1. Prolapse and Incontinence
Craig Dyson
Sioned Griffiths
October 2013

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

3. Anatomy

4. 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.

5. 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.

6. 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 year old’s but uncertain
Uterocoele, Cystocoele, Rectocoele, Enterocoele

7. 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.

8. 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

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

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

11. Types
Posterior
Rectocoele

12. 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

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

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

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

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

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

18. 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.

19. 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

20. 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: PMC 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): 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