PELVIC ORGAN PROLAPSE, uterine prolapse , cystocele, rectocele, urethrocele, supports of uterus, sling surgeries, pessaries, grades of prolapse, uterine preserving surgery for pop, pelvic floor repair, vaginal hysterectomy, ward mayos surgery, pop q grading, grading of prolapse, laproscopic surgeries for prolapse, peregee, apogee , mesh repair, tot, tvt, colpo suspension, colpoclysis, SUI management, epidemiology of prolapse, decubitus ulcer, best ppt for pelvic organ prolapse, better understanding of pelvic organ prolapse and pelvic floor.

1. PELVIC ORGAN PROLAPSE
Dr. M. GOKUL RESHMI.

2. INTRODUCTION
DEFINITION:
Descent of the anterior vaginal wall, posterior vaginal wall, the uterus
(cervix), or the apex of the vagina (vaginal vault or cuff scar after
hysterectomy),or other pelvic viscera alone or in combination.
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 due to weakness in their supporting structures.

3. ANATOMY
The support system :
Level I – The uterosacral/cardinal ligament
complex, - apical defect.
Level II – Endopelvic fibromuscular connective
tissue to the arcus tendineus and levator fascia.
– anterior (upper 2/3rd )/ posterior( lower 2/3rd )
wall defect .
Level III - The muscles and connective tissue
surrounding the distal vagina and perineum. –
anterior wall ( lower 1/3rd ), perineal body,
genital hiatus defect.

4. The pelvic floor muscles:
The levator ani muscles is the most important & consists of 3 parts: –
The ischio-coccygeus muscle,
The ilio-coccygeus muscle,
The pubo-coccygeus muscle;
The most important part Others include obturator internus, coccygeus.

6. DEFECTS AND ITS EFFECTS
Level I : Suspension defect – Descent of
the cervix, enterocele, apical/ vault
prolapse.
Level II : attachment defect – cystocele,
rectocele.
Level III : fusion defect – gaping
introitus, deficient perineum,
urethrocele.

7. DEFECTS AND ITS EFFECTS
APICAL COMPARTMENT: Level I
1. The loss of cardinal/uterosacral support
with resultant cervical/uterine or vaginal cuff
descent
2. fibromuscular vagina : anterior rectum -
enterocele or, at times, sigmoidocele.
3. Tears or attenuation - post hysterectomy, -
central apical descent as a ballooning defect.

8. DEFECTS AND ITS EFFECTS
ANTERIOR COMPARTMENT: Level II
1. Central defect or distension cystocele
– Rugae absent
– Lateral vaginal sulci present
2. Lateral (paravaginal) defect or
displacement cystocele.
– Rugae present
– Lateral vaginal sulci absent
3. The presence or absence of sulci lateral
detachment to the arcus is maintained or
lost.

9. DEFECTS AND ITS EFFECTS
ANTERIOR COMPARTMENT:
Classification of Cystocele:
Paravaginal defect (central,
displacement),
Midline defect (central, distention) or
Transverse defect (apical)
depending on whether the pubocervical
fascia is separated from the vaginal cuff,
separated from the uterosacral ligament, or
mixed.

10. DEFECTS AND ITS EFFECTS
POSTERIOR COMPARTMENT: Level II
Perineal detachment of Denonvillier
(pararectal) fascia - perineal
rectocele, associated with defecation
difficulty .

11. EPIDEMIOLOGY
11% life time risk.
Common Problem in Women – 50% of parous women have some prolapse,
10-20% have symptoms.
1% Lifetime Risk for Surgery – Of these, 29% require repeat surgery.
5-7% Develop Post-Hysterectomy Vault Prolapse.
The risk of POP increased 1.2 times with each vaginal delivery.

12. ETIOLOGY
• Weakness of the structures supporting the organs in position.
Anatomical factors Clinical factors
Aggravating
factors Predisposing
factors:
• Acquired
• Congenital
• Anterior inclination of pelvis.
• Gravitational stress.
• Stress of parturition.
• Pelvic floor weakness due to
urogenital hiatus and the
direction of obstetric axis
through the hiatus.
• Inherent weakness of the
supporting structures.

