Pelvic Organ Prolapse

• Prolapse of the genital organs

Definition: descent of one or more of the genital organs below
its normal position or protrusion of one or more of the pelvic
organs via the pelvic pariets
 Pelvic organ prolapse

Incidence: common in parous women (laxity of

pelvic floor) and increase with age.

 It is a common gynecological problem that

affect quality of life of many women
especially during their climacteric years but
not life threatening.
Normal supports of the pelvic organs:

Supports of the uterus: the uterus is kept in place by the following:

A‑ Facial supports
B‑ Muscles of the pelvic diaphragm
C‑ Skeletal support
D‑ Position of the uterus (AVF)

A) Fascial supports of the uterus:

1. False uterine ligaments (1ry support)

a] Mackenrodt's ligaments (cardinal, transverse cervical)
b] Uterosacral ligaments
c] Pubo‑cervical ligaments
2. Pelvic cellular tissue
3. Endopelvic fascia
4. Pelvic fascia
B) Muscular support or pelvic floor: (secondary support)

C) Skeletal support: normally, in young ladies in the standing position, the

bony pelvis assumes a tilted position that make an angle of about 70° with
the horizon. This tilt gets the pelvic viscera away from the access of
increased abdominal pressure and is considered to be protective against
genital descent. This tilt is decreased after the menopause.

B) Position of the uterus: normally, the uterus assumes an anteverted-

anteflexed position, due to proposed factors which include:
‑ Traction exerted by uterosacral ligaments.
- Effect of abdominal pressure will act on the back of the uterus increasing anteversion and
anteflexion.
If the uterus becomes retroverted to lie along the axis of the vagina, intra-
abdominal pressure will tend to force the uterus, downwards along the
vaginal canal.
Supports of the vagina:
* Upper vagina: is supported by its attachment to the cervix
which is supported by the Mackenrodt's ligaments
* Middle vagina: by the decussating fibers of the pubovaginalis
part of the levator ani narrowing the hiatus urogenitalis
*Lower vagina: by the perineal body

Supports of the urethra:

1. Upward attachment to the bladder
2. Adhesion of urethral and vaginal fascia
3. Levator ani fibers
4. Pubourethral ligaments
Supports of the bladder:
1. Pubovesicocervical ligaments
2. Levator ani

Supports of the rectum:

3. Uterosacral ligaments
4. Levator ani (Lushka fiber)
5. Perineal body (which separates it from the
posterior vaginal wall)
 Pelvic organ prolapse
• Walls of pelvic cavity: anteroinferior wall, two lateral walls, and a posterior
wall

• The pelvic floor: the levator ani and coccygeus muscles and the fascias

Pelvic diaphragm viewed from below Pelvic diaphragm viewed from above
 Pelvic organ prolapse
Risk Factors
 Pelvic organ prolapse

Etiology:
Predisposing factors:

A) Congenital and developmental factors: weakness of the ligaments

(endopelvic fascia)
B) Obstetric injury of the supports: is the commonest cause leading to
weakness of the ligaments and laceration of the pelvic floor and
perineal body and is caused by.
1. Straining during the 1st stage.
2. Forceps or breech extraction before full dilatation of cervix.
3. Precipitate labor.
4. Delivery of large baby leads to overstretching of the cervical
ligaments which are also attached to the vaginal vault.
5. Successive deliveries at short intervals (no time for the ligaments to
involute)
6. Overstretching or prolonged distention of the perineum.
7. Untreated or badly repaired perineal tear
8. Poor health and early ambulation after labor
 Pelvic organ prolapse

C Postmenopausal atrophy: due to estrogen deficiency

which causes loss of tone of the ligaments.
D Retroverted position of the uterus: brings the uterus
in the axis of the vagina and tends to force it
downwards by intra-abdominal pressure (acting as a
digger.
E Asthenia: from chronic‑ill health or severe weight
reduction
 Pelvic organ prolapse

Pathological anatomy:
(1 Vagina:
a. Becomes everted by prolapsed uterus and is
stretched.
b. Loses its rugae and looks smooth.
c. Epithelium gets keratinized and thick as a result of
chronic congestion
d. Trophic ulcer (decubital ulceration) is due to:
‑ Venous stasis.
‑ Friction with the underwear.
‑ Repeated irritation by urine.
‑ Atrophic changes (after menopause)
(2Cervix:

Keratinization and trophic ulceration.

