Management Principles of Pelvic Organ Prolapse and Stress Urinary Incontinenc

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PELVIC ORGAN PROLAPSE PELVIC FLOOR
DYSFUNCTIONSurgical Anatomy and Current
Management guidelines

• Dr Malleswar Rao Kasina, MD,DGO
• Consultant Obstetrician Gynaecologist
• Hyderabad

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Normal axis
Axis of the uterus and vagina anteverted and
anteflexed
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Pelvic diaphragm
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(Inferior view - Diagrammatic)
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Inferior view of the pelvic diaphragm
(Anatomical) Superficial Perineal muscles,
Perineal Body and Levat Ani
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Elements comprising the Pelvis

• Bones
• Ilium, ischium and pubis fusion
• Ligaments
• Muscles
• Obturator internis muscle
• Arcus tendineus levator ani or white line
• Levator ani muscles
• Urethral and anal sphincter muscles

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• Endopelvic fascia
• Meshwork of collagen, elastin and smooth muscle
• Extends from the level of uterine artery to the
  fusion of the vagina and levator ani
• Attached to uterus is parametrium
  cardinal-uterosacral ligament complex
• Attached to vagina is paracolpium pubocervical
  and rectovaginal fasciae

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Pelvic Floor Muscles and Endopelvic Fascia
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Arcus Tendineus Fascia pelvis Arcus Tendineus
Levator Ani with endopelvic fascia Lavator Ani
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Normal Vaginal Support Anatomy

• Bladder, upper two-third vagina and rectum lie in
  a horizontal axis
• Urethra, distal one-third vagina and anal canal
  are vertical in orientation
• Pelvic floor is horizontal and like a hammock
  levator plate
• Levator ani muscles and perineal body support the
  vertical orientation urethra, distal 1/3rd of
  vagina, anal canal.

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horizontal vaginal axis

• The vaginal lies in a nearly horizontal axis when
  the woman is standing. Hence any intra-abdominal
  downward force will appose the vagina on the
  pelvic floor muscles preventing descent.

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The axes of pelvic support(Pelvic Fascia)

• Three support axes
• Upper vertical axis (cardinal-uterosacral
  ligament complex)
• Horizontal axis leads to lateral and paravaginal
  supports
• Two platforms pubocervical fascia and
  rectovaginal septum
• Lower vertical axis supports the lower third of
  the vagina, urethra and anal canal

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Pelvic diaphragm (Schematic)
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Pelvic Diaphragm (Anatomic) - Horizontal Axis of
the upper 2/3rds of Vagina Rectum
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Prevention of Prolapse(Horizontal axis of
upper2/3rds of Vagina Rectum)
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Horizontal Axis of the upper 2/3rds of Vagina
Rectum above pelvic diaphragm
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CONTINENCE MECHANISM
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HAMMOCK THEORY OF EXTRINSIC CONTINENCE MECHANISM
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DeLanceys three levels of vaginal support

• Apical suspension
• Upper paracolpium suspends apex to pelvic walls
  and sacrum
• Damage results in prolapse of vaginal apex
• Midvaginal lateral attachment
• Vaginal attachment to arcus tendineus fascia
  pelvis and levator ani muscle fascia
• Pubocervical and rectovaginal fasciae support
  bladder and anterior rectum
• Avulsion results in cystocele or rectocele
• Distal perineal fusion
• Fusion of vagina to perineal membrane, body and
  levators
• Damage results in deficient perineal body or
  urethrocele

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

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Level 1 (suspensory axis)

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

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• Round ligament
• (mackenrodts lig / transverse/lateral cevical
  cervical ligament at the base of broad lig with
  uterine A V

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Defects in level 1

• Uterovaginal UV prolapse
• Enterocele
• Vault prolapse

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Level 2 (attachment axis)

• Level II- Pelvic fascias and paracolpos
• Fascial septae connects mid vagina to the pelvic
  sidewalls
• Anteriorly on Supine (Above on standing position)
• Pubocervical
• Posteriorly on Supine (Below on standing
  position)
• Rectovaginal fascia
• which connects the vagina to the white line on
  the lateral pelvic wall through arcus tendinous
  fascia pelvis (ATFP)

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Horizontal axis of pubocervical fascia and
rectovaginal fascia (pelvic fascia) with
underlying Levator Ani
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Horizontal Vertical (Distal) portions of
pubocervical fascia
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Defects in level 2

• 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.
• In level II, 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.