13. Cont…
AGGRAVATING FACTORS:
Postmenopausal atrophy.
Poor collagen tissue repair with
age.
Increased intra-abdominal
pressure as in COPD and
constipation.
Occupation (weight lifting).
Asthenia and undernutrition.
Obesity.
Increased weight of the uterus
as in fibroid or myohyperplasia.

14. Cont…
PREDISPOSING FACTORS
Acquired: vaginal delivery causing injury (tear or break) to:
(1) Ligaments
(2) Endopelvic fascia
(3) Levator muscle (myopathy)
(4) Perineal body
(5) Nerve (pudendal) and muscle
damage due to repeated child birth
Congenital: Inborn weakness of supporting structures.

15. Risk Factors Associated with Pelvic Organ
Prolapse
Pregnancy - Vaginal childbirth,
Menopause – Aging – Hypoestrogenism.
Chronically increased intraabdominal pressure – COPD, Constipation, Obesity,
Pelvic floor trauma,
Genetic factors - Race, Connective tissue disorders,
Spina bifida.

16. THE BADEN-WALKER HALFWAY SYSTEM -
SYMPTOMS
Urethral - Urinary incontinence, Falling out
Vesical - Voiding difficulties, Falling out
Uterine - Falling out, Heaviness and so forth
Cul-de-sac - Pelvic pressure (standing), Falling out
Rectal - True bowel pocket, Falling out
Perineal - Anal incontinence, Too loose (gas/feces)

17. Shaw's System
Anterior wall
Upper 2/3 cystocele
Lower 1/3 urethrocele
Posterior wall
Upper 1/3 enterocele
Middle 1/3 rectocele
Lower 1/3 deficient perenium
Uterine prolapse
Grade 0 Normal position
Grade 1 descent into vagina not reaching introitus
Grade 2 descent up to the introitus
Grade 3 descent outside the introitus
Grade 4 Procidentia

18. Comparison of systems used to quantify pelvic
organ prolapse
–

19. PELVIC ORGAN PROLAPSE

20. PELVIC ORGAN PROLAPSE QUANTIFICATION
(POP-Q).

21. PELVIC ORGAN PROLAPSE QUANTIFICATION
(POP-Q).

22. PELVIC ORGAN PROLAPSE QUANTIFICATION
(POP-Q).

24. LEVATOR TONE
Grade 0 –no discernible pelvic floor contraction
Grade 1 –a flicker under finger.
Grade 2 – a weak contraction or increase in tension without any
discernible lift or squeeze
Grade 3 – a moderate contraction with partial lifting of postvaginal
wall and squeezing of finger, contraction > grade 3 is visible.
Grade 4–good pelvic contraction causing elevation of postvaginal
wall against resistance and indrawing of perineum.
Grade 5 – strong contraction of pelvic floor against strong resistance.

25. SYMPTOMS
Asymptomatic
Fullness in the vagina
Mass descending per vaginum
– On straining
– At rest
Urinary symptoms
– Sensation of incomplete emptying
– Frequency/urgency
– Dysuria
– Stress incontinence
– Need to manually reduce to void
– Urinary retention
Bowel symptoms
– Constipation
– Incomplete emptying
– Splinting and straining
Sexual symptoms
– Sexual dissatisfaction
– Dyspareunia.
Vaginal discharge
Bleeding
Low backache

26. DIFFERENTIAL DIAGNOSIS
Cervical/endometrial polyps.
Chronic inversion of uterus.
Hypertrophic elongation of
cervix.
Gartner cyst, vaginal cyst.
Urethral diverticula are rare,
always small and are situated
low down in the anterior vaginal
wall.
Congenital elongation of the
cervix.

27. Complications of Prolapse
1. Kinking of ureter with resulting renal damage.
2. Urinary tract infection (chronic) in a large cystocele with residual
urine can lead to upper renal tract infection and renal damage.
3. In rare cases, cancer of the vagina is reported over the decubitus
ulcer and if the ring pessary is left in over a long period.

