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    Uv Prolapse: Shehryar Shaikh Jarry Masood Fahim Rizvi Ashar Moinuddin

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    Syeda Shariqa Anjum
    Pelvic organ prolapse (POP) occurs when pelvic organs herniate into or beyond the vagina. It is caused by weakness in the levator ani muscles and supporting ligaments of the pelvis. POP can be assessed in three levels - level 1 involves the uterosacral ligaments, level 2 the vaginal fascia, and level 3 the perineal body. Treatment options include pessaries, pelvic floor exercises, and surgery depending on the severity and location of the prolapse. Surgeries aim to reinforce the pelvic floor through techniques like colporrhaphy, sacrocolpopexy, or sacrospinous ligament fixation. Preventive measures consist of

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    Uv Prolapse: Shehryar Shaikh Jarry Masood Fahim Rizvi Ashar Moinuddin

    Uploaded by

    Syeda Shariqa Anjum
    70 views26 pages
    Pelvic organ prolapse (POP) occurs when pelvic organs herniate into or beyond the vagina. It is caused by weakness in the levator ani muscles and supporting ligaments of the pelvis. POP can be assessed in three levels - level 1 involves the uterosacral ligaments, level 2 the vaginal fascia, and level 3 the perineal body. Treatment options include pessaries, pelvic floor exercises, and surgery depending on the severity and location of the prolapse. Surgeries aim to reinforce the pelvic floor through techniques like colporrhaphy, sacrocolpopexy, or sacrospinous ligament fixation. Preventive measures consist of

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    Pelvic organ prolapse (POP) occurs when pelvic organs herniate into or beyond the vagina. It is caused by weakness in the levator ani muscles and supporting ligaments of the pelvis. POP can be assessed in three levels - level 1 involves the uterosacral ligaments, level 2 the vaginal fascia, and level 3 the perineal body. Treatment options include pessaries, pelvic floor exercises, and surgery depending on the severity and location of the prolapse. Surgeries aim to reinforce the pelvic floor through techniques like colporrhaphy, sacrocolpopexy, or sacrospinous ligament fixation. Preventive measures consist of

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    © All Rights Reserved
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    70 views26 pages

    Uv Prolapse: Shehryar Shaikh Jarry Masood Fahim Rizvi Ashar Moinuddin

    Uploaded by

    Syeda Shariqa Anjum
    Pelvic organ prolapse (POP) occurs when pelvic organs herniate into or beyond the vagina. It is caused by weakness in the levator ani muscles and supporting ligaments of the pelvis. POP can be assessed in three levels - level 1 involves the uterosacral ligaments, level 2 the vaginal fascia, and level 3 the perineal body. Treatment options include pessaries, pelvic floor exercises, and surgery depending on the severity and location of the prolapse. Surgeries aim to reinforce the pelvic floor through techniques like colporrhaphy, sacrocolpopexy, or sacrospinous ligament fixation. Preventive measures consist of

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    UV PROLAPSE

    SHEHRYAR SHAIKH
    JARRY MASOOD
    FAHIM RIZVI
    ASHAR MOINUDDIN
    Pelvic Organ Prolapse (POP)

     POP is the herniation of pelvic organs to and beyond the vaginal


    walls

     It is caused by the failure of interaction between the levator ani


    muscles and the ligaments and the fascia that support the pelvic
    organs.
    Levels of pelvic support

     There are three levels of suppourting ligaments and fascia which


    workd together to suppourt the uterus:

    1. Level 1
    2. Level 2
    3. Level 3
    Level 1(apical suppourt)

     It is provided by the uterosacral ligament

     It attaches cervix to sacrum

     Defects in level 1 suppourt can be seen on examination by the descent


    of uterus within vagina

     Level 1 suppourt remains critical even after hysterectomy, so it is


    important to reattach the uterosacral ligament during the procedure

     In women who have previously undergone hysterectomy, level 1


    support defects will manifest as vaginal vault prolapse.
    Level 2
     Level 2 support is provided by the fascia that surround the vagina, both
    anteriorly and posteriorly.

     Anteriorly, suppourt is provided by the pubocervical fascia, which lies between


    the bladder and the vagina.

     Defects in the fascia providing level 2 suppourt will lead to prolapse of the
    vaginal wall into the vaginal lumen.

     Posteriorly, support is provided by the rectovaginal fascia which lies between


    the rectum and the vagina.

     Deficency anteriorly results in anterior vaginal wall prolapse and deficency


    posteriorly results in posterior vaginal prolapse.

     On examination, the affected vaginal wall will be seen bulging into the vagina.
    Level 3

     It is provided by the fascia between the distal posterior vagina and


    perineal body

     Defects of the perineal body usually cause the development of


    lower posterior vaginal wall prolapse but the loss of the perineal
    body increases the size of the vaginal opening andd therefore
    predisposes to anterior vaaginal prolapse as well
    Terminologies
     Anterior Compartment Prolapse – hernia of anterior vaginal wall, which
    can be associated with:

    1. Cystocele (bladder descent) with upper half anterior wall prolapse

    2. Urethrocele (urethral descent) with lower half anterior wall prolapse

    3. Cystrourethrocele (descent of bladder and urethra)

     Posterior compartment prolpase – hernia of posterior vaginal wall, which


    can be associated with:

    1. Enterocele (small bowel descent) with upper 1/3 rd posterior wall


    prolapse

    2. Rectocele (rectal descent) with lower 2/3 rd posterior wall prolapse


     Apical Compartment Prolapse:

    1. Uterus: Prolapse of uterus with inversion of vaginal apex

    2. Cervix: Prolapse of caervix with inversion of vaginal apex

    3. Vaginal apex: Prolapse of the upper vagina through the vagina

    4. Vault: Post-hysterectomy prolapse of the vaginal vault


    Symptoms of pelvic organ prolapse

     POP can cause symptoms directly due to the prolapsed organ or


    indirectly due to organ dysfunction secondary to displacement from
    the anatomical position.