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Schematic representation of the connective tissue
support of the upper 2/3rd of Vagina Uterus
(paracolpium Parametrium CL, USL)
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Oblique sagittal view of anatomy of the lateral
attachments of the vagina
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Level 3 (fusion axis )

• Level III-Fusion of the Pelvic Fascia of the
  lower 1/3rd of Vaginal walls
• Anteriorly (On Supine position) or
• Inferiorly (On Standing position)
• Urethra
• Urogenital diaphragm
• Pubis
• laterally (On both positions)
• Levator ani fascia (Fascia Tendineus Levator Ani
  -FTLA) (Denoted by Asterisks in next slide)
• Posteriorly (On both positions)
• Perineal body

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Levator Ani with superior inferior layers of
fascia (endopelvic pubocervical fascias) and
lateral fused ATFP



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Current Theories Relating to Maintenance of
Continence

• Pathophysiology of SUI relating to urethral
  hypermobility is based on DeLanceys theory of
  urethral support Hammock theory(DeLancey,1994).
• The fascial covering of levator ani consists of
  two leaves endopelvic fascia (abdominal side)
  and pubocervical fascia (vaginal side).
• The two leaves fuse laterally to attach on to
  ATFP, creating a hammock of support under the
  urethra and bladder neck

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Hammock Theory (DeLancy)
Normal support
Tearing
Sagging
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(PROCIDENTIA)
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Perineum

• Anterior pubic arch, posterior coccyx tip,
  lateral ischiopubic rami, ischial tuberosities
  and sacrotuberous ligaments frame the perineum
  into a diamond shape
• Divided into two angulated triangles
• Posterior anal triangle contains the anal canal
• Anterior urogenital triangle contains the vagina
  and urethra

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External genital muscles and the Urogenital
diaphragm
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Pelvic Relaxation

• Cystocele
• Stress urinary incontinence
• Rectocele
• Enterocele
• Uterine and vaginal prolapse
• Result of weakness or defect in supporting
  tissues - endopelvic fascia and neuromuscular
  damage

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Boat in dock analogy

• Boat- pelvic organs
• Water- levator muscles
• Moorings- Endopelvic fascial ligaments
• Problem is with the water or moorings or both
• Result is sinking of the boat
• Really the boat itself is fine

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PROLAPSE

• Mutifactorial involving both neuromuscular and
  endopelvic fascial damage
• Relaxation of the tissues supporting the pelvic
  organs may cause downward displacement of one or
  more of these organs into the vagina, which may
  result in their protrusion through the vaginal
  introitus.

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Factors promoting prolapse

• Erect posture causes increased stress on muscles,
  nerves and connective tissue
• Acute and chronic trauma of vaginal delivery
• Aging
• Estrogen deprivation
• Intrinsic collagen abnormalities
• Chronic increase in intraabdominal pressure
• heavy lifting
• coughing
• constipation

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Clinical Evaluation

• Hormonal and neurologic evaluation
• Level of estrogenization
• Sensory and sacral reflex activity
• Quantitative site-specific assessment of pelvic
  floor components
• in lithotomy position, patient sitting
• at rest and with valsalva
• ability to contract levator and anal sphincter
  muscles

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Patient position for evaluating pelvic floor
defects
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Physical Examination of Pelvic Floor Function
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Baden Walker POP-Q System
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POP-Q System
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POP Q System

• Created in an effort to provide objectivity to
  POP quantification
• Nine specific points of measurement are obtained
  in relation to the hymenalring
• 6 vaginal points (Aa, Ba, C, D, Ap, and Bp)
  measured during Valsalva manoeuvre.
• Points above hymen negative
• Points below hymen positive.
• Genital hiatus (gh) represents the size of the
  vaginal opening
• Perineal body (pb) represents the distance
  between the vagina and the anus.
• Total vaginal length (tvl) is measured by
  reducing the prolapse and measuring the depth of
  vagina.

