Pelvic Organ Prolapse

Overview

Pelvic organ prolapse is an abdnormal herniation of pelvic organs from their normal anatomic position. It is the third most common reason for elective hysterectomy.

11% of women undergo surgery for prolapse or incontinence in their lifetime.

Levels of vaginal support

Level	Structure	Defect
Level I	Cardinal and uterosacral ligaments. Holds the	Defect leads to apical prolapse associated with uterine descent and enterocele
Level II	Paravaginal attachments contiguous with cardinal and uterosacral complex	Defect leads to lateral or paravaginal prolapse which is associated with cystocele
Leve III	Perineal body, perineal musculature and connective tissue supporting the distal 1/3 of the vagina	Defect leads to anterior and posterior prolapse

Types of prolapse

Defect	Prolapse
Anterior vaginal wall prolapse	Cystocele or urethrocele or cystourethrocele
Lateral vaginal wall/ paravaginal prolapse (most common defect)	Cystocele
Posterior vaginal wall prolapse	Rectocele (more distal) or enterocele (more proximal)
Apical vaginal wall prolapse	Enetrocele or uterine prolapse

Grading of uterine prolapse

Degree	Description
1st degree	Cervix protrudes below its normal level on valsava
2nd degree	Cervix protrudes from vulva on straining
3rd degree (complete procidentia)	Whole uterus is completely prolapse outisde the vulva, even without valsava

• Risk factors
  • Multiparity
  • Older age: decreased oestrogen decreases strength of ligaments
  • Other obstetric risk factors
    • Macrosomia
    • Prolonged second stage
    • Episiotomy
    • Lacerations
    • Epidural analegesia
    • Forceps use
  • Connective tissue disease e.g. Marfans and Ehler’s Danlos
  • Race: whites and hispanics > blacks and asians
  • Increased abdominal pressure e.g. chronic constipation
• Pathophysiology
  • Pelvic floor support is provided by the levator ani (iliococcygeus, pubococcygeous, and puborectalis), fascia and ligaments
  • Direct damage to these structures or nerves can weaken the pelvic floor
  • Fascia and ligaments get weaker with age causing pelvic organ prolapse
• Signs and symptoms
  • Bulge symptoms (more specific to pelvic organ prolapse)
    • Sensation of vaginal protrusion or pressure
    • “Heaviness”
  • Urinary symptoms
    • Stress incontinence
    • Urgency and Frequency
    • Weak or prolonged stream and hesitancy
    • Feeling of incomplete emptying
    • Difficulty with complete emptying
  • Bowel symptoms
    • Feeling of incomplete emptying
    • Incontinence
    • Digital evacuation
  • Sexual symptoms: dyspareunia
  • Pain: back pain, genital pain
• Physical examination
  • Visual examination while standings, with and without valsava
  • Bimanual examination
  • Bivalve speculum examination
  • Split speculum examinaiton
  Note the anatomic position of the prolapsed portion Note the presence or absence of rugae on the prolapsed portion (rugae presents = lateral or paravaginal defect) Approximate the distance or extent of prolapse in relation to hymen
• Investigations
  • Urodynamic testing (not required in most cases)
    • Cystometry: to measure pressure in the bladder during filling
    • Uroflowmetry: to measure volume and speed of urine flow over time
    • Pressure flow studies: to meausre the bladder pressure required to urinate and flow rate at a given pressure
  • Pelvic floor electromyography (EMG): to measure the electrical activity of muscles and detect neuromuscular abnormalities
  • Simple cystometrics: infuse saline or sterile water into the bladder and ask the patient to indicate when they feel the liquid, when their bladder feels full, and when they experience an urge to urinate
  • Pelvic floor ultrasound: trans-anal, trans-perineal, and vaginal view to capture images during coughing or straining to see how pelvic organs move
  • Anorectla manometry and defecography (proctography)
• Non-surgical treatment
  • Pessary: first-line treatment for pelvic organ prolapse. Evaluate for vaginal atrophy prior to placement. Remove nightly to weekly
    • Ring pessary: for first and second degree prolapse
    • Gellhorn pessary: for third degree prolapse
  • Kegel exercise
• Surgical treatment
  • Obliterative
  • Reconstructive