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

“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

What is POP ? Herniation of adjacent structures into vagina

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

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

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

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

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

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

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

LEVEL 2 and LEVEL 3 SUPPORTS

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

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

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

POP-Q System

POPQ

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

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

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

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

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

Entero-Rectocele

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

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

Procidentia

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

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

Open Sacrocolpopexy sigmoid Sacral promontory rectum vault bladder

CLOSURE OF CUL-de-SAC prevents ENTEROCELE FORMATION

Transvaginal Sacrospinous Ligament Fixation

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

CONCLUSION

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

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 !

Thank You for your Patience !