PELVIC ORGAN PROLAPSE

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PELVIC ORGAN PROLAPSE

• Neena Agarwala,M.D.
• Laparoscopic Surgery Urogynecology

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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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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

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The axes of pelvic support

• 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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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 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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Fascial and Muscular layers of the Pelvic Floor
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Attachments of cardinal/uterosacral ligaments
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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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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 endopelvic 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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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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Evaluation of a cystourethrocele
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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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Complete genital procidentia
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Enterocele

• A true hernia of the rectouterine 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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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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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