Seminar presentation

1. MUHAMMAD AFFAN SYAFIQI | NUR AMANINA NASIR | NIK NOR LIYANA SUHAIM
PELVIC ORGAN
PROLAPSE

2. WHAT IS PELVIC ORGAN
PROLAPSE?
Pelvic organ prolapse is the descent of the genital organs
beyond their normal anatomical confines. It is caused by
herniation through deficient pelvic fascia or due to
weakness or deficiency of the ligaments or muscles or
blood or nerve supply to the pelvic organs.

3. DEFINITION AND CLASSIFICATION
A prolapse is protrusion of an organ or structure beyond its
normal confines. Prolapses are classified according to their
location and the organs contained within them
Anterior vaginal
wall prolapse
POSTERIOR
vaginal wall
prolapse
APICAL vaginal
prolapse
Urethrocele
Urethral descent
Cystocele
Bladder descent
Cystourethrocele
Descent of bladder and urethra
Rectocele
Rectal descent
Enterocele
Small bowel descent
Uterovaginal
Uterine descent with inversion
of vaginal apex
Vault
Post-hysterectomy inversion of
vaginal apex

4. Varieties of prolapse

5. PREVALENCE
 41-50 % of women over age of 40 years.
 Lifetime risk:
- 7% operation for prolapse
- 11% operation for incontinence/prolapse
 The annual incidence of surgery for pelvic organ
prolapse within 15-49 per 10000 women.

6. GRADING
 1ST Degree
Descent within the vagina
 2nd Degree
Descent to the introitus
 3rd Degree
Descent outside the introitus

7. GRADING

8. The connective tissue, levator ani and intact nerve
supply are vital for the maintenance of the position of
the pelvic structures and are influenced by pregnancy,
childbirth and ageing.
Whether congenital or acquired, connective tissue
defects appear to be important in the aetiology of
prolapse and urinary stress incontinence.
AETIOLOGY

9. AETIOLOGY
1. Congenital
 2% of symptomatic prolapse occurs in nulliparous women
 Genital prolapse is rare in Afro-Caribbean women
2. Childbirth and Raised Intra-Abdominal Pressure
 Major factor – vaginal delivery
 Nerve and mechanical damage resulting from vaginal delivery
 Parity is associated with increasing prolapse
 Prolapse during pregnancy is rare, but may be mediated by the effects
of progesterone and relaxin
 Increase in intra-abdominal pressure will put an added strain on the
pelvic floor
 Conditions such as constipation or chronic cough can also raised intra-
abdominal pressure

10. 3. Ageing
 Loss of collagen and weakening of fascia and connective tissue
 Particularly during the post-menopause as a consequence of
oestrogen deficiency
4. Postoperative
 Poor attention to vaginal vault support can lead to vault prolapse
 Usage of mechanical displacement such as colposuspension may lead
to development of rectocele or enterocele
AETIOLOGY

11. PATHOPHYSIOLOGY
There are three components that are responsible for
supporting the position of the uterus and vagina
LIGAMENTS AND FASCIA
LEVATOR ANI MUSCLES
POSTERIOR ANGULATION OF THE VAGINA
By suspension from pelvic side walls
By constricting thereby maintaining the position of the organ
Which is enhanced by rises in intra-abdominal pressure
causing closure of the ‘flap valve’

12. LIGAMENTS AND FASCIA

13. Levator ani

14. ANGULATION OF VAGINA

15. NORMAL CONDITION
 At rest, tonic contraction of levator ani muscles provides support
to pelvic organs with their activity adjusting to variation in posture,
increased vaginal distension, and intra-abdominal pressure.
 In presence of normal support by levator ani muscle, the supportive
connective tissues of vagina pulled the vagina superiorly and back
towards the sacrum placing the upper vagina at a nearly horizontal
orientation over the levator ani muscle.
 With presence of intra-abdominal pressure, the upper vagina is
compressed against the levator ani muscles and pelvic organ
support is maintained.

16. PELVIC ORGAN PROLAPSE
 Damage to any component of vaginal connective tissue support
changes the vaginal axis to a vertical position directly over the
genital hiatus.
 Thus with increase in intra-abdominal pressure, the vagina is no
longer compressed against the levator ani muscles but directed
downward toward the genital hiatus thus can cause pelvic organ
prolapse.

17. ANALOGY DEMONSTTRATING THE SUPPORT

18. CLINICAL
FEATURES
CLINICAL
FEATURES

19. Non-specific clinical features
 Pressure, pain or “fullness” in vagina or rectum or both
 Sensation of ‘your insides falling out’ – vaginal tissue bulge
 Urinary incontinence
 Urine retention
 Fecal incontinence
 Chronic constipation
 Back or pelvic pain
 Tampons pushing out
 Dyspareunia (painful / difficult sexual intercourse)
 Apareunia (inability to perform sexual intercourse)
 Coital incontinence (leakage of urine or stool during intimacy)

20. Specific clinical features
CYSTOURET
HROCELE
RECTOCELE
• Urinary frequency & urgency
• Voiding difficulty
• Urinary Tract Infection (UTI)
• Stress incontinence
• Incomplete bowel emptying
• Digitation
• Splinting
• Passive anal incontinence

