Prolapse and Incontinence Craig Dyson Sioned Griffiths October 2013

Contents Normal Anatomy Causes of prolapse Types of Prolapse Investigation Management Treatment of prolapse described since beginning of written history.

Anatomy

Anatomy When 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.

Anatomy The 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.

Prolapse “To fall out” Protrusion of an organ or structure beyond its normal confines and with an epithelial surface Genitourinary prolapse – Descent of one or more of pelvic organs. 41% of 50-79 year old’s but uncertain Uterocoele, Cystocoele, Rectocoele, Enterocoele

Pathophysiology Levator Ani/Endopelvic Fascia important Damage to these structures can occur through: Trauma Neuropathic Injury Disruption/Stretching Multifactorial – 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.

Risk Factors Increasing Age (Double risk with every decade) Vaginal Delivery Increasing parity Obesity Spina Bifida Pregnancy Variables Macrosomia Prolonged 2nd stage Episiotomy Use of forceps/oxytocin FH of prolapse Constipation Connective Tissue Disorder Occupation

Types Anterior Urethrocoele Cystocoele Both Urinary Stress Incontinence Rare Cystocoele Increased frequency UTI Sensation of mass No Symptoms Both Most Common

Types Middle Uterine Prolapse Vaginal Vault Prolapse Enterocoele Post Hysterectomy Assoc with cystocoele, rectocoele and enterocoele. Retention Enterocoele Pouch of Douglas Cough Impulse

Types Posterior Rectocoele

POPQ System Pelvic Organ Prolapse Quantification System Valsalva - ? Left Lateral Stage 0 Stage 1 – 1cm above hymen Stage 2 - Within 1 cm of hymen Stage 3 - >1cm below plane of hymen but <2cm of total length of vagina Stage 4 – Complete eversion of vagina Introitus – Above – Level 1, At – Level 2, Below – Level 3

Symptoms General Urinary Coital Bowel Fullness Sensation of bulge Backache Urinary Incontinence Frequency Coital Dypareunia Flatus Bowel Constipation/Incontinence Need to apply digital pressure

Investigations History and Examination Urinalysis Post-Voidal Urine volume testing Urodynamics US Urea/Creatinine

Management Conservative Watchful Waiting Lifestyle Modification Pelvic Floor Exercises Evidence? Vaginal Oestrogen Creams Pessary

Pessary Inserted into vagina to reduce prolapse Made of silicon or plastic or Soaked in wine… Good short term option

Management Surgical Effective Re-operation required in 29% of cases Fitness of patient Sexually Active Surgeons Advice

Surgery Anterior Colporrhaphy Hysterectomy Sacrospinous Fixation Involves plication of anterior vaginal wall to reinforce. Hysterectomy Sacrospinous Fixation Unilateral or bilateral fixation of uterus to sacrospinous ligament Sacocolpoplexy Mesh used to attach top of vagina to sacrum.

Summary Prolapse is increasingly common with age. Can be classified according to compartment or level of prolapse Can be clear on examination Good conservative and surgical options available Good prognosis

References Pessary 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: PMC1472875. Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Sender Herschorn Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092–1139. Rectocele | Vaginal Surgery & Urogynecology Institute .vaginalsurgeryandurogynecologyinstitute.com Int J Med Sci 2012; 9(10):894-900. doi:10.7150/ijms.4829. 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 http://www.patient.co.uk/health/Genitourinary-GU-Prolapse.htm www.pelvicfloor.com/knowledge/imagelibrary/1/img/1.jpg www.bristolsurgery.com/images/Preop%20Rectocele.jpg