PELVIC ORGAN PROLAPSE & ITS

ASSOCIATED COMPLICATIONS

GEOFFREY MAINAR QUE , MD., DPOGS, FPSURPS

Urogynecologist and Reconstructive Pelvic SurgeonObstetrician and Gynecologist

• Incidence• Risk Factors• Classification• Diagnostic Evaluation

• Clinical Evaluation• Laboratory Investigation

• Conservative Management• Surgical Management

• Anterior Vaginal Wall • Posterior Vaginal Wall• Middle or Apical Vaginal Wall

LEARNING OBJECTIVES

• Abnormal descent or herniation of the pelvic organs from their normal attachment sites

• Poorly understood condition that has relatively high recurrence rate (nearly 30%)

• Presently, no surgical form of treatment offers 100% chance of cure

• Many have modified , improvised or developed various surgical techniques all in the hopes of improving outcomes

PELVIC ORGAN PROLAPSE

Womens Health Initiative (WHI) - 16, 616

13,000 or 80% of women 50-79 years oldhave some degree of prolapse

Cystocele - 34.3% Rectocele - 18.3% Uterine Prolapse - 14.2%

Hendrix SL, et al. AJOG, June, 2002. Pelvic organ prolapse in the Women’s Health Initiative: Gravity and gravidity.

INCIDENCE

PREDISPOSE INCITE PROMOTE DECOMPOSE

Genetic (Congenital / Hereditary)

Race (white>african)

Gender (F > M)

Pregnancy & Delivery

Surgery ( such as hysterectomy for prolapse)

Obesity Smoking Pulmonary Disease (Chronic cough)

RecreationalOccupationalActivities (frequent or heavy lifting)

Aging Menopause

Bump RC, Norton PA. Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 1998;25:723–46. Copyright 1998

PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)

PELVIC ORGAN PROLAPSE QUANTIFICATION SYSTEM (POP-Q)

AaAnterior Wall

BaAnterior Wall

CCervix/ Cuff

GHGenital Hiatus

PBPerineal Body

TVLTotal Vaginal Length

ApPosterior Wall

BpPosterior Wall

DPosterior Fornix

POP-Q.exe

Inter-Observer and Intra-Observer Evaluation

Quantitates the Severity of Prolapse

Quantitates the Result of Treatments

POP-Q ICS ADVANTAGE

CLINICAL EVALUATION• “ PALPABLE INTROITAL MASS ”

• Common Complaint • Not specific to one compartment

• COMMONLY ASSOCIATED • Urinary Stress Incontinence• Transient Voiding Dysfunction

• Advance prolapse makes the patient continent due urethral kinking or obstruction

• 15 - 80% occult or unmasked stress incontinence -> benefit with continence surgery

DIAGNOSTIC EVALUATION

CLINICAL EVALUATIONDefecatory Dysfunction i.e, incomplete emptyingSexual Function – Pre / Post Surgery

DIAGNOSIS OF POP CAN ONLY BE MADE BY P.E.Systematic Assessment(Standing,Lithotomy)

Anterior vaginal wallPosterior vaginal wallMiddle or apical compartment

DIAGNOSTIC EVALUATION

ANTERIOR COMPARTMENT PROLAPSE STAGE III

POSTERIOR COMPARTMENT PROLAPSE STAGE II

MIDDLE COMPARTMENT PROLAPSE STAGE III

MIDDLE COMPARTMENT PROLAPSE STAGE III

MIDDLE COMPARTMENT PROLAPSE STAGE IV

LABORATORY INVESTIGATIONBladder testing should be part of initial workup

3 important factsUTI ScreeningPost Void Residual Urine VolumePresence or Absence of Bladder SensationVoided volume with sensation of fullness, voiding diary or by

bladder filling)

DIAGNOSTIC EVALUATION

BLADDER FUNCTION ASSESSMENT is ESSENTIAL prior to ANY form of Surgical InterventionSimple Retrograde Filling Cystometry (Office)Fill the Bladder until subjective fullness while recording