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Pelvic Organ Prolapse Quantification (POPQ)
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Anterior compartment defects

• Urethral hypermobility
• Distal 4 cm of anterior vaginal wall
• Cotton swab test
• If describes an arc greater than 30 degrees from
  horizontal with valsalva
• Results in genuine stress incontinence
• Cystocele

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Cystocele

• Main support of urethra and bladder is the
  pubo-vesical-cervical fascia
• Essentially a hernia in the anterior vaginal wall
  due to weakness or defect in this fascia
• Midline weakness allows bladder to descend
  causing central cystocele
• Tearing of end pelvic fascial connections from
  lateral sulci to arcus tendinii causes lateral or
  displacement cystocele
• Detachment of pubocervical fascia from
  pericervical ring causes a transverse or apical
  cystocele
• Symptoms include pelvic pressure and bulge or
  mass in the vagina

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Defects in Pubocervical fascia (Schematic)
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PARAVAGINAL DEFECTS (Anatomic)
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PARAVAGINAL REPAIR
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Repair of Cystocele (Anterior Colporrhaphy)
Lateral defect Repair
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Cystocele

• Classified as Grade I, II, or III
• Grade III is prolapse outside the introitus
• Surgical repair is treatment of choice
• Anterior Colporrhaphy
• Paravaginal repair
• Colpocleisis
• Vaginal pessary

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Posterior compartment defects

• Rectocele
• Perineal deficiency
• Bulbocavernous and superficial transverse muscle
  heads retracted
• Perineal descent
• Sagging and funneling of the levator ani around
  the perineum such that anus becomes most
  dependent
• Difficulty with defecation

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Rectocele

• Chiefly a hernia in the posterior vaginal wall
  secondary to weakness or defect in the
  rectovaginal septum or fascia of Denonvilliers
• Symptoms include difficulty evacuating stool, a
  vaginal mass, and fullness sensation
• Rectovaginal exam confirms diagnosis

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Rectocele

• Damage generally due to excessive pushing in
  childbirth or chronic constipation
• Surgical treatment if symptomatic
• Posterior Colporrhaphy
• Laxatives and stool softeners
• Temporary relief
• Pessary not helpful

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Evaluation of a rectocele
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Apical defects

• Uterine prolapse
• Normal cervix located in upper third of vagina
• Degree of prolapse measured by position of cervix
  at maximum intraabdominal pressure, without
  traction
• Complete uterovaginal prolapse is called
  procidentia
• Vault prolapse
• Enterocele

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Uterine prolapse

• Weakness of endopelvic fascia and detachment of
  cardinal and uterosacral ligaments
• Complains of severe pelvic or abdominal pressure,
  bulge or mass, and low back pain
• Surgical management includes hysterectomy and
  vaginal cuff or apex suspension
• Estrogen replacement important

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Complete Uterovaginal procidentia
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Enterocele

• A true hernia of the recto uterine or cul-de-sac
  pouch (pouch of Douglas) into the rectovaginal
  septum
• Descent of bowel in a peritoneum-lined sac
  between posterior vaginal apex and anterior
  rectum
• Pulsion enterocele is filled with bowel and
  distended by abdominal pressure
• Can occur anteriorly as well
• Generally after a surgical change in vaginal axis
• Symptoms of fullness and vaginal pressure or
  palpable mass
• Bowel peristalsis confirms diagnosis

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Enterocele

• Commonly found in association with other defects
• Surgical approach
• Vaginal
• Abdominal
• Laparoscopic
• Ligation of hernia sac and obliteration of the
  pouch of Douglas

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Conservative treatments

• Obstetric care to protect pelvic floor
• Decreased pushing times
• Avoid forceps, major lacerations
• Permit passive descent
• General lifestyle changes
• Smoking cessation and cough cessation
• Routine use of Kegel pelvic floor exercises
• Regular physical activity
• Proper nutrition
• Weight loss
• Avoid constipation and repetitive heavy lifting
• Hormone replacement therapy

