Pelvic organ prolapse

GENITAL PROLAPSE

• Common complaint of elderly woman• Mostly in post menopausal and multiparous women• In prolapse straining causes protrusion of vaginal walls at vaginal

orifices• Extreme cases uterus may be protrude

Normal axis

Axis of the uterus and vagina: anteverted and anteflexed

PELVIC SUPPORTS

• PELVIC FLOOR • Comprises

Pelvic diaphragmEndopelvic fasciaPerineal membranePerineal body

PELVIC DIAPHRAGM

Pelvic diaphragm

Perineal membrane

Uterine ligaments

PERINEAL BODY

• The pelvic structures are divided into 3 compartments : • Anterior : urethra /bladder • Middle : uterus/vault • Posterior : rectum/anus

Levels of support of uterusDeLancey's three levels of support • 3 levels

Level 1 (suspensory axis)

• Level I- Uterosacral and cardinal ligaments • support the uterus and vaginal vault.

• Round ligament• (mackenrodts lig /

transverse/lateral cevical cervical ligament at the base of broad lig with uterine A & V

• Defects in level 1• Uterovaginal UV prolapse• Enterocele• Vault prolapse

Level 2 (attachment axis)

• Level II- Pelvic fascias and paracolpos • Fascial septae connects mid vagina to the pelvic sidewalls • Anteriorly

• Pubocervical • Posteriorly

• Rectovaginal facia• which connects the vagina to the white line on the lateral pelvic wall through

arcus tendinous

Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.

Defects in level2

• Paravaginal & para rectal defects

Level 3 (fusion axis )

• Level III-Levator ani muscle • supports the lower one-third of vagina.

• Anteriorly • Urethra• Urogenital diaphragm• Pubis

• laterally• Levator ani fascia

• Posteriorly• Perineal body

Etiology

• Menopause • birth injury • Prolonged bearing down in the second stage • Delivery of a big baby • Rapid succession of pregnancies • Lack of rest in peuperium • Peripheral nerve injury• raised intra-abdominal pressure • Surgeries • Congenital

Etiology

• Menopause • prolapse are of menopausal age when the pelvic floor muscles• d/t oestrogen deficiency and decreased collagen content in fascias atonicity

and asthenia that follow menopause

Causes related to child birth

• Birth injury

excessive stretching of the pelvic floor

muscles and ligaments

overstretching causes atonicity

Perineal tear is less harmful than

overstretching

whereas torn muscle could be

stitched or toned up

Causes related to child birth

• Peripheral nerve injury such as pudendal nerve during childbirth

• Delivery by untrained dais • This is because the patients are made to bear down before full dilatation of

the cervix and when the bladder is not empty

• Prolonged bearing down in the second stage

• Lacerations of the perineal body during childbirth, unless sutured immediately, will widen the hiatus urogenitalis

Causes related to child birth

• Delivery of a big baby• Lack of rest in peurperium• Lack of any pelvic exercises • Rapid succession of pregnancies

Raised intra abdominal pressure

• chronic bronchitis, • large abdominal tumours or • obesity • Smoking, • chronic cough and • constipation

Prolapse in unmarried or nulliparous women• spina bifida occulta and • split pelvis• Collagen vascular diseases

congenital weakness of the pelvic floor muscles• in unmarried or nulliparous women• h/o precipitate labour • Family h/o uterine prolapse

Surgeries

• Abdominoperineal excision of the rectum and • radical vulvectomy • Operations for stress incontinence such as Stamey and Pereyra

operations

Classification of prolapse

Upper two-third-Cystocele

Lower one-third-Urethrocele

Anterior vaginal

wall(anterior compartment)

Uterine descent

Middle compartment Upper one-third-

Enterocele (pouch of Douglas hernia)

Lower two-third-Rectocele

Posterior compartment

Cystocele the vesical and vaginal fasciae are thinned out and fail to support the bladder, so that the bladder prolapses with the anterior vaginal wall.

