Pelvic Floor Prolapse (POP)

Pelvic Organ Prolapse

DR: MONA AHMED

Definition

• Prolapse: Latin word- procedere- to fall.

• POP: The herniation of the pelvic organs to or beyond the vaginal walls.

Pelvic Organ Prolapse

• ANTERIOR COMPARTMENT PROLAPSE Hernia of anterior vaginal wall often associated with descent of the bladder (cystocele)

• POSTERIOR COMPARTMENT PROLAPSE Hernia of the posterior vaginal segment often associated with descent of the rectum (rectocele).

• ENTEROCELE Hernia of the intestines to or through the vaginal wall

• APICAL COMPARTMENT PROLAPSE (uterine prolapse, vaginal vault prolapse)

• PROCIDENTIA Hernia of all three compartments through the vaginal introitus.

Prevalence

• One of the most common gynaecological disorder
• 3rd most common cause of gynaecological surgery.
• Lifetime risk for age 80yrs >10%

Supports of Pelvic Organ:

• ENDOPELVIC CONNECTIVE TISSUE. AND
• PELVIC DIAPHRAGM.

Deep Endopelvic Connective Tissue

Muscles of Pelvic Diaphragm

• Levator Ani Ms.
• Coccygeus
• Pyriformis

Levator Ani

Normal Axis of Uterus/Vagina and the Levator Plate

Etiology Main Cause of POP Are:

Acquired

• Levator muscle weakness
• Ligaments injury
• Nerve injury (Pudendal nerve)
• Endopelvic fascial weakness
• Perineal body weakness

Congenital

• Inborn weakness of support system.

Risk Factors

• Genetic predisposition.
• Vaginal birth
• Parity
• Menopause
• Advancing age
• Prior pelvic surgery
• Connective tissue dis.
• ↑ IA pressure
• Obesity
• Chronic constipation
• ↑ Straining

3 Most Important Established RF

1. Vaginal delivery
2. Advancing age
3. Obesity

Staging of POP

POP Quantitative Scoring

Stage	Description
0	No descent of Pelvic Organs
I	Leading edge of Prolapse remaing≥1cm above the hymenal ring
II	Leading edge of Prolapse extends from 1cm above or 1cm below the hymenal ring
III	From 1cm beyond the hymenal ring but without complete eversion of vagina
IV	Essentially complete eversion of vagina

Staging of POP

Cough may be helpful for assessing stages

• Stage 0

  • No prolapse

• Stage 1

  • The most distal portion of the prolapse is >1 cm proximal to the level of the hymen

• Stage 2

  • The most distal portion of the prolapse is ≤1 cm proximal or distal to the level of the hymen

• Stage 3

  • The most distal portion of the prolapse is <1 cm beyond the hymen but protrudes no further than 2 cm less than total length of vagina

• Stage 4

  • Complete vaginal eversion

Clinical Features:

Clinical Manifestation:Z

• Feeling like sitting on a small ball
• Dyspareunia.
• Frequent urination or a sudden urge to empty the bladder
• Low backache
• Uterus and cervix that stick out through the vaginal opening
• Repeated bladder infections
• Feeling of heaviness or pulling in the pelvis
• Vaginal bleeding
• Increased vaginal discharge

Examination

• Abdominal Examination

  • To exclude organomegaly / Abdominal mass

• Vaginal Examination

  • Examine in dorsal position ( if protrude beyond introitus )

• Combined Rectal & Vaginal Examination

  • To differentiate rectocele from enterocele

DD OF CYSTOCELE GARTN ER DUCT CYST

CYSTOCELE

D/D Uterine Prolapse

1. Congenital elongation of cervix
2. Chronic inversion
3. Fibroid polyp

Enterocele

Rectocele

Investigation:

• Routine pre operative investigations
• Urine for C/S if any symptoms suggestive if UTI
• Urodynamic studies:
• No urinary symptoms – not justified.
• Do only if significant urinary symptoms.

Management:

• Management
  • Preventive
  • Conservative
  • Surgical

Preventive

1. Adequate ANC & intra-natal care: avoid injury to supporting structure, correct anaemia, avoid prolong labour, careful instrumental delivery.
2. Adequate post-natal care: Early ambulation, Pelvic floor exercise.
3. Contraceptives: avoid too many & too frequent birth.
4. General measures: avoid strenuous exercise, chronic cough, constipation, heavy wt lifting.

Conservative

Indications:

1. Asymptomatic women
2. Mild degree of prolapse
3. POP in early pregnancy

Conservative

1. Improvement of general health
2. Oestrogen replacement therapy may improve minor degree prolapse in post menopausal women.
3. Pelvic floor exercise- Kegel’s exercise.
4. Pessary treatment.

Pessary

can cause infection should change every 2-3 weeksY

Surgical Management

• Preventive
• Curative

Preventive Surgeries to Prevent Vault Prolapse After Hysterectomy

1. Utero-sacral ligament fixation with the vault
2. Sacro-spinous fixation

Vaginal Wall Prolapse

Anterior vaginal wall	Cystocele, & paravaginal defect	I - Anterior colporrhaphy
Posterial vaginal wall ( lower 2/3rd )	Rectocele	perineorrhaphy
Posterial vaginal wall ( Upper 1/3rd )	Enterocele	I- Repair of enterocele