gynaecologist, urologist or colorectal surgeon !

43. Thank You for your Patience !