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Pelvic Organ Prolapse Conservative Surgical
Management(Classic Current)
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Complications

• Kinking of ureter
• UTI
• Ca vagina

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Mx of decubitus ulcer

• Smear for cytology
• Colposcopy and directed biopsy
• Reduction of prolapse
• Oestrogen cream - if postmenopausal

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Conservative management

1. Mild degrees of prolapse
2. Unfit for surgery or unwilling for surgery
3. Childbearing not complete
4. In pregnancy
5. Awaiting for surgery

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• Pelvic floor muscle training
• Kegels exercises
• Life style measures
• Lose weight, avoid weight lifting
• Stop smoking
• Treat c/c cough constipation
• Vaginal Pessaries

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Vaginal Pessaries

• Indications
• Unfit / unwilling for surgery
• Awaiting for surgery
• Pregnancy
• Lactation
• For decubitus ulcer to heal

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• Support pessaries
• Smith Hodge pessary or
• Ring pessary
• Stage I II
• Space filling pessaries
• Gelhorn and Cube pessaries
• Advanced stages
• More support

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Complications of Pessaries

1. Vaginal discharge
2. Vaginal irritation
3. Erode vaginal ------ fistula
4. Ca vagina

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Surgical Management(Classic reconstructive)
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Principles of reconstructive pelvic surgery

• Site-specific repair
• Rebuild weakened endopelvic fascia, repair
  fascial tears, and reattach prolapsed tissues to
  stronger sites
• Goal is a vagina of normal depth, width and axis
• Denervation or muscle trauma cannot be corrected
  surgically

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Anterior CompartmentPosterior
compartmentMiddle compartmentEnteroceleNulli
parous prolapse

• Where is the defect?

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• Reconstructive
• Obliterative
• Le Forts Colpocleisis

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Anterior Compartment

• Anterior cystocele
• Midline defect
• Paravaginal defect / lateral cystocele
• Detachment from arcus tendinus fascia

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• Site Specific Repair of the local fascia
  lateral, midline and Apical or Transverse defects
  in the Pubocervical fascia.

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Anterior Colporrhaphy

• Plication of pubo-vesico-cervical fascia
• Inverted T shaped incision
• Horizontal bladder sulcus
• Vertical - to just below ext urethral meatus
• Cut vesicocervical ligament, push bladder up
• Bladder buttressing
• Site specific repair pubocervical fascia to
  arcus tendineus

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Paravaginal repair

• Abdominal
• Vaginal
• Laparoscopic
• Approximating vagina and arcus tendinus fascia
  pelvis

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Posterior Compartment

1. Posterior colporrhaphy
2. Site specific repair
3. Perineorrhaphy

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Posterior Coplorrhaphy

• Plication of rectovaginal fascia
• Pair of allis forceps either side, at lower
  labium minora
• 3rd forceps on post vaginal wall midline, above
  bulge
• Horizontal incision dissect vaginal mucosa from
  prerectal fascia
• Vertical incision to apex
• Approximate prerectal fascia in midline
• Anterior plication of pubococcygeus also
• Perineorrhaphy
• Repair of perineal body

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Middle compartment

• Uterine prolapse
• Vault prolapse
• Enterocele

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Vaginal Hysterectomy

• (Ward Mayo repair)
• Uerovaginal prolapse childbearing complete

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Vaginal Hysterectomy

• 1st clamp Uterosacral Cardinal lig
• 2nd clamp Uterine vessels
• 3rd clamp round ligament, f.tube, ovarian lig
• Enterocoele correction
• Close peritoneum Purse string suture

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Vaginal vault prolapse

• 1) Vaginal Approach
• Sacrospinous colpopexy
• - vaginal vault to sacrospinous
  ligament
• McCalls Culdoplasty
• -approximation of uterosacral lig
  
  vaginal vault to uterosacral
  ligament
• Iliococcygeus Colpopexy - vaginal vault to
  iliococcygeus
• Uterosacral lig suspension - vaginal vault to
  uterosacral lig

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• 2) Abdominal Approach
• Abdominal Sacrocolpopexy vaginal vault to
  anterior sacral ligament
• Abdominal uterosacral suspension
• vaginal vault to utero sacral ligaments.
  