     Prolapse symptoms include:


    1. Sensation of vaginal bulge
    2. Heaviness or visible protrusion at or beyond the introitus
    3. Lower abdominal or back pain
    4. Dragging discomfort relived by lying or sitting
    Indirect Symptoms of prolapse

     Depend on which other organs are involved in the prolapse

     May include symptoms like difficulty in voiding urine or emptying


    the bowel and sensation of incomplete emptying of bladder or
    rectum. Patients may have to support or reduce the prolapse with
    their fingers to be ableto void or evacuate stool completely (termed
    Digitation)

     Urinary or fecal incontinence may also be present.

     It is also important to ask about sexual activity, weather they have


    disomfort during intercourse and loss of sensation
    Clinical Assessment of prolapse

     History should include presenting symptoms and severity and


    questions to ascertain if the patient has any coexisting urinary,
    faecal or sexual symptoms.

     Clinical Examination should ideally be done in the lithotomy position


    with a sims speculum. This allows retraction of the anterior and
    posterior vaginal wall to allow full assessment of the degree of
    prolapse and assess how much descent of the cervix and uterus is
    present
     Rectal and Vaginal examination can be an aid to differentiate
    rectocele from enterocele

     US to exclude pelvic or abdominal masses if suspected clinically

     If urinary incontinenct – urodynamic studies

     If rectal symptoms – Endoanal ultrasound, rectal manometry,


    flexibble sigmoidoscopy and defecating proctogram
    Stages of Prolapse

     Prolapse is described in three stages of descent:

    1. Stage 1: Prolapse does not reach hymen

    2. Stage 2: Prolapse reaches hymen

    3. Stage 3: Prolapse is mostly or wholly outside the hymen. When the


    uterus prolapses wholly outside, this is termed as procidentia

     A note should be made whether prolapse occurs at patient


    straining or at rest and whether traction has been applied
     Vaginal Prolapse is staged using the method mentioned but the
    most important assessment is whether the vaginal prolapse reaches
    to or beyond the hymen.

     It is important the assess whether the perineal body is intact or has


    become attenuated, resulting in an enlarged vaginal opening.
    Etiology

     Vaginal delivery: Most important factor, uncommon in nulliparous


    and increases with parity. It is due to damage to pudendal nerves
    after childbirth

     Menopause: loss of collagenous connective tissue following


    estrogen withdrawl

     Iatrogenic: Vaginal hyterectomy, Burch colposuspension

     Chronic factors: Coughing, Constipation, heavy lifting, pelvic mass


    Treatment of prolapse

     Conservative treatment:
    1. Pelvic floor muscle exercises: reduces symptoms but may will not
    reduce the anatomical extend of the prolapse
    2. Use of supportive vaginal pessaries: Leads to resolution of many
    symptoms. Has an advantage of avoiding surgey. Eg: Ring
    pessaries, Shelf pessaries, Gelhorn pessaries

     Ring pessaries are used first but intact perineal body is necessary for
    these to be retained.
     Shelf and Gelhorn pessaries are useful in women with deficient
    perineal body
     Pessaries are not currative
     Pesssaries are indicated if:
    1. Patients wish

    2. Childbearing not complete

    3. Medically unfit

    4. During and after pregnancy

    5. While awaiting surgery


    Surgery

     Offered if conservative treatments have failed or if the patient


    chooses surgery.

     Procedure chosen depends on which compartment is affected and


    whether the women wishes to retain her uterus and whether vagial
    or abdominal route is chosen
    Manchester (Fothergill) Repair

     Suitable when the women wishes to conserve her uterus

     Involves partial amputation of cervix and approximation of cardinal


    ligaminets anterior to cervical stump

     It may be combined with anterior and posterior colporrhaphy


    Sacrehsteropexy

     Suitable when the women wishes to conserve her uterus

     Involves attachment of utero-cervical junction to the sacrum using a


    mesh and closure of Pouch of Douglas
    Hyterectomy

     Suitable when the women doesn’t wish to conserve her uterus

     It is extremly important to re-attach the uterosacral ligament to the


    vaginal vault and maintain level 1 suppourt
    Anterior Colporrhaphy

     It is anterior vaginal repair done for anterior compartment prolapse

     Invloves application of sutures to reinforce fascia between vagina


    and bladder

     Complications include Bladder injury and High recurrence rate


    Posterior Colporrhaphy

     It is posterior vaginal repair done for posterior compartment


    prolapse

     Involves application of sutures to reinforce fascia between vagina


    and rectm

     Complications include Rectal injury and Dyspareunia


    Sacrocolpoplexy

     Involves attachment of invereted vaginal vault to sacrum using a


    mesh and closure of pouch of douglas
    Sacrospinous ligament fixation

     It is a vaginal procedure, with low success rate

     Involves suturing the vaginal vault to the sacrospinous ligament.


    Preventive measures

     Weight Reduction

     Avoid traumatic instrumental delivery

     Encouraging postnatal pelvic floor exerises

     Treatment of chronic cough and constipation

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