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Pelvic Organ Prolapse : Overview of Causes and Surgical Options Vincent Tse MB BS ( Hons ) MS ( Syd ) FRACS Male and Female Incontinence Urodynamics Neuro-urology.

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Presentation on theme: "Pelvic Organ Prolapse : Overview of Causes and Surgical Options Vincent Tse MB BS ( Hons ) MS ( Syd ) FRACS Male and Female Incontinence Urodynamics Neuro-urology."— Presentation transcript:

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

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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 – 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 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,recto cele Level 3 Support – Perineal descent,low rectocele

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13 LEVEL 2 and LEVEL 3 SUPPORTS

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

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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

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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 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

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

27 AuthorYearMeshNF- up mths Anatom. success % Infection%Vaginal erosion % Julian1996Marlex Flood1998Marlex Adhoute2004Gynemesh Shah2004Prolene Dwyer2004Atrium Milani2004Prolene de Tayrac2007Polypropylene Hiltunin2007Polypropylene (vs 61.5 AR) 017 Sivaslioglu2008Polypropylene (vs 72% AR) 06.9 Nieminen2008Polypropylene (vs 59% AR) 08.0 Mesh Use in PRIMARY Cystocele Repair

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 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 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

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36 Open Sacrocolpopexy rectum sigmoid bladder vault Sacral promontory

37 CLOSURE OF CUL-de-SAC prevents ENTEROCELE FORMATION

38 Transvaginal Sacrospinous Ligament Fixation

39 Open vs Transvaginal Sacrocolpopexy Open 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 !


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