1. Pelvic Organ Prolapsed
Obstetrics & Gynecology 2005;106:
OBGY R2 LEE EUN SUK

2. Abstract
Pelvic organ prolapse, including anterior and posterior vaginal prolapse, uterine prolapse, & enterocele, is a common group of clinical conditions affecting millions of American women.
Pathophysiology of prolapse is multifactorial and may operate under a "multiple-hit" process in which genetically susceptible women are exposed to life events that ultimately result in the development of clinically important prolapse.
Evaluation of women with prolapse requires a comprehensive approach, with attention to function in all pelvic compartments based on a detailed patient history, physical examination, and limited testing.
Treatment is warranted based on specific symptoms, prolapse management choices fall into 2 broad categories: nonsurgical, which includes pelvic floor muscle training and pessary use; & surgical, which can be reconstructive (eg, sacral colpopexy) or obliterative (eg, colpocleisis).

3. Clinical Importance
Based on projections from the United States Census Bureau, the number of American women aged 65 years and over will double in the next 25 years, to more than 40 million women by 2030
Demand for health care services related to pelvic floor disorders
will increased at twice the rate of the population itself
Although the overall rate of prolapse surgery has dropped, this represents a substantial drop in the rate of surgery for women less than 50 years old & a moderate increase for women aged 50 years and greater

4. Clinical Importance
Fig 1

5. Pathophysiology
Table 1

6. Diagnostic Approach Women with prolapse often have urinary symptoms
Some women have stress incontinence symptoms due to urethral incompetence, but many women, particularly those with advanced anterior vaginal prolapse, are continence
Defecatory symptoms such as excessive straining, incomplete rectal emptying, or the need for perineal or vaginal pressure to accomplish defecation
Influence of prolapse on sexual functioning should be addressed in women of all ages

7. Physical Examination
Diagnostic Approach
The extent of prolapse should be systematically assessed
With advanced prolapse, determining the extent of prolapse
& its constituents ( anterior and posterior vagina; cervix or
vaginal apex ) is usually not difficult
The use of vaginal speculums or retractors is very helpful in determining what vaginal sites are affected by prolapse
An unidentified vaginal bulge can be clearly identified as the vaginal apex, once the anterior and posterior vagina are retracted

8. Physical Examination
Diagnostic Approach
fig2

9. Physical Examination
Diagnostic Approach
fig3

10. Diagnostic Approach
fig4

12. Physical Examination
Diagnostic Approach
The maximal extent of prolapse is demonstrated with a standing straining examination when the bladder is empty
Pelvic muscle function should be assessed after the bimanual
examination → palpate the pelvic muscles a few centimeters
inside the hymen, along pelvic sidewalls at the 4 & 8 o’clock
Resting tone & voluntary contraction of the anal aphincters should
be assessed during rectovaginal examination

14. Testing
Bladder Testing
At minimum, for all patients with prolapse, 3 pieces of information should be obtained;
Screening for urinary tract infection
Postvoid residual urine volume
Presence or absence of bladder sensation
Women with prolapse and urinary incontinence should have stress testing performed with the prolapse reduction because this will mimic bladder and urethral function when the prolapse is treated
In the setting of a positive reduction stress test → recommend
that as incontinence procedure should be performed at the time of
prolapse surgery

15. Indications for Treatment
Therapeutic Approach
Indications for Treatment
Choice of treatment for prolapse depends on symptoms severity and severity of prolapse
Symptoms associated with stage I or II prolapse require careful evaluation, especially if surgery is being considered
Many women with stress urinary incontinence have stage I or II , although stress incontinence is not a symptom of prolapse
; it is simply a coincident symptom

16. Therapeutic Approach
Observation
Observation is appropriate for women whose symptoms are not sufficiently bothersome to warrant active management
There is no indications for treatment, particularly surgery, for women with asymptomatic prolapse “ before the problem gets any worse”
Occasionally a patient will present with advanced prolapse, yet she will say that she’s asymptomatic → is observation still qppropriate?
An important consideration is her efficiency of bladder emptying
Other risks : exposed vaginal epithelium & evisceration

17. Nonsurgical Management
Therapeutic Approach
Nonsurgical Management
Includes adjunct therapy to address concomitant symptoms,
pelvic floor muscle training, and pessaries
Ideally, nonsurgical management will decrease the frequency
and severity of symptoms, delay or avoid surgery & potentially prevent worsening the prolapse

18. Therapeutic Approach
Adjunct Therapy
Addresses symptoms of urinary, defecatory & sexual dysfunction
Patient often present with defecatory symptoms, such as excessive straining at stool and a feeling of incomplete evacuation, and physical examination reveals stage II or early stage III posterior vaginal prolapse (rectocele) → evaluation from the GI perspective
Age-appropriate screening for colorectal cancer
: diet history (fiber and fluid intake), exercise history, review of
medications for GI adverse effects, and bowel movements
Adjunct therapy includes advice on lifestyle alterations, weight loss, and a general exercise program