• 3) Laparoscopic
• Laparoscopic Sacrocolpopexy vaginal vault to
  anterior sacral lig

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SACROSPINOUS LIGAMENT INTERNAL PUDENDAL
NEUROVASCULAR BUNDLE
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Course of Internal Pudendal Neurovascular Bundle
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PUDENDAL CANAL
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Sacrospinous Colpopexy

• In Procidentia Vault prolapse
• Vault of Vagina to sacrospinous ligament

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Abdominal Sacrocolpopexy

• Y shaped mesh
• Long arm anterior longitudinal ligament
• Short arms ant post vagina
• In Nullipara Sacro hysteropexy
• Uterocervical jn ant long. ligament

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Le Forts Colpocleisis

• Obliterative procedure
• In elderly women unfit for repair operation
• Remove vaginal epi suture ant
  post walls
• Laterally tunnels
• Disdav- vaginal intercourse not possible

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Manchester / Fothergills operation

• In women completed family , but wish to retain
  uterus
• In lesser degrees of UV prolapse, with
  supravaginal elongation of pelvis
• Prior dilatation of cervix

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• Shirodkars extended (Modified Manchester repair)
  
• Cervical amputation avoided
• Uterosacral ligaments as slings in front of
  cervix

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Enterocoele

• Vaginal
• McCalls Culdoplasty
• Open cul de sac dissect high excise
• Approximate uterosacral lig to vaginal vault

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Abdominal

• Vaginal vault ----- Uterosacral ligament
• Halban procedure
• AP sutures b/w post vagina peritoneum over
  recto sigmoid
• Moscowitz procedure
• Concentric(purse string) sutures uterosacrals
  peritoneum..

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Nulliparous prolapse

1. Abdominal Sacrohysteropexy uterocervical
   junction to anterior longitudinal sacral ligament
   
2. Purandares sling operation cervix to anterior
   abdominal wall (fascia lata)
3. Shirodkars sling procedure cervix to anterior
   longitudinal sacral ligament
4. Khannas posterior sling cervix to ASIS

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5 Virkuds composite sling operation

• ?Tape is anchored from the post aspect of isthmus
  to sacral promontory on the Rt. side ant. abd.
  Wall on the Lt. Side
• ?Utrosacral ligament is plicated
• ?Technically easy

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Associated Stress Incontinence

• Vaginal Tension Free Vaginal tape
• (TVT, TOT)
• Polypropylene mesh kept under midurethra
• Abdominal Burchs colposuspension
• At level of bladder neck ---- ileopectineal lig
  / coopers ligament

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Clinical Evaluation of SUI
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Current Surgical Management (Minimally Invasive)
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INTEGRAL THEORY OF EXTRINSIC CONTINENCE MECHANISM
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• Integral Theory Surgical Techniques
• Surgical Repair of Connective Tissue Structures
• Reconstructive pelvic floor surgery according to
  the Integral Theory differs from conventional
  surgery in four ways
• It is minimally invasive (day-care).
• It is based on specific surgical principles which
  minimize risk, pain and discomfort to the
  patient.
• It takes an holistic approach to pelvic floor
  dysfunction by isolating the contribution(s) of
  each zone of the vagina to dysfunction.
• It has a symptom-based emphasis (the Pictorial
  Diagnostic Algorithm) which expands the surgical
  indicators to include cases with major symptoms
  and only minimal prolapse.

