4AnatomyWhen the body is in a standing position, the levator plate is horizontal and supports the rectum and upper two thirds of vagina above it. Weakness of the levator ani may loosen the sling behind the anorectum and cause the levator plate to sag. This opens the urogenital hiatus and predisposes to pelvic organ prolapse. Women with prolapse have been shown to have an enlarged urogenital hiatus on clinical examination.
5AnatomyThe perineal body is a pyramidal fibromuscular structure in the midline between the anus and vagina with the rectovaginal septum at its cephalad apex. Attached to the perineal body are the rectum, vaginal slips from the pubococcygeus, perineal muscles, and the anal sphincter; it also contains smooth muscle, elastic fibers, and nerve endings. During childbirth, the perineal body distends and then recoils. It is an important part of the pelvic floor; just above it are the vagina and the uterus. Acquired weakness of the perineal body gives rise to elongation and predisposes to defects such as rectocele and enterocele.
6Prolapse“To fall out”Protrusion of an organ or structure beyond its normal confines and with an epithelial surfaceGenitourinary prolapse – Descent of one or more of pelvic organs.41% of year old’s but uncertainUterocoele, Cystocoele, Rectocoele, Enterocoele
7Pathophysiology Levator Ani/Endopelvic Fascia important Damage to these structures can occur through:TraumaNeuropathic InjuryDisruption/StretchingMultifactorial – Orientation of bones may be a factor.The pelvic organs are mainly supported by the levator ani muscles and the endopelvic fascia (a connective tissue network connecting the organs to the pelvic muscles and bones). Genitourinary prolapse occurs when this support structure is weakened through direct muscle trauma, neuropathic injury, disruption or stretching. A multifactorial cause for this damage is likely. The orientation and shape of the bones of the pelvis have also been implicated in the pathogenesis of genitourinary prolapse.
8Risk Factors Increasing Age (Double risk with every decade) Vaginal DeliveryIncreasing parityObesitySpina BifidaPregnancy VariablesMacrosomiaProlonged 2nd stageEpisiotomyUse of forceps/oxytocinFH of prolapseConstipationConnective Tissue DisorderOccupation
9Types Anterior Urethrocoele Cystocoele Both Urinary Stress IncontinenceRareCystocoeleIncreased frequencyUTISensation of massNo SymptomsBothMost Common
10Types Middle Uterine Prolapse Vaginal Vault Prolapse Enterocoele Post HysterectomyAssoc with cystocoele, rectocoele and enterocoele.RetentionEnterocoelePouch of DouglasCough Impulse
12POPQ System Pelvic Organ Prolapse Quantification System Valsalva - ? Left LateralStage 0Stage 1 – 1cm above hymenStage 2 - Within 1 cm of hymenStage 3 - >1cm below plane of hymen but <2cm of total length of vaginaStage 4 – Complete eversion of vaginaIntroitus – Above – Level 1, At – Level 2, Below – Level 3
13Symptoms General Urinary Coital Bowel Fullness Sensation of bulge BackacheUrinaryIncontinenceFrequencyCoitalDypareuniaFlatusBowelConstipation/IncontinenceNeed to apply digital pressure
14Investigations History and Examination Urinalysis Post-Voidal Urine volume testingUrodynamicsUSUrea/Creatinine
16Pessary Inserted into vagina to reduce prolapse Made of silicon or plastic or Soaked in wine…Good short term option
17Management Surgical Effective Re-operation required in 29% of cases Fitness of patientSexually ActiveSurgeons Advice
18Surgery Anterior Colporrhaphy Hysterectomy Sacrospinous Fixation Involves plication of anterior vaginal wall to reinforce.HysterectomySacrospinous FixationUnilateral or bilateral fixation of uterus to sacrospinous ligamentSacocolpoplexyMesh used to attach top of vagina to sacrum.
19Summary Prolapse is increasingly common with age. Can be classified according to compartment or level of prolapseCan be clear on examinationGood conservative and surgical options availableGood prognosis
20ReferencesPessary treatment for pelvic organ prolapse and health-related quality of life: a review. Lamers BH, Broekman BM, Milani AL - Int Urogynecol J (2011)Rev Urol. 2004; 6(Suppl 5): S2–S10. PMCID: PMC Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Sender HerschornHerschorn S, Carr LK. In: Campbell’s Urology. 2002:1092–1139.Rectocele | Vaginal Surgery & Urogynecology Institute .vaginalsurgeryandurogynecologyinstitute.comInt J Med Sci 2012; 9(10): doi: /ijms Three-dimensional Ultrasound Appearance of Pelvic Floor in Nulliparous Women and Pelvic Organ Prolapse Women. Tao Ying Corresponding address, Qin Li, Lian Xu, Feifei Liu, Bing Hu