19. Pelvic Floor Muscle Training
Therapeutic Approach
Pelvic Floor Muscle Training
Designed to increase the strength abd endurance of the pelvic muscles, thereby improving support to pelvic organs
“Kegel” exercises
With virtually no adverse effects, its only negative is the cost of providing instruction and follow-up for patients

20. Therapeutic Approach
Pessaries
To decrease symptom frequency and severity, delay or avoid surgery, and potentially prevent worsening of prolapse
The most important relative contraindication for pessary use occurs when the patient cannot comply with follow-up
Pessary use must be discontinued for persistent vaginal erosions
Unsuccessful fitting is associated with short vaginal length (less than 7cm) and wide introitus ( 4 finger-breadths)

21. Nonsurgical Management

22. Therapeutic Approach
Pessaries
Separated into 2 broad categories : support and space-filling
Ring pessary (with diaphragm) and other support pessaries are commonly recommended for stage II and early stage III
Space-filling pessaries such as the Gellhorn are usually used for more advanced prolapse
If some perineal support is preserved, a ring pessary ( without support when cervix is present, with support after hysterectomy)
is good first choice

23. Nonsurgical Management

24. Therapeutic Approach
Pessaries
Gellhorn pessaries are useful for women with more advanced prolapse and less perineal support because they sometimes
stay in place when ring pessaries do not
The Gellhorn is fitted so that the disk is centered in the upper vagina & the stem points downward behind the perineal body

25. Nonsurgical Management

26. Therapeutic Approach
Pessaries
The goal of changing the pessary at frequent intervals to prevent vaginal irritation that leads to discharge, infection, and erosion
If daily changing is too bothersome, a schedule of weekly or twice-weekly removal can be used
Vaginal estrogen is commly employed with pessaries
In women with vaginal atrophy at pessary initiation, local estrogen is important to prevent vaginal erosions

27. Surgical Management - Approach
Approach to prolapse surgery include vaginal, abdominal, and laparoscopic routes or combination of approaches
Vaginal approach results in fewer wound complications, less postoperative pain, shorter hospital stay, and less cost than abdominal surgery
Surgical procedures for prolapse : cathegorized into 3 groups
Restorative → use the patient’s endogenous support structures
Compensatory → replace deficient support with some type of graft
Obliterative → close the vagina

28. Prolapse Procedures – Anterior Vaginal Repair
Surgical Management
Prolapse Procedures – Anterior Vaginal Repair
Traditionally repaired with anterior colporrhaphy
→ vaginal epithelium separated from the underlying fibromuscular
connective tissue, followed by midline plication of the vaginal
muscularis with interrupted stitches
→ excision of excess epithelium & closure
Richardson reintroduced the concept of paravaginal repair
→ reattaches the anterior lateral vaginal sulcus to the obturator
internus muscle and fascia at the level of the arcus tendineus
fasia pelvis (“white line”) via transvaginal or retropubic access

29. Paravaginal defects -Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop)

30. Prolapse Procedures – Posterior Vaginal Repair
Surgical Management
Prolapse Procedures – Posterior Vaginal Repair
Traditionally posterior colporrhaphy
→ vaginal epithelium separated from the underlying fibromuscular
connective tissue (rectovaginal septum, in between the vaginal
muscularis and the rectovaginal adventitia) followed by midline
plication of the vaginal muscularis with interrupted stitches
→ excision of excess epithelium & closure
Other procedures can be combined with posterior colporrhaphy, such as levator ani plication and peroneorrhaphy
Dyspareunia after posterior colporrhaphy
→ blamed on levator ani plication
& narrowing can also occur with overzealous perineorrhaphy
The vaginal configuration is altered by the Burch procedure
→ the upward displacement of the anterior vaginal tube
→ create a transverse ridge in the posterior vagina

31. Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage

32. Prolapse Procedures – Posterior Vaginal Repair
Surgical Management
Prolapse Procedures – Posterior Vaginal Repair
Despite careful attention to ensure adequate introital caliber after posterior repair, 38% of women after Burch and posterior repair
→ persistent dyspareunia 1 year or more after surgery
Levator ani plication is associated with postoperative dyspareunia
→ recommend not to be performed in sexually active women
In non-sexually active women, levator ani plication performed to reinforce the repair, intentionally narrow the mid & lower vagina
; high perineorrhaphy can be added to further close the introitus

33. Prolapse Procedures – Vaginal Apical Repair
Surgical Management
Prolapse Procedures – Vaginal Apical Repair
Apical vaginal prolapse includes uterine prolapse with or without enterocele and vaginal vault prolapse, typically with enterocele
The standard treatment for symptomatic uterine prolapse
→ hysterectomy with procedure to suspend the vaginal apex,
address enterocele when indicated, repair coexisting anterior
& posterior vaginal prolapse
→ perform anti-incontinence procedure

34. Vaginal Apical Repair
Enterocele Repair
Whether by vaginal, abdominal, of laparoscopic access, enterocele repair is traditionally performed by sharply dissecting the peritoneal sac from the rectum and bladder
A purse-string suture can be used to close the peritoneum
as high as possible

35. Sacrospinous Ligament Suspension
Vaginal Apical Repair
Sacrospinous Ligament Suspension
Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle

36. Iliococcygeal vaginal suspension
Vaginal Apical Repair
Iliococcygeal vaginal suspension
Iliococcygeal vaginal suspension involves attachment of vaginal apex to the iliococcygeus muscle and fascia, usually bilaterally

37. Uterosacral Ligament Suspension
Vaginal Apical Repair
Uterosacral Ligament Suspension
Used prophylactically at hysterectomy or therapeutically for vaginal apical suspension
Once access to the posterior cul-de-sac has been attained, the uterosacral ligament remnant can be found
Sutures in each ligament and incorporated into the ant & post fibromuscular layer of vagina

38. Nonsurgical Management

39. Comparison of Vaginal Approaches to Apical Repair
Prolapse procedure
Comparison of Vaginal Approaches to Apical Repair
Sacrospinous ligament suspension may leave the anterior vaginal at greater risk for subsequent failure & because the procedure is extraperitoneal → rare ureteral and rectal injury
Iliococcygeal suspension is straightforward procedure to learn and teach. It carriers virtually no risk of ureteral or small bowel injury, there are no vital structures nearby at risk for surgical injury
Uterosacral ligament suspension traditionally requires peritoneal entry → challenging in posthysterectomy prolapse, especially in the setting of bowel adhesions → engendering the rare occurrence of bowel injury
Uterosacral ligament suspension carreies a risk of ureteral injury
(usually kinking due to medial displacement or suture ligation that impedes urinary flow)

40. Abdominal Apical Repair
Prolapse procedure
Abdominal Apical Repair
Abdominal Sacral Colpopexy uses graft material attached to the anterior and posterior vaginal apex and suspended to the anterior longitudinal ligament of the sacrum for repair of apical prolapse
Peritoneal closure over the graft & obliteration of the cul-de-sac for treatment or prevention of enterocele
The cure rate range from 78% to 100%
Complications
: intra-operative hemorrhage, laparotomy (adhesion & small bowel
obstruction) , and graft infection or erosion

41. Comparison of Abdominal and Vaginal Approaches to Apical Repair
Prolapse procedure
Comparison of Abdominal and Vaginal Approaches to Apical Repair
Success rates appear to favor the abdominal approach to apical vaginal prolapse
Abdominal sacral colpopexy is more durable in providing apical support, but at the cost of increased complications
Younger women benefit more also likely to be more from durability, with the reduced chance they will need prolapse surgery in future

42. Nonsurgical Management

43. Prolapse procedure
Colpocleisis
In a healthy, sexually active woman the vagina may be surgically attached to the sacrospinous ligament, sacrum or fascia support system. But, they can be associated with occasional serious complications such as severe hemorrhage or major nerve injury
In those frail elderly women who do not wish to be sexually active in the future → total colpocleisis is a simple, safe, and effective surgical procedure that reliably relieves these women of their symptoms
Total colpocleisis procedure often coupled with a tension free vaginal tape (TVT) sling procedure for urinary incontinence

44. Surgical Management
Diagnosis and Treatment of Stress Incontinence with Pelvic Organ Prolapse
Stress Incontinence (activity leakage)
Loss of urine during coughing, sneezing, laughing or lifting something heavy. These activities cause an increase in "belly pressure“
→ forces the urine out of the bladder
Stress incontinence occurs almost exclusively in women & thought to be due to "pelvic (vaginal) relaxation" from childbirth or aging.

45. Surgical Management
Diagnosis and Treatment of Stress Incontinence with Pelvic Organ Prolapse
Stress Incontinence - Treatments
    Conservative Therapy         Pelvic Floor Exercises         Urinary Meatal Occlusion Devices         Collagen Injections
   Urinary Incontinence Surgery         Anterior Repair and Kelly plication         Pubovaginal Sling Procedures         TVT Sling Surgical Procedures         Burch Urethropexy Procedures
In an attempt to support the urethra, actually the vagina under and beside the urethra is the area which the operation takes place. The two most successful operations described
→ Pubovaginal Sling procedure & Burch urethropexy
(colposuspension)

46. Surgical Management
Adjunctive Materials
The most common prolase procedures using ajunctive materials are abdominal sacral colpopexy and anterior & posterior vaginal repairs
The ideal adjunctive material should be biocompatible yet inert, nonallergenic, noninflammatory, resistant to mechanical stress and conveniently available
It is critically important for surgeons to discuss the use of adjunctive materials with patients before surgery so patients are well-informed of risks and benefits and participate in the decision to use materials