Urethrocele When the urethra along with the lower one-third of the anterior wall prolapses (failure of pubocervical ligament

Rare

stress incontinence

Uterine prolapse

Uterine descent

• Uterine descent • - Descent of the cervix into the vagina • - Descent of the cervix up to the introitus • - Descent of the cervix outside the introitus • -Procidentia-All of the uterus outside the introitus

Symptoms

• something protruding either at the vulva or externally• aggravated by straining and coughing, and by heavy work• reduces itself when she lies down

• large prolapse, the external swelling difficulty in walking or carrying out her everyday duties

Symptoms

• Backache • uterosacral strain

• Towards evening • relieved by rest

decubitus ulcer

• benign and is present on dependant part. • d/t venous stasis tissue anoxia.

• treated by • keeping the prolapse reduced, which will restore circulation and help in

healing. Prolapse can be kept in reduced position by packing.

micturition disturbances

• imperfect control of micturition• Frequency of micturition • (diurnal or nocturnal)• (d/t chronic cystitis & incomplete emptying

of the bladder)

• Manual reduction of the cystocele into the vagina with their fingers• Straining to pass urine

• Stress incontinence

• Ureteric obstruction and hydronephrosis } severe massive prolapse

Bowel symptoms

• Urgency • Straining • Feeling of incomplete emptying• Pressure on vagina or perineum to start or complete defaecation

Discharge per vaginum

• Mild vaginitis• Chronically inflamed lacerated cervix• Decubitus ulcer – discharge and bleeding

Coital difficulties

• With third degree uterine prolapse and procidentia prevents penetration and orgasm due to a lax outlet.

Signs

• Assessment of prolapse• In lithotomy position• Look for stress incontinence on a full bladder• patient is asked to strain / perform valsalva manoeuvre• Stress incontinence

• Vulva examined for perineal laceration • Three compartments evaluated separately;• decubitus ulcer

Per speculum examination

Anterior compartment

• Sim’s speculum retracting posterior vaginal wall

• Look for cystocele• Lateral cystocele or

paravaginal defect• Urethrocele } stress

incontinence

Middle compartment

• Degree of descent • Ulceration of cervix• Vagina may show

keratinisation• Vaginal examination –

length of cervix,position and mobility of uterus,any adnexal mass

• Cervical cytology

Posterior compartment

• Sim’s speculum retracting anterior vaginal wall

• Enterocele – bulge appears from above downwards

• Rectal examination – impulse on

• tip of finger- enterocele• pulp - rectocele• Bimanual examination-

r/o pelvic mass

Pelvic floor muscles

• Pubococcygeus part of levator ani assessed at 4 and 8o’clock position • Perineal body • Rectal examination – tone of anal sphincter

Lab investigations

• Hb • Urine examination,Urine culture,Xray,ECG• High vaginal swab in cases of vaginitis• RFT in long standing prolapse• Urodynamic investigations in case of incontinence• USG to r/o pelvic mass and hydronephrosis• IVP }massive prolapse• CT/MRI}

Differential diagnosis

• Vulval cyst or tumour• Cysts of anterior vaginal wall• Urethral diverticula• Congenital elongation of cervix• vaginal portion of the cervix is elongated and• no vaginal prolapse. • deep fornices

• Cervical fibroid polyp• Chronic inversion

COMPLICATIONS OF PROLAPSE

• Kinking of ureter with resulting renal damage • Surgical injury to ureter• Urinary tract infection (chronic) in large cystocele with residual urine

• decubitus ulcer and keratinisation pigmentation• if ring pessary is left in over a long period malignancy

ProphylaxisAntenatal physiotherapy ,relaxation exercises,due attention to

weight gain and anaemiaProper supervision and management of second stage of labourA generous episiotomyLow forceps delivery if there is delay in second stageSuture perineal tear Postnatal exercises and physiotherapyearly postnatal ambulationAdequate spacing of birthsAvoid multiparityProphylatic HRT in postmenopausal women