28. MANAGEMENT
INVESTIGATIONS:
Fitness for surgery
– Haemoglobin
– Blood sugar
– Serum creatinine
Urine culture
Pap smear
Evaluate decubitus ulcer
– Cytology
– Colposcopy and biopsy, if required
Ultrasonogram
– If pelvic pathology suspected
Pessary test
– To rule out occult stress incontinence
Urodynamic evaluation
Proctography
MRI

29. Radiological classification of
cystoceles
Originally proposed by Green,
Based on:
Descent of the bladder neck, retrovesical angle (the angle
between the proximal urethra and the trigonal surface of the
bladder ) and the degree of urethral rotation.

30. Radiological classification of cystoceles
Green type I is described as cystocele with open retrovesical angle (≥
140°) and urethral rotation < 45°.
Green type II describes a cystocele with open retrovesical angle (≥
140°) and urethral rotation between 45 and 120°, also called
cystourethrocele.
A cystocele with intact retrovesical angle (< 140°) is defined as Green
type III

32. Urodynamic Abnormalities
Bladder obstruction is among the most common reasons to order urodynamic
testing for POP.
Bladder outlet obstruction can be defined as a low maximum free flow rate of less
than 12 mL/s that persists for the patient in combination with high detrusor
pressure greater than 20 cm H2O during a pressure-uroflow study.
This test looks for bladder obstruction, muscle weakness, stress induced
incontinence, urethra strength, and other disorders that affect the pelvic organs,
muscles, and tissues.

33. Apical cystocele is located upper third of the vagina. The structures involved are
the endopelvic fascia and ligaments. The cardinal ligaments and the uterosacral
ligaments suspend the upper vaginal-dome. The cystocele in this region of the vagina is
thought to be due to a cardinal ligament defect.
Medial cystocele forms in the mid-vagina and is related to a defect in the suspension
provided by to a sagittal suspension system defect in the uterosacral ligaments
and pubocervical fascia. The pubocervical fascia may thin or tear and create the cystocele.
An aid in diagnosis is the creation of a 'shiny' spot on the epithelium of the vagina. This
defect can be assessed by MRI.
Lateral cystocele forms when both the pelviperineal muscle and its ligamentous–fascial
develop a defect. The ligamentous– fascial creates a 'hammock-like' suspension and
support for the lateral sides of the vagina. Defects in this lateral support system results in
a lack of bladder support. Cystocele that develops laterally is associated with an anatomic
imbalance between anterior vaginal wall and the arcus tendineus fasciae pelvis – the
essential ligament structure.

34. MANAGEMENT - TREATMENT:
Conservative management:
Lifestyle modification.
Pelvic floor exercises / pelvic
floor muscle training (PFMT).
Vaginal pessary.
Indications:
Mild or moderate degree of
prolapse
Asymptomatic women
Unfit for surgery
Old women
Prolapse in pregnancy
While awaiting surgery

35. GOALS OF CONSERVATIVE MANAGEMENT:
Prevent worsening prolaps, Decrease the severity of symptoms
Increase the strength, endurance, and support of the pelvic floor
musculature
Avoid or delay surgical intervention

36. CONSERVATIVE MANAGEMENT
MECHANICAL DEVICES - PESSARIES
Types : Support and space filling.
M/C used:
support pessary - ring pessary for stage I and II prolapse,
Gelhorn pessary is a commonly used space-filling pessary for stage III
and IV prolapse.

37. PESSARIES

38. Cont…
Placement and Management:
The patient’s desire and motivation to use this type of device.
In hypoestrogenic women, treatment of the vagina with estrogen and
maintenance of intravaginal estrogen treatment is recommended.
Fitting a Pessary:
Examined in the lithotomy position after emptying her bladder.
Size of the pessary is estimated after a digital examination.
When fitted, the patient is asked to stand, perform Valsalva, and cough to
ensure the pessary is retained.
should be able to void with the pessary in place before leaving .