Marked hypertrophy and elongation of the
supravaginal part in long standing cases which
is caused by:
a. Chronic congestion.
b. Chronic infection.
c. Glandular hypertrophy.
d. Upper part of Mackenrodt's ligament is the strongest
part and therefore it resists traction by the prolapsed
vagina, while the lower part yields more easily leading
to stretching and elongation of the cervix .
 Pelvic organ prolapse

(3 Uterus:
a) Normal position is disturbed: becomes RVF to be in
line with the axis of the vagina.
b) Congestion of the endometrium: thickened
endometrium of uterus  hypermenorrhea or
menorrahgia .

(4Tubes and ovaries: becomes prolapsed with the

uterus.This causes dysparuenia and ovarian
congestion  polymenorrhea.
 Pelvic organ prolapse

(5 Bladder & urethra:

a) Incomplete emptying of the bladder leads to partial

retention of urine (residual urine) which encourages
infection (cystitis)

b) When the bladder is prolapsed, if the neck of the

bladder becomes detached from the back of
symphysis pubis, this interfere with the integrity of
the internal sphincter which give rise to frequent
desire of micturition and stress incontinence.

(6 Ureter: is kinked at pelvic brim leading to

hydroureter & hydronephrosis (in severe cases)
 Pelvic organ prolapse

Clinical varieties
(1Vaginal prolapse:
A) Anterior vaginal wall prolapse: with or without cystocele
+ stress incontinence
– Cystocele  affects upper 2/3 of anterior vaginal wall
– Uretherocele  affect lower 1/3 of the anterior vaginal
wall
– Cystouretherocele  affect the whole anterior vaginal
wall.
 Pelvic organ prolapse

B) Posterior vaginal wall prolapse:

– Enterocele  affects the upper 1/3 of posterior vaginal

wall which is related to the peritoneum of pouchof
douglas

– Rectocele  affects the middle portion of posterior

vaginal wall which is related to the ampulla of rectum
 Pelvic organ prolapse

Deficient perineum  affects the lower 1/3 of posterior vaginal

wall which is related to the perineal body
N.B. Deficient perineal body allows gaping of the introitus
without any actual descent of the pelvic viscera.
 Uterine prolapse

– 1st degree: the cervix descend below its normal level

when the patient strain but does not protrude through the
vulva or the external os below ischial spine and cervix
above the vaginal introitus.
– 2nd degree: in which the external os is below the level of
vaginal introitus but the body still in the vagina.
– 3rd degree: complete uterovaginal prolapse. Both the
cervix and body are outside the vaginal introitus
(procidentia)
 Pelvic organ prolapse

3)Vault prolapse:

1ry vault prolapse (Enterocele)  hernia of D. pouch in

presence of the uterus

2ry vault prolapse  after subtotal or total hysterectomy

 Pelvic organ prolapse

Baden-Walker Halfway System POP-Q

Pelvic organ prolapse
Utero-vaginal prolapse….

27
 Pelvic organ prolapse

Clinical picture and investigation of a case of prolapse:

A History suggestive of the etiology:
 Congenital
 Traumatic (difficult labor or operation)
 Chronic malnutrition or debilitating disease
 Chronic chest troubles
B Symptoms:
1) Sense of weakness and of a lack of support around the perineum
2) bearing down sensation
3) A sensation of swelling or mass protruding which is aggravated by
straining (coughing and exercise) and disappears when the patient lies
down
4) Backache due to uterosacral strain and pelvic congestion
5) Vaginal discharge: may be purulent or blood stained from chronically
inflamed cervix, vaginitis or decubital ulcer.
 Pelvic organ prolapse

6) Urinary symptoms:
a. Stress incontinence
b. Frequency of micturition due to chronic cystitis, irritability of the bladder due
to displacement or due to residual urine
c. In severe degree of cystocele difficulty in performing the act of micturition
except when the patient pushes cystocele with her fingers into the vagina.
d. Dysuria .
e. Interruption of stream.
f. Urge incontinence.
7) Rectal symptoms:
‑ Constipation ‑
- Heaviness in the rectum
‑ Difficulty in emptying the bowel (rectocele)
8) Menstrual disturbances:

- Polymenorrhea, menorrhagia  due to pelvic congestion

- Metrorrhagia due to ulcer

9) Infertility due to dysparuenia, congestion of the endometrium and RVF

 Pelvic organ prolapse

II) Examination:
A General examination:
‑ General condition as asthenia and anemia
‑ Chest examination e.g. Bronchitis

B Abdominal examination:
‑ Abdominal masses or ascites
‑ Tone of the abdominal muscles and hernia
‑ Enlarged tender kidney (hydronephrosis)

C Local examination:
Inspection:
- Perineal tears
‑ Gaping introitus
‑ Genital prolapse reaching the introitus (on straining)
‑ Sterss incontinence (ask the patient to cough)
 Pelvic organ prolapse

2 Palpation:

 Verify the anatomical parts prolapsed (anterior vaginal wall, posterior

vaginal wall)
 State of pelvic floor muscles
 Diameter of the introitus in fingers (denote the bulbocavernosus tone)
 Test of the levator ani (pubococygeus part) .
 Pelvic organ prolapse

 Bimanual examination: to detect RVU or pelvic masses

 Recto-vaginal examination: to detect enterocele and rectocele

 Rectal examination: to detect rectocele

 Speculum examination: to exclude cervical erosion and to observe

descent of vault especially enterocele while the speculum is withdrawn

 Sounding of the uterus: to detect supravaginal elongation.

 Volsellum traction test: when the patient is unable to bear down and
when the full extent of prolapse is needed to be seen (this is especially
so in hospitalized patients) when rest results in some improvement in
the grade of descent
 Pelvic organ prolapse

NB: The following points should be ascertained in examining a

case of prolapse.
1. Degree of Type of prolapse.
2. Condition of perineum.
3. Direction of the uterus
4. Supravaginal elongation of cervix
5. Ulcers on cervix or vagina.
 Pelvic organ prolapse

III) Special investigations:

‑ Majority of patients with prolapse do not require any special investigations

‑ Special tests (if urinary symptoms are present).

A. Chart to assess drinking & voiding habit.

b. Urodynamic assessment (identify any lower urinary tract dysfunction).
c. Post micturition U/S (identify a large urinary residual volume).
d. Midstream specimen of urine for culture & sensitivity
e. IVP or renal U/S to exclude upper U.T damage in cases of severe cystocele or
procidentia.
f. Cystoscopy if the symptom of urgency & frequency of micturition are
unusually severe.
 Pelvic organ prolapse

Differential diagnosis of a mass protruding

through the vulva:

A) Cystocele
B) Gartner cyst
C) Urethral or vesical diverticulum
D) Rectocele
E) Second and third degree uterine prolapse
F) Congenital elongation of the cervix
G) Cervical mucus polyp
 Pelvic organ prolapse

Complications
1. Keratinisation of vaginal walls
2. Decubital ulceration
3. Hypertrophy of the cervix.
4. Elongation of the supravaginal portion
5. Congestion and edema.
6. Chronic infection
7. Infection of the urinary tract
8. Obstruction of ureter in severe prolapse causing hydronephrosis.
9. Incarceration of the prolapse.
10.Cancer cervix is very rare in prolapse.
11.Cornification of the cervical epithelium resist malignant changes
 Pelvic organ prolapse

Treatment of genital prolapse:

I) Prophylactic measures:

‑ Avoid straining and forceps delivery before the cervix is fully

dilated .
‑ Bladder should be empty during labor.
‑ Episiotomy and repair of any perineal tear.
‑ Proper spacing of pregnancies.
‑ Encourage pelvic floor and other postnatal exercises.
‑ Any factor which  abdominal pressure should be avoided.
‑ Avoid early ambulation in the puerperium, while the uterus is
still heavy and uninvoluted.
‑ During total hysterectomy, it is advisable to suture the round
ligament, Mackenred's ligament and uteroscral ligament to the
vaginal vault.(Suspention)
 Pelvic organ prolapse

II Curative:

 Mild with no symptoms → physiotherapy

 All other cases of prolapse need surgery

A- Physiotherapy: has a place in prevention and treatment
of prolapse especially those cases with mild stress
incontinence or sexual dysfunction.

Technique
• Pelvic floor exercises: contraction of the pelvic floor as if she
interrupts urine stream or bowel motion several hundred
times / day. 15 ‑ 30 contractions / 1/2 hour.
• Electrical stimulation: applied to the levator intermittently
 Pelvic organ prolapse

B- Pessary treatment ( ring pessary and cup & stem

pessary)

Indication
 Early pregnancy
 Puerperal
 Pessary test
 Waiting operation
 For healing of trophic ulcers
 Temporary until the patient complete family.
 Surgical:

All cases of symptomatic prolapse need

surgery. Repair is the definitive & curative
treatment.

Indications:
If prolapse is symptomatic.
Second or 3 rd degree uterine prolapse.
 Pelvic organ prolapse

Time of operations:

6 months after delivery to allow complete involution

Postmenstrual to decrease blood loss and to avoid soiling of the operative
field by menses

Preoperative preparation:
 Improvement of general condition.
 Correct anemia, treat
 chest infection,
 weight reduction if obese and
 assess creatinine and blood urea.
 Urinary tract should be investigated and cleared of infection.
 Treatment of vaginitis.
 Decubital ulcers are treated by daily reposition of the prolapse and vaginal
pack with tampon of gauze impregnated with an antiseptic solution with
estrogen application.
 Stress incontinence diagnosed or excluded.
 Pelvic organ prolapse

Choice of operative methods: depends on proper

anatomical diagnosis
– Posterior vaginal wall prolapse→
• (prineorrhaphy) (is a component of every operation to narrow the
hiatus urogenitalis
– Anterior vaginal wall prolapse→
• (anterior colporraphy)
– Anterior vaginal wall prolapse & cystocele →
• (Classical repair) i.e. anterior colporrhaphy & supporting the
bladder (bladder fascia plication)
 Pelvic organ prolapse

Anterior & posterior vaginal wall prolapse→

(anterior & posterior colpoperineorraphy)

Anterior & posterior vaginal wall prolapse & prolapse of the

uterus→ (Manchester or modified Fothergell's operation) i.e.
anterior & posterior colpoperineorraphy & shortening of the
Mackenrodt's ligament for preservation of uterus(Outdated
nowadays)

Uterine prolapse & pathological uterus →

(vaginal hystersctomy & Mayo's repair of the pelvic floor)

Sacrospinous fixation

Sacrocolpoplexy ( mesh)
 Pelvic organ prolapse

Le fort's operation: close the vagina partially and longitudinally

to prevent descend of the uterus for old unmarried high risk
postmenopausal women

Vault prolapse after hysterectomy: vaginal repair or abdominal

repair. Vaginal repair by fixation of the vault to the
sacrospinous ligament .
Abdominal repair by sacral colpopexy using strip of fascia or
inorganic mesh.
 Pelvic organ prolapse

Complications of operations for prolapse:

1. Hemorrhage (primary, reactionary and secondary).

2. Sepsis (vaginal, pelvic cellulitis and

thrombophelebitis).

3. Urinary (cystitis, retention of urine or fistula).

4. Injury and ligation of ureter

5. Unsuccessful (failed repair).

 Pelvic organ prolapse

Causes of recurrence:
a‑ Preoperative:
persistence of predisposing factors.
 Chronic bronctitis.
 Ascites.
 Constipation.
 Anemia not corrected.
 Presence of infection.

b‑ Operative:
 Bad choice of operation.
 Imperfect haemostasis .

C- Post operative:
 Early ambulation
 Pregnancy.
 Pelvic organ prolapse

Types of pessary