Treatment

• Surgical }• in women over 40• C/I in pregnancy

• Conservative management • mechanical devices and • pelvic floor muscle exercises ,abdominal massage,

• in mild degrees of prolapse,• surgery not desired by patient ,• in whom child bearing is not complete

• Should be advised 3 to 4 months following delivery• Surgery Pregnancy – contraindication for surgery

Pessaries

• Indications A young woman planning a pregnancyDuring early pregnancy (<18 weeks)PuerperiumTemporary use while clearing infection and decubitus ulcerA woman unfit for surgeryIn case a woman refuses for surgery

pess

arie

s

Support

Space filling

eg:ring pessarystage 1 and 2 prolapse

eg:gelhorn and cube pessaries for advanced stages

soft

pla

stic

poly

viny

l ch

lorid

e m

ater

ial

Limitations

• Never curative only palliative• Vaginitis• Needs to be changed every 3 months• Dyspareunia• Expulsion (if vaginal orifice is very patulous)• May cause ulcer,rarely Ca vagina and a vesico vaginal fistula• Does not cure urinary stress incontinence

SURGICAL APPROACHES• Ward-Mayo’s operation-vaginal hysterectomy with

pelvic floor repair with or without: sacrospinous colpopexy –vault suspended from

sacrospinous ligament• Fothergill’s or Manchester operation –uterus preserved

and part of cervix is cut• Shirodkar’s Extended Manchester operation-both

cervix and uterus preserved• Le Fort’s operation –obliterative procedure of anterior

and posterior walls of vagina

Anterior colporrhaphy

Anterior colporrhaphy

• performed to repair a cystocele and cystourethrocele

Anterior colporrhaphy

• TOC for anterior cystocele• Procedure

Lithotomy positionArea cleansed and drapedBladder emptiedSim’s speculum introducedAnterior lip of cervix pulled down using volsellum forceps

Inverted T-shaped incision on anterior vaginal wallVaginal flaps seperated from bladderVesicocervical ligament boldly cut,bladder pushed upBladder buttressing with delayed absorbable suturesIn large defects, plication in two layersExcess vaginal mucosa trimmed and closedBladder drained

• ComplicationsInfection, bleeding, injury, recurrence, failure

• AftercareAvoid lifting weights, coughing, sneezing, straining at

stools, sexual intercourse

• Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant.

• Metal catheter is introduced to know the lower limit of bladder.• Inverted T incision made to anterior vaginal wall.

• Horizontal incision is made below the bladder and • vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below

the external urethral meatus.

• The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection.

• The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted laterally.

• The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.

• The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side.• The cut margins of the vagina are apposed by interrupted sutures with No 'O'

chromic catgut using cutting needle.• The catheter is reintroduced once more to be sure that the bladder is not

injured.• Toileting of the vagina is done.• Vagina is tight packed with roller gauze smeared with antiseptic cream.• A self retaining catheter is introduced

Paravaginal repair

• To correct lateral cystocele• Done abdominally, vaginally or laparoscopically• Repairing abdominallyInvolves entering retropubic space till arcus tendinous fascia pelvis

seen lateral vagina raised to arcus tendinous fasciaBoth are approximated with interrupted sutures

WARD-MAYO REPAIR

• Commonest operation in case of utero vaginal prolapse in cases where child bearing is complete• Indication• In an elderly women who has completed her family

WARD-MAYO REPAIR

• Vaginal hysterectomy + pelvic floor repair ± sacrospinous colpopexy

• Combined with cystocele,enterocele or rectocele repair Cystocele-ant.colporrhaphy(AC) Enterocele-Mc Call’s culdoplasty Rectocele-posterior colporrhaphy(PC)

WARD-MAYO REPAIR

VH

PFR

• anterior colporrhaphy and

• colpoperineorrhaphy

Sacrospinous colpopexy

• procidentia with complete vaginal eversion

• Vault prolapse.