39. Cont…
Follow-Up Recommendations:
Initially in 1 to 2 weeks and then at 4 to 6 weeks,
Proper placement of the pessary, support of the prolapse and continence
efficacy should be ensured.
The pessary’s integrity should be checked, and the tissues should be
evaluated for irritation, pressure sores, ulceration, and lubrication

40. CONSERVATIVE MANAGEMENT
Complications :
vaginal discharge and odor, Failure to retain the pessary too large pessary
could lead to excoriation or irritation.
With reduction of vaginal prolapse, de novo or increased stress incontinence
may occur,
More severe complications:
vesicovaginal or rectovaginal fistula, small bowel entrapment,
hydronephrosis, and urosepsis.

41. MANAGEMENT - TREATMENT:
Surgical management:
Vaginal
Abdominal
Laparoscopically
Combined approach
Robotic
Type:
Reconstructive procedures
Compensatory (augmentation)
Obliterative procedures

42. Factors determining the choice of surgical
treatment.
Age
Parity
stage of prolapse
Prior surgery for prolapse
Intra-abdominal adhesions
– Endometriosis
– PID
Type of prolapse
– Anterior vaginal wall
– Posterior vaginal wall
– Apical/vault
Associated stress incontinence

43. Surgical management
Primary aims
To relieve symptoms,
To restore vaginal anatomy so that sexual function may be
maintained or improved without significant adverse effects or
complications.

44. RESTORATIVE VAGINAL REPAIRS
NATIVE TISSUE:
No biological graft or synthetic mesh.
No risk of mesh related complications.
Slightly higher recurrence rates.
GRAFT REPAIR:
Biological graft – human cadaveric dermal tissue, bovine collagen.
MESH REPAIR:
Mono-filament(polypropylene)
No longer FDA approved.

45. Surgical management - Vaginal Procedures:
LEVEL I
The Apical Compartment:
Apical support is the key to a successful prolapse repair.
Transvaginal repairs (extraperitoneal procedures)
Sacrospinous suspensions,
Iliococcygeal suspensions, and
High paravaginal suspensions of the apical vaginal fornices to the arcus
tendineus at the level of the ischial spine or to the endopelvic fascia,
Transvaginal repairs (intraperitoneal suspensions)
Uterosacral suspensions and Mc Call culdoplasties.

46. Surgical management - Vaginal Procedures:
LEVEL I
Sacrospinous Ligament Fixation:
Extraperitoneal via the rectovaginal space with penetration of the
pararectal (Denonvillier fascia) at the level of the ischial spine to
expose the muscle and ligament.
Variations in this approach to the ligament include entrances through
an anterior lateral access, an apical passage posterior to the
uterosacral ligament, and a laparoscopic approach.

47. Surgical management - Vaginal Procedures:
LEVEL I
Sacrospinous Ligament Fixation - Advantages :
(1)Its transvaginal extraperitoneal approach;
(2) Resultant posterior vaginal deflection; and
(3) It is a durable repair if performed correctly. Reported success for
apical support has been good (89% to 97%)

48. Surgical management - Vaginal Procedures: LEVEL I
Sacrospinous Ligament Fixation - Disadvantages :
(1) relative difficulty in adequately exposing the ligament;
(2) an unnatural lateral vaginal deflection toward the fixation site;
(3) an inability to perform without excessive tension when the vaginal length is
compromised, as may be the case in repeat procedures;
(4) potential risk for injury to the sciatic nerve or pudendal nerve or vessel; and
(5) occasional need to shorten or narrow the upper vagina when a fibromuscular
defect involves much of the apical area.

49. Surgical management - Vaginal Procedures:
Iliococcygeal Vaginal Suspension:
The attachment, usually bilaterally, of the vaginal apex to the
iliococcygeus muscle and fascia.
Extraperitoneal access is achieved via the posterior vagina

50. Surgical management - Vaginal Procedures:
LEVEL I
Enterocele repairs :
1. Removal of the peritoneal sac with closure of the peritoneal defect, followed by
closure of the fascial or fibromuscular defect or both below it
2. Dissection and reduction of the peritoneal sac and closure of the defect
3. Obliteration of the peritoneal sac from within with transabdominal Halban or
Moschcowitz type procedures or transvaginal McCall or Halban procedures
4. If the posterior vaginal wall is significantly elongated and enlarged, excision of
that area to establish an acceptable vaginal length and to eliminate redundancy

51. Surgical management – Abdominal Procedures:
LEVEL I
Moschcowitz Culdoplasty: cul-de-sac - at the base and are directed
upward at level of the vaginal apex, through the posterior vaginal wall -
right uterosacral ligament - the rectosigmoid colon muscularis, and
finally the left uterosacral. 3-4 concentric rings, 1-2 cm apart.