Sensations and Pressure ChangesCough Stress Test – prolapse out and reduced15-80% occult SUI when prolapse is reduced

PREOPERATIVE URODYNAMIC EVALUATION is recommended in patients with POP to detect occult or unmasked SUI

● Observation● Pelvic Floor Rehabilitation● Use of Mechanical Devices ( i.e, pessaries)● Surgery

Unfortunately, there is little evidence - based information with scarcity of rigorously conducted trials comparing various therapeutic approaches

MANAGEMENT

SexualFunction

Vaginal Axis and

Depth

BowelFuncti

on

Support of the Anterior

Posterior & Superior

Compartments

UrinaryFunction

GOALS OF PELVIC RECONSTRUCTIVE SURGERY

3 LEVELS OF PELVIC SUPPORT

Levels of pelvic support ( from Delancey JOL, Anatomic aspects of vaginal eversion after hysterectomy. AJOG 1992; 166: 1719,

● Depending on the Severity and Extent of Prolapse

● SURGERY usually involves combination of repairs addressing the ANTERIOR, POSTERIOR, MIDDLE / APICAL VAGINA AND PERINEUM

● Concomitant surgery for bladder neck and anal sphincters

SURGICAL MANAGEMENT

ANTERIOR COLPORRHAPHY• Described by Kelly 1913• Closure of central defect • Indicated for LARGE cystocele• 37 – 100% success rate

• Mesh augmentation increasessuccess rate for recurrent prolapse

SURGICAL MANAGEMENT

COMPLICATIONS• Ureteral Injury kinking of intramural ureters medially or• direct ligation rare

• TIGHT PLICATION could lead to 1. Bladder neck obstruction2. Voiding dysfunction3. Urinary retention

• Vaginal narrowing compromises sexual function• Cystocele Recurrence and Stress Incontinence

BURCH COLPOSUSPENSIONSuspend the bladder neck and urethra to the Coopers

ligament bilaterally restoring the support to the distal anterior vaginal wall

Historically regarded as a CONTINENCE procedureOption for early stage Anterior Vag Wall prolapseEspecially for short anterior vaginal wallLess superior to Ant. Colporrhaphy- (66 vs 97%)

BURCH COLPOSUSPENSION COMPLICATIONS

• Bleeding from pelvic veins during retropubic dissection or vaginal suture placement

• Overcorrection of UVJ may lead to bladder outlet obstruction with urinary retention ( 4-5%)

• De novo urge incontinence (11-17%)• Alteration of Vaginal axis predisposes to vault prolapse,

enterocele and rectocele

POSTERIOR COLPORRHAPHY

• Close the posterior wall herniation by re-approximation of the medial edge of the levator muscles over the midline

• 76 – 96% - LONG TERM anatomic cure rates Maher 2006

• Transvaginal route is superior to Transanal route in terms of recurrent prolapse

• Midline plication offers superior anatomic and functional outcome as compared to site specific repair

POSTERIOR COLPORRHAPHY COMPLICATIONS

Hemorrhage Ureteric injury Rectal injury Pain with Defecation Sexual Dysfunction

MIDDLE /APICAL COMPARTMENT Many operations have been described Vaginal route enjoys the advantage of being

easily performed, repair of other associated site of prolapse and with faster recovery

Abdominal route is associated with longer vaginal length

SURGICAL MANAGEMENT

Primarily an APICAL support procedure

Used to treat or prevent enterocele formation

Internal stitches have been placed from one USL to the other incorporating the peritoneum and tied obliterating the cul de sac

External stitch is tied suspending the vaginal cuff

SURGICAL MANAGEMENT

McCALL CULDOPLASTY

• 89 – 100% success rates• Risk of ureteric injury• McCall Culdoplasty was more effective than either simple

closure of the peritoneum or Moschcowitz over a 3 year follow up in preventing enterocoele

(Cruikshank and Kovac 1999)