Vaginal hysterectomy

A circular incision is made over the cervix below the bladder sulcus, and the vaginal mucosa dissected off the cervix all around.

To proceed as that of anterior colporraphy up to pushing up of

bladder

the UV fold of peritoneum incised

The cervical incision is extended posteriorly along the cervicovaginal junction and the pouch of douglas is

opened

Uterus is delivered anteriorly

First clamp on utero sacral and cardinal ligaments,tissues cut and ligated on

both sides

Second clamp involves uterinevessels which are cut and ligated

Third clamp on round ligament,fallopian tube and ovarian ligament which are cut and ligated

Uterus removed

Peritonium closed by purse string suture

enterocele correction done by McCall’s culdoplasty

Anterior colporrhaphy is completed

Posterior colpoperineorrhaphy performed if there is rectocele.

SACROSPINOUS COLPOPEXY

• Apical suspension procedure in procidentia with complete vaginal eversion Vault prolapse• Sacrospinous ligament is used to suspend the vault,by an approach

through rectovaginal space

Abdominal sacrocolpopexy

• Abdominal method of apical suspension • Used in Vault prolapse mainly • A mesh in the form of Y is used

• Long arm y anterior longitudinal ligament of sacrum @ sacral promontory

• Short arms anterior & posterior vagina

Manchester/Fothergill’s operation

• In a women who has completed her family• With lesser degrees of uterovaginal prolapse with supra vaginal

elongation of cervix• but wishes to retain the uterus and opts for a vaginal procedure • it can be combined with AC , PC or enterocele repair

Manchester/Fothergill’s operationDilatation of cervix

Anterior colporrhaphy

Isolation and ligation of cardinal ligaments

Amputation of cervix

Suturing the cardinal ligaments to the front of cervix

Reforming the lips of cervix using the vagina

The patient is placed in the dorsal lithotomy position. Thorough examination of the pelvis is performed. The bladder is not catheterized because it can be identified and dissected with greater safety when partially filled than when empty.

Dilation & cuerettage

The labia may be tacked to the perineum for retraction if they are redundant. A Jacobs tenaculum is placed on the anterior lip of the cervix. Downward traction on the cervix exposes the junction of the vagina and cervix where a 360° circumcision incision is made. The bladder is sharply and bluntly dissected off the lower uterine segment up to the vesicouterine fold

A right-angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. This is picked up and opened.

The anterior cul-de-sac is opened, a finger is inserted, and the fundus and adnexa are explored.

A right-angle Heaney retractor is placed in the anterior cul-de-sac, allowing elevation of the bladder and ureter. The cervix is rotated anteriorly, and the posterior cul-de-sac is exposed. The peritoneum of the posterior cul-de-sac is picked up and opened.

The posterior cul-de-sac is opened. A finger may be inserted into the cul-de-sac, and the uterus and adnexa explored.

the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament->through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.

Both Mackenrodt's ligaments have now been ligated and the cervix almost completely amputated. A vulsellum is attached to the anterior lip of the cervix above the amputation

A covering for the posterior lip of the cervix has been fashioned from the mobilized vaginal skin of the posterior fornix and this has been secured to the new cervix by deep sutures. Fothergill's stitch is illustrated and it should be noticed that it passes through vaginal skin in the region of Fothergill's lateral point, through Mackenrodt's ligament and through the anterior lip of the cervix into the cervical canal, and thence out to the other side and through Mackenrodt's ligament and vaginal sk

Shirodkar’s Extended Manchester operation

• Shirodkar’s Extended Manchester operation- in a women who wants to conceive

• Vaginal sling operation• Uterus and cervix are preserved• Strenghthening of uterosacral ligaments• Best for women with strong uterosacrals

STEPS..

AC done

Vaginal incision extended posteriorly around the cervix

The pouch oh Douglas is then opened

The uterosacral ligaments identified and divided close to cervix

They are isolated to form slings

They are crossed and stitched together infront of the cervix

Le Fort’s operation • Le Fort’s operation In very elderly women who is medically unfit for a

repair procedure and not desirous of vaginal intercourse.