52. Surgical management – Abdominal Procedures:
LEVEL I
Halban Culdoplasty: Several rows of 2-0 gauge permanent sutures are
placed longitudinally through the serosa and muscularis of the
rectosigmoid 1 cm apart - through the deep cul-de-sac and up toward
the apex of the posterior vaginal wall. As much of the cul-de-sac as
possible is obliterated, but to avoid ureteral injury, sutures are not
placed lateral to the uterosacral ligament.

53. Surgical management - Vaginal Procedures:
LEVEL I
Uterine Preservation:
when the uterus or cervix is to be kept in place, additional apical support
procedures include Manchester and Gilliam procedures and fixation of the
cervix to the sacrospinous ligament.

54. Surgical management - Vaginal Procedures:
LEVEL I
Uterosacral Ligament Suspension:
The vaginal apex is suspended to the uterosacral ligaments above the level of
the ischial spines.
Excellent success rates.
Most common serious complication - ureteral obstruction secondary to
ureteral kinking 11% or incorporation of a ureter in a suspension stitch 2% to
3% .
Cystoscopy is performed to document ureteral patency.

55. The two most commonly performed transvaginal native tissue apical
prolapse repairs are the sacrospinous ligament suspension and
uterosacral ligament suspension.
(1) vaginal apical descent to more than one-third of the total vaginal
length;
(2) anterior or posterior vaginal wall descent beyond the hymen;
(3) bothersome vaginal bulge symptoms; and
(4) retreatment of prolapse.
The 2-year success rate was 59% versus 61% for uterosacral and
sacrospinous ligament suspension, respectively.

56. Surgical management - Vaginal Procedures:
The Anterior Compartment - LEVEL II
Anterior Vaginal Colporrhaphy:
Anatomic correction of an anterior defect or cystocele will relieve symptoms
of protrusion and pressure.
Improve micturition function when abnormal micturition is associated
temporally with the defect.
If the patient has significant stress incontinence an appropriate incontinence
procedure may be performed simultaneously with the anterior repair.
Mid urethral sling procedure is done with a separate incision for the sling.

57. Surgical management - Vaginal Procedures:
The Anterior Compartment - LEVEL II
Paravaginal Repair:
The paravaginal or “lateral defect” repair involves reattachment of the
anterior lateral vaginal sulcus to the obturator internus fascia and, in some
cases, muscle at the level of the arcus tendineus pelvis (“white line”).

58. OPERATIVE GOALS OF ANTERIOR VAGINAL
RECONSTRUCTION
Central: Reconstruct the pubocervical septum or repair of distention
cystocele.
Proximal: Reattach the proximal pubocervical septum to the
suspensory support of the paracolpium. Rebuild the pericervical ring
and compensate for the defect left by the absence of the cervix
(DeLancey Level I).
Lateral: Reattach the pubocervical septum to the arcus tendineus
fasciae pelvis (white line) or paravaginal repair (DeLancey Level II).
Distal: Urethropexy (DeLancey Level III).

59. Surgical management - Vaginal Procedures:
The posterior Compartment
Traditional Posterior Colporrhaphy:
The Denonvillier fascia is mobilized from the vaginal epithelium.
After defects in the rectal muscularis are repaired, the fascia is plicated in the
midline with interrupted or continuous sutures.
Perineal body or perineal membrane reconstruction is performed after
posterior colporrhaphy for PB defect.
Dyspareunia is reported in 8% to 26% of sexually active patients who have
traditional posterior colporrhaphy.