21. EXAMINATIONS
ABDOMINAL EXAMINATION
VAGINAL EXAMINATION
COMBINED RECTAL AND VAGINAL EXAMINATION
 To exclude organomegaly / abdominopelvic mass
 Examine in dorsal position (if protrude beyond introitus)
 Assess with ptt straining in left lateral position & Sims speculum
 To differentiate rectocele from enterocele

22. DIFFERENTIAL DIAGNOSIS
Anterior
wall
prolapse
1. Congenital / inclusion dermoid
vaginal cyst
2. Uretheral diverticulum

23. DIFFERENTIAL DIAGNOSIS
UTERINE
PROLAPSE
1. Congenital elongation of cervix
2. Chronic inversion
3. Fibroid polyps

24. MANAGE
MENT
MANAGE
MENTPREVENTIVE |
CONSERVATIVE | SURGERY

25. There is no single way to
COMPLETELY prevent these
problems.
MANAGEMENT
1. Overweight women are at a significantly increased risk.
2. Avoid constipation and chronic straining – increase fiber and fluid intake.
3. Seek medical attention if chronic cough which increases abdominal and
pelvic pressure.
4. Avoid heavy lifting and learn how to lift safely
5. Do not smoke.
6. Avoid repetitive strenuous activities.

26. MANAGEMENT
To avoid injuries to
supporting
structures during
time to vaginal
delivery either
spontaneously or
instrumental.
Encourage early
ambulation and
encourage pelvic floor
exercise by squeezing
the pelvic floor
muscles during
puerperium
Avoid strenuous
activity and avoid
pregnancy too soon
and too many by
contraceptive
practice
Antenatal and
Intranatal Care
POSTNATAL Care
GENERAL
MEASURES

27. REMEMBER!
1. Antenatal physiotheraphy & relaxation exercises (attention to weight gain
and anemia)
2. Proper supervision and management of second stage of labour
3. A generous episiotomy
4. Low forceps delivery if there is delay in second stage
5. Suture perineal tear
6. Postnatal exercises and physiotherapy
7. Early postnatal ambulation
8. Adequate spacing of births
9. Avoid multi-parity
10. Prophylatic HRT in postmenopausal women

28. REMEMBER!
1. Antenatal physiotheraphy & relaxation exercises (attention to weight gain
and anemia)
2. Proper supervision and management of second stage of labour
3. A generous episiotomy
4. Low forceps delivery if there is delay in second stage
5. Suture perineal tear
6. Postnatal exercises and physiotherapy
7. Early postnatal ambulation
8. Adequate spacing of births
9. Avoid multi-parity
10. Prophylatic HRT in postmenopausal women

29. REMEMBER!
If symptoms are mild,
practice pelvic floor
physiotherapy (Kegel
Exercise).
Once prolapse has
developed, Kegel will not
correct the problem but
may prevent the
prolapsed from worsen.

30. CONSERVATIVE
PESSARY TREATMENT

31. TYPES

32. Silicon rubber
based ring
pessaries most
popular form
Ring pessary is
made of soft
plastic polyvinyl
chloride & available
in different sizes.

33. INDICATIONS?
 A young woman planning a
pregnancy
 During early pregnancy
 Puerperium
 Temporary use while clearing
infection and decubitus ulcer
 A woman unfit for surgery
 In case a woman refuses for
surgery

34. LIMITATIONS
 It is never curative and only be palliative
 It can cause vaginitis
 Pessary needs to be changed every 3 months
 The wearing of pessary is not comfortable to some women and may cause
dyspareunia
 If the vaginal orifice is very patulous, the pessary is often not retained.
 A forgotten pessary can be the cause of ulcer, rarely carcinoma of vagina and
vesicovaginal fistula
 A pessary does not cure urinary stress incontinence

35. SURGERY
AIMING TO Relieve symptoms, Restore anatomy AND
Restore sexual function

36. TYPES OF SURGERY
OFFERED TO PATIENTS WITH
PROLAPSE DEPENDS ON:
1. The age of patient
2. Desire to retain the uterus
3. Menstrual history
4. General condition
5. Degree of uterine prolapse
6. Uterine abnormality

38. 1. Anterior Colporrhaphy
To correct cystocele &
urethrocele or
cystourethrocele

39. 2. Perineorrhaphy / Colpoperineorrhaphy
To repair the prolapse of
posterior vaginal wall

40. UTEROVAGINAL PROLAPSE
UTERINE PRESERVING SURGERY
1. Hysterosacropexy
 Open or laparoscopic route
 Mesh is attached to the isthmus of cervix and uterus to other part of
anterior longitudinal ligament on sacrum
2. Manchester repair
 Accessing uterus vaginally
 Amputate cervix
 Use uterosacral cardinal ligament complex to support uterus
 Rare method
3. Le Fort colpocleisis
 Partial closure of vagina while preserving the uterus

41. UTEROVAGINAL PROLAPSE
Hysterosacropexy Manchester (cardinal
ligament)

42. PROCEDURE INVOLVING HYSTERECTOMY
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 uterine vessels
which are cut and ligated
1. VAGINAL HYSTERECTOMY

43. PROCEDURE INVOLVING HYSTERECTOMY
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