• Colpocleisis• Obliterative procedure • Total colpocleisis-total obliteration of cavity• Partial colpocleisis-some part of vaginal epithelium is left unsutured

to provide drainage tract ,useful in women with uterus to drain cervical secretions

Le Fort’s operation

Vaginal epithelium is removed

Suturing of anterior and posterior wall of the denuded vagina

• Repairing vaginallyMore difficultMore risk of hemorrhageIf a paravaginal defect is present,retropubic space can be

reached readily vaginally4-6 permanent sutures between arcus tendineus and

lateral edge of fibromuscular layer

POSTERIOR COMPARTMENT

• Posterior colporrhaphy to correct rectocele

Posterior colporrhaphy

• ProcedurePair of Allis forceps at lower end of labium minus and a third one on

posterior vaginal wall above rectoceleIncision put joining first two forcepsVaginal mucosa dissected from prerectal fascia(Denonvillier’s fascia)

upto third forcepsVertical incision put from middle of this incision to the apex

Prerectal fascia approximated in the midline with delayed absorbable sutures

If defect identified, better to do a defect repairUsually anterior plication of pubococcygeus part of

levator ani also performed across the rectumThen vaginal mucosa trimmed and closedCombined with perineorrhaphy when defective

perineal body Superficial perineal muscles are plicated in the

midline and skin closed

Mesh repair

In repeat sxReplace patients own weak tissue • 4 types• Type 1 monofilament mesh preferred(pore size >75 micrometre)• Mesh of choice : Monofilament macroporous light weight

polypropylene mesh (eg : Gynemesh)• Main problem with use of mesh is mesh erosion

Postoperative care

• Parental fluids until bowel sounds return.• Early oral fluids are now advocated. • Antibiotics, sedatives, metronidazole for 24 hours IV. • Indwelling catheter for 48 hours. • Vaginal pack for 28 hours. • Early ambulation• DVT prophylaxis

Mc call culdoplasty for enterocele repair

VAULT PROLAPSE

Enterocele Secondary vault prolapse

ENTEROCELE• Herniation of upper third of posterior vaginal wall• Contain omentum or even loop of small bowel• Always look for and correct during prolapse repair• Prophylactic correction during vaginal or abdominal hyterectomy

MANAGEMENT• VAGINAL CORRECTION• STEPS

Inverted T shaped incisionDissect and expose sac Sac opened and contents pushed awayPeritoneum dissected and excisedPurse string suture – neck of the sacCervix pulled up ,interrupted suture around uterosaral ligaments

• VAGINAL CORRECTION OF POST HYSTERECTOMY ENTEROCELE• Uterus absent• internal Mc call suture

• ABDOMINAL CORRECTION• Vaginal vault – suspend to uterosacral ligament• Other procedure

HALBAN PROCEDURE MOSCOWITZ PROCEDURE

SECONDARY VAULT PROLAPSEProlapse of vaginal vault following

hysterectomyDue to failure to recognise and correct

– enterocele- during hyserectomyCan be

Vaginal eversion – vault suspensionCystocele Anterior and posterior Rectocele colporrhaphy

MANAGEMENTVaginal approach

Sacrospinous colpopexy + anterior and posterior colporrhaphyPreferred in old and less healthy women

• Abdominal approachSacrocolpopexy + Halban procedurePreffered in young women bcoz resultant vagina is longer

NULLIPAROUS PROLAPSE

• More likely to have spina bifida or connective tissue disorder• Uterine +vaginal prolapse , may include

complete vaginal inversion• Mesh required for repair• Following repair- aviod vaginal delivery –

perform elective caesarean section

MANAGEMENT

• Abdominal sacrohysteropexy• Teflon or mersilene mesh

• Purander’s sling operation or cervicopexy• Shirodkar’s sling operation• Khanna’s posterior sling