60. Surgical management – Vaginal Procedures:
Transvaginal Mesh Procedures
“bridging material to reinforce native structures”
(1) nonantigenic;
(2) exhibit a low infection rate;
(3) decrease or negate recurrence of anatomic defects;
(4) cause no harm with respect to bowel or renal function; and
(5) relatively inexpensive.
Graft exposure/erosion may produce bothersome discharge, pain, and sexual
dysfunction with vaginal scarring.
Monofilament and large pore size grafts (type 1) mesh is used.

61. Surgical management – Vaginal Procedures:
Transvaginal Mesh Procedures

62. Corrective surgery for vaginal vault prolapse
Laparoscopic approach:
Laparoscopic sacrocolpopexy
- Vaginal vault to anterior sacral ligaments

63. Surgical procedures for anterior and posterior vaginal wall
prolapse
Anterior vaginal wall
Anterior colporrhaphy - Plication of pubovesicocervical fascia
Posterior vaginal wall
Posterior colporrhaphy - Plication of rectovaginal fascia
Site-specific repair – Perirectal fascial repair at the site of defect
Perineorrhaphy - Approximation of pubovaginalis; repair of perineal body
McCall culdoplasty - Plication of uterosacrals; attaching uterosacrals to vaginal vault
Moskowitz procedure (abdominal) - Purse-string plication of peritoneum of POD

64. Uterus-preserving surgeries in pelvic organ
prolaps
Fothergill/ Manchester surgery
Suspension/sling procedures
Apogee and perigee
Abdominal sacrohysteropexy
Purandare sling procedure
Shirodkar sling procedure
Khanna sling procedure

65. APOGEE AND PERIGEE

66. UTERUS - PRESERVING SURGERIES
Sacral hysteropexy:
Open laparotomy or laparoscopy
Mesh is attached to sacrum at one end and posterior or both
anteroposterior suface of uterine isthmus on other.
Burch operation may be performed concomitantly.

67. Corrective surgery for vaginal vault prolapse
Vaginal approach:
Sacrospinous colpopexy (unilateral or bilateral)
Vaginal vault to sacrospinous ligament.
Mc Call culdoplasty
Approximation of uterosacral ligaments; vaginal vault to uterosacral
ligaments.
Iliococcygeus colpopexy
Vaginal vault to iliococcygeus muscle.
Bilateral high uterosacral ligament suspension
Vaginal vault to uterosacral ligaments

68. Corrective surgery for vaginal vault prolapse
Abdominal approach:
Abdominal sacrocolpopexy
Vaginal vault to anterior sacral ligament
Abdominal uterosacral suspension
Vaginal vault to uterosacral ligament

69. Colpocleisis
Consider colpocleisis for women with vault or uterine prolapse
who do not intend to coitus and who have a physical condition
that may put them at increased risk of operative and
postoperative complications.

70. Complications of surgical procedures
Haemorrhage – primary, reactionary, secondary haemorrhage.
Sepsis
Trauma to the bladder, urethra and rectum mainly in repeat surgery.
Urinary infection.
Thrombo-embolism.
Late sequelae:
Narrow scarred vagina and dyspareunia.
Granulation tissue.
Recurrence of vault prolapse
Fistula

71. Postoperative care
postoperative fluid management, adequate analgesia and monitoring for vital signs and bleeding.
The prophylactic antibiotics should include broad spectrum antibiotics covering anaerobic
organisms also. The most commonly used regimen is amoxicillin + clavulanic acid 1.2 gm and
metronidazole 500 mg perioperatively in prophylactic doses.
The duration of postoperative catheterization should be minimum depending on extent of
bladder dissection and type of surgery performed.
Woman should be ambulated after effect of anesthesia wears off.
The perineal hygiene should be taken care of.

72. Reasons for failure or recurrence of prolapse
 Wrong choice of surgical procedure
 Poor surgical technique
 Omission to recognise and treat enterocele
 Shortening of anterior vaginal wall
 Inherent weakness of supports
 Pregnancy and delivery following operation.

73. Reference
Williams Gynecology
Berek and Novaks Gynaecology
Campbell Urology
TeLindes Operative Gynecology
DC Dutta Gynaecology
Lakshmi Seshadri Gynecology

74. THANK YOU 