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Pictorial Diagnostic Algorithm
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Lower Urinary Tract Symptoms caused by Pelvic
Organ Prolapse
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Bowel Symptoms caused by Pelvic Organ Prolapse
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Birth-related laxity The diagram shows the
babys head severely stretching ligaments and
other tissues in and outside the vagina. This may
cause various degrees of looseness, prolapse of
the bladder and bowel, and urine and bowel
incontinence. Fundamental in any surgical
treatment is the approximation of laterally
displaced tissues, and the strengthening of
damaged suspensory ligament(s)
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PELVIC LIGAMENTS
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The 5 main structures which require repair with a
tape are outlined in yellow Anterior zone 1
external urethral ligament (EUL) 2
pubourethral ligament (PUL) 3 suburethral
vagina (hammock)  Middle zone 4 arcus
tendineus fascia pelvis (ATFP) 5 pubocervical
fascia (PCF) 6 anterior cervical ring/cardinal
ligament (CL) ZCE excess tightness, usually
scar tissue below bladder neck (tethered
vagina) Posterior zone7 uterosacral ligament
(USL) 8 rectovaginal fascia (RVF)9 perineal
body (PB).
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Clinical Assessment Sheet
(Suburethral Vagina)
Cardinal Ligament gtgtgtgtgtV
UteroSacralLigamentgtgtgtgtgt
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In keeping with the overall framework of the
Integral Theory, the surgical techniques are
organized by zone. The zones consist of nine key
structures which potentially need repair in
pelvic reconstructive surgery (fig 1-10).

• Fig. 1-10 The key connective tissue structures of
  the pelvic floor. Perspective view from above
  and behind, level of pelvic brim. PCM
  pubococcygeus muscle force LP levator plate
  muscle force LMA longitudinal muscle of the
  anus force ZCE Zone of Critical Elasticity

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Organ prolapse and symptoms are related, and both
are mainly caused by laxity in the four main
suspensory ligaments and perineal body.
Restoration of ligament/fascial length and
tension is required to restore anatomy and
function.

• The babys head (circles) may damage the
  ligaments and vaginal tissues to varying degrees
  as it descends through the vagina to cause stress
  incontinence1, cystocele 2, uterine/apical
  prolapse 3, and rectocoele 4. PUL
  pubourethral ligament ATFP arcus tendineus
  fascia pelvis USL uterosacral ligament. Not
  shown are cardinal ligament (Middle Zone) and
  Perineal Body (Posterior zone)

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THE DYNAMIC ANATOMY OF NORMAL FUNCTIONThe
muscles support the organs, vagina, bladder, and
bowel from below, and also, open and close them
by three external directional muscle forces (red
arrows)
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Using a special delivery system, polypropylene
tapes are inserted as an anterior sling at
midurethra, a posterior sling in the position of
the USLs, and other positions according to which
structure in which zone has been damaged
Cystocoele Repair Tapes are inserted in positions
4 to repair lateral and central defects, and
6 to repair transverse defect (high
cystocoele/anterior cervical ring).

• TFS Site specific repair of cystocoele (cardinal
  ligaments, lateral and central defects)Uterine/ap
  ical prolapse Repair of the cardinal ligaments
  (6) and uterosacral ligaments (7) is
  sufficient for even 4th degree prolapse.

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TFS site specific repair for uterine prolapse
Reinforcement of cardinal ligaments 6 and
uterosacral ligaments7.Rectocoele repairThe
whole posterior vaginal wall is supported by
repairing the uterosacral ligaments ('7) and
perineal body ('9) Repair of large rectocoele
Reinforcement of perineal body (PB) rectovaginal
fascia and uterosacral ligaments (USL)
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The 5 main structures which require reinforcement
with polypropylene tapes are pubourethral (PUL),
cardinal, arcus tendineus fascia pelvis (ATFP),
uterosacral (USL) ligaments and perineal body
(PB)
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TFS site specific repair of the 5 sites causing
prolapse and abnormal pelvic floor symptoms. 3D
view from above and behind.Polypropylene tapes
T may be used to reinforce the five main
structures which support the pelvic organs
pubourethral (PUL), cardinal, arcus tendineus
fascia pelvis (ATFP), uterosacral (USL)
ligaments, cardinal ligament(CL) and perineal
body (PB)..
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The mini or micro sling is sinserted
exclusively form the vagina. It avoids most
complications of tension-free slings.

• The Tissue Fixation System(TFS) minisling is a
  new approach to surgery for prolapse. It works by
  approximating laterally displaced tissues, and by
  reinforcing the 4 suspensory ligaments of the
  vagina, PUL, ATFP, CL, USL, and also, the PB.

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