• Prophylactic McCall Culdoplasty at the time of vaginal hysterectomy for vaginal prolapse is the routine practice

SURGICAL MANAGEMENT

McCALL CULDOPLASTY

Described by Ritcher in 1968 SSL is used as anchoring point to suspend the vaginal apex 64 – 99% success rate 37% recurrence rate of the anterior vaginal wall due to

posterior displacement of the vault BICF decreases the rate of cystocele recurrence Paraiso et al 1996

SURGICAL MANAGEMENT

SACROSPINOUS LIGAMENT FIXATION

Vascular injury particularly to the inferior gluteal and pudendal vessels which are located superior and posterior to the ligament

7% - neural injury or entrapment and may result in gluteal pain and numbness

High recurrence rate of anterior vaginal wall prolapse

SACROSPINOUS LIGAMENT FIXATION COMPLICATONS

BILATERAL ILIOCOCCYGEAL FIXATION● Similar to SSLF but uses Iliococcygeus muscle fascia just

anterior to the ischial spine as an anchorage site to suspend the vaginal apex

● Bilateral suspension maintains the normal alignment of vaginal canal

● 91 % versus 94% COMPARABLE SUCCESS RATE and concluded that these procedures were equally effective for vault prolapse with less morbidity Maher 2001

SURGICAL MANAGEMENT

ABDOMINAL SACROCOLPOPEXY

SURGICAL MANAGEMENT

● Designed to correct the vaginal vault or on women who have failed prior vault suspension

● Vaginal apex is suspended to anterior longitudinal ligament of sacrum ( S1- S2) using a synthetic mesh

● Sacrohysteropexy is performed on women who desire uterine preservation● 78 – 100% success rate● Maintains normal vaginal axis and caliber

COMPLICATIONS● Procedure of choice in those who have other indication for

laparotomy i.e, oophorectomy or simultaneous retropubic urethropexy for USI

● Hemorrhage from presacral vessels can occur during the sacral component of the procedure

● 5 – 7% Vaginal erosion rate● Small asymptomatic vaginal opening, to infection, abscess

or fistula

ABDOMINAL SACROCOLPOPEXY

COMPARTMENT VAGINAL ROUTE ABDOMINAL ROUTE

ANTERIOR VAGINA Anterior ColporrhaphyParavaginal Repair

Burch ColposuspensionParavaginal RepairSacrocolpopexy

POSTERIOR VAGINA Posterior Colporrhaphy(Fascia,Myorrhaphy, Site Specific Repair)Transanal Repair

Sacrocolpopexy

MIDDLE / APICAL VAGINA

Lefort ColpocleisisSacrospinous Ligament FixationPrespinous Ligament Fixation / BICFUSL SuspensionUSL PlicationMc Call Culdoplasty

SacrohysteropexySacrocolpopexyUSL FixationMoschowitz ProcedureHalbans Procedure

Pelvic Organ Prolapse Stage IV

Vesicocervical Pubocervical fascia

Vesicouterine Fold

Peritoneal cavity

Uterosacral Cardinal Ligament

ComplexUterine Vessels

Utero tubal- Broad / Round

Ligament Vaginal Cuff

Mc Call Culdoplasty

Anterior Vaginal Wall Dissection

Exposed Pubocervical

FasciaMidline Plication

Anterior Colporrhaphy

Vaginal Apex

Genital Hiatus

Dissection of Posterior Vaginal

Wall

Extending laterally until Ischial Spines are palpated

Bilateral Iliococcygeal

Fixation

Suspending the Vaginal Apex

Midline Plication

Posterior Colporrhaphy Perineorrhaphy

Before Surgery

Post Surgery

POP GIRLS of PGH

Abnormal Descent of Pelvic OrgansIntroital Mass, Pelvic Discomfort and HeavinessMultifactorial EtiologyDiagnosis thru Pelvic ExaminationBladder Testing Should be part of PRE-OP

EvaluationConservative and Surgical management

Summary