Pelvic Floor Prolapse

M L Padwick MD FRCOG

IN THE NAME OF GOD

What is prolapse ?

•Prolapse is a condition in which organs, which are normally supported by the pelvic floor, namely the bladder, bowel and uterus, herniate or protrude into the vagina. This occurs as a result of damage to the muscles and ligaments making up the pelvic floor support. At least half of women who have children will experience prolapse in later life.

Statistics

• ratio surgery for prolapse vs incontinence: 2:1

•prevalence of 31% in women aged 29-59 yrs

•20% of women on gynaecology waiting lists

•11% lifetime risk of at least one operation

• re-operation in 30% of cases

Factors associated with pelvic floor

prolapse•age

•parity

•big babies

•menopause

•obesity

•occupation

•home delivery

• family history

Diagnostic Approach

•fig4

Pathophysiology

•Table 1

Pathogenesis

•childbirth

•connective tissue disorders

•menopause

•chronic intra-abdominal pressure

• iatrogenic (hysterectomy)

What are the symptoms of pelvic

floor prolapse?•This depends on the types and the severity of the prolapse.

•Generally, most women are not aware of the presence of mild prolapse.

•When prolapse is moderate or severe, symptoms may include sensation of a lump inside the vagina or disturbance in the function of the affected organs, such as:

Bladder

•stress incontinence

•urgency

• frequency

• incomplete emptying

•dribbling

•recurrent urine infections

Bowel

• low back pain or discomfort

• incomplete emptying

• constipation

• manual decompression

• incontinence of flatus

Sexual problems

• looseness and lack of sensation

• difficult entry and expulsion

• discomfort or painful intercourse

• vaginal bleeding in neglected cases

Other

•can see and feel it

•back ache

•dragging sensation

• increased discharge

•skin irritation

How can prolapse be prevented?

•appropriate antenatal and intrapartum care

•regular postnatal pelvic floor exercises to compensate for childbirth damage

• in postmenopausal women, oestrogen cream helps maintain tissue strength

Living with pelvic organ prolapse

Avoid standing for long periods of time.

Do pelvic floor exercises

Prevent or correct constipation

Wear a girdle

Try yoga

Wear a pantyliner or incontinence padExplore alternatives to sexual intercourse

Carry wet wipes

Pelvic organ prolapse Non-

surgical treatments•Physiotherapy - pelvic floor exercises

and

•Hormone Replacement Therapy (HRT) - may be local oestragens

•Vaginal Pessaries - many choices but regular checks and changes needed and best combined with oestragen creams

Genital prolapse and Pelvic floor muscle exercises

SummaryWe found no RCTs or observational studies of

sufficient quality examining the effects of pelvic floor muscle exercises on the symptoms of genital

prolapse.CommentAlthough pelvic floor muscle exercises appear to be effective in reducing the symptoms of urinary stress incontinence (see benefits of pelvic floor

muscle exercises in stress incontinence chapter), their usefulness in the treatment of genital

prolapse is unproven.

Nutrititon.Supplements

The supplement programme below should be taken for at least three months in order to achieve best results

Your supplement plan— A good multivitamin and mineral tablet

— Vitamin C with bioflavonoids (1000mg twice a day)— Vitamin A (as beta-carotene at 25,000iu per day)

— Proanthocyanidins (50 mg per day) — Manganese (5mg per day)

— Cranberry supplement (only needed for stress incontinence)

At the end of three months you should reassess your condition and adjust your supplement programme accordingly.

Nonsurgical Management

Nonsurgical Management

The Surgical Management of

Prolapses

•Restoration of pelvic structures to normal anatomical relationship

•Restore and maintain urinary &/or faecal continence

•Maintain coital function

•Correct co-existing pelvic pathology

•Obtain a durable result

Principles of Pelvic Reconstructive Surgery

The Surgical Management of

Prolapses

• Careful history

•Physical examination

•Neurological assessment

•Urodynamic evaluation

•Anorectal investigations

Patient assessment

The Surgical Management of

Prolapses• Surgeons' own expertise, experience and

preference

• Pre-op voiding or bowel dysfunction

• Duration of efficacy

• Complications

• Learning curveof life factors

• First or repeat surgery

• The need to treat other pathology

• Fitness of the patient

• Underlying pathology

• Success rates for different procedures

Factors affecting choice of operation

The Surgical Management of

Prolapses

•Uterovaginal prolapse is multifactorial in origin

•Treatment needs to be individualised

•Approach often needs to be multidisciplinary

•Quality of life assessment is essential

Summary - Female Pelvic Organ Prolapse

Types Of Surgery

•Anterior and posterior repairs

•Vaginal hysterectomy

•Laparoscopic vaginal vault suspension (± mesh)

•Laparoscopic sacrocolpopexy

•Laser Vaginal Rejuvenation

•Designer Laser Vaginoplasty

• Vaginal approach to prolapse repair incorporating mesh

•Laparoscopic paravaginal repairs

Total colpocleisis procedure often coupled

with a tension free vaginal tape (TVT) sling procedure for urinary

incontinence

Sacrocolpopexy and paravaginal repairSacrocolpopexy and paravaginal repairfor total pelvic floor prolapsefor total pelvic floor prolapse