Chap 18: Pelvic Organ Prolapse

Mechanical support devices

(pessaries) may be used to manage prolapse and the associated symptoms, or the defect may be repaired surgically

Paradoxically, stress incontinence can appear to "improve" as the prolapse worsens

As the support for the anterior vaginal wall weakens and the bladder descends, a kink is introduced into the urethra. It is a mechanical obstruction that masquer- ades as "improvement."

Damage to any one of these structures can potentially result in a weakening or loss of support to the pelvic organs

Damage to the anterior vaginal wall pubocervical fascia can result in her- niation of the bladder (cystocele) and/or urethra (urethrocele) into the vaginal lumen.

The reported prevalence of pelvic organ prolapse in population-based surveys ranges from 2.9% to 9%.

Population-based surgical intervention studies report a higher prevalence of symptomatic prolapse quoting an 11% to 19% lifetime risk for undergoing surgery.

For those patients who have significant bother from her prolapse symptoms, intervention is appropriate.

Regardless of the etiology, symptomatic pelvic organ prolapse is essentially a structural problem and therefore requires therapies that reinforce the lost support to the pelvis.

Cystocele

Repair Procedure: Anterior colporrhaphy Plication (reinforcement) of the endopelvic fascia and reattachment to the apex or uterine cervix (if present) to resuspend the anterior vaginal wall and bladder

Vaginal vault prolapse (after hysterectomy)

Repair Procedure: Sacrospinous ligament fixation Or Abdominal sacral colpopexy The vaginal apex is suspended to the sacrospinous ligaments via a vaginal approach Uses mesh to attach the vaginal apex to the sacrum via an abdominal, laparoscopic, or robotic approach

Enterocele

Repair Procedure: Vaginal enterocoele repair The enterocele is repaired along with the reattachment of the rectovaginal fascia to the apex or uterine cervix (if present)

correction of cystoceles and rectoceles can be accomplished by

anterior and posterior colporrhaphy, respectively. These procedures repair the fascial defect through which the herniation occurred

A prolapsed uterus

can also be viewed on split-speculum examination or by bimanual pelvic exami- nation.

Conservative modalities begin with

exercises to strengthen the pelvic floor musculature (Kegel exercises).

In postmenopausal women,

low-dose vaginal estrogen can be an important supplemental treatment, improving tissue tone and facilitating reversal of atrophic changes in the vaginal mucosa.

When symptomatic, patients often complain of

pelvic pressure, heaviness in the lower abdomen, or a vaginal bulge that may worsen at night or become aggravated by prolonged standing, vigorous activity, or lifting heavy objects.

Pelvic support is most commonly compromised by

pregnancy and subsequent deliv- ery; chronic increases in intra-abdominal pressure from obesity, chronic cough (COPD and emphysema), or chronic heavy lifting; connective tissue disorders; and atrophic changes due to aging or estrogen deficiency.

Complete procidentia

refers to complete eversion of the vagina with the entire uterus prolapsing outside the vagina

In women who have prolapse of the vaginal vault after hysterectomy,

the vaginal vault prolapse is corrected by suspension of the vaginal apex to fixed points within the pelvis such as the sacrum (abdominal sacral colpopexy), the uterosacral ligaments (high uterosacral ligament suspension), or sacrospinous ligaments (sacrospinous ligament fixation).

Women with prolapse often experience concurrent

urinary dysfunction with complaints ranging from incomplete blad- der emptying and obstructed voiding to overactive bladder.

Pelvic relaxation is best observed by separating the labia and viewing the vagina while the patient strains or coughs.

A split- speculum examination should be performed by using a Sims speculum or the lower half of a Grave speculum to provide better visualization of the anterior vaginal wall, posterior vagi- nal wall, and apex individually. Using this method, the specu- lum is used to retract the posterior vaginal wall and a cystocele may cause a downward movement of the anterior vaginal wall when the patient strains (Fig. 18-3).

With significant uterine prolapse, abdominal or vaginal hysterectomy may be indicated although the removal of the uterus in and of itself is not curative for descent.

In addition to the hysterectomy, an apical suspension procedure is often performed to prevent later prolapse of the vaginal vault.

Symptomatic patients who are not happy with nonopera- tive approaches may require surgical correction

In general, surgical repair for pelvic relaxation produces good results although the recurrence rate over time may be as high as 30%.

Injuries to the endopelvic fascia of the rectovaginal septum in the posterior vaginal wall can result in herniation of the rectum (rectocele) into the vaginal lumen.

Injury or stretching of the uterosacral and cardinal ligaments can result in descensus, or prolapse, of the uterus (uterine prolapse).

More commonly, however, the Pelvic Organ Prolapse Quantitative scale (POP-Q) is used as an objective, site- specific system for describing, quantifying, and staging pelvic support in women.

It provides a standardized means for documenting, comparing, and communicating clinical findings of pelvic organ prolapse that focuses on the physical extent of the vaginal wall prolapse, and not on which organ is pre- sumed to be prolapsing within that defect (Fig. 18-6). In order to quantitatively assess the degree of prolapse involved, the POP-Q uses six points within the vagina that are measured relative to a fixed point of reference: the hymen. POP-Q is particularly helpful in both the clinical and research settings for comparing patients' examinations over time and among different examiners.

Many clinicians formerly use the Baden-Walker Halfway Scoring System for quantifying pelvic organ prolapse.

It re- cords the amount of descent of the structure (bladder, rectum, etc.) using a four-point system with the hymen as a fixed point of reference (Fig. 18-5). Zero represents normal anatomic position (i.e., no descensus), 1 represents descensus halfway to the hymen, 2 represents descensus to the hymen, 3 represents descensus halfway past the hymen, and 4 represents maximum descent. The examination is conducted with the patient strain- ing in order to record maximum descent.

The diagnosis of pelvic organ prolapse depends primarily on an accurate history and thorough physical examination

Other tools that may be useful in the diagnosis and preoperative eval- uation of cystoceles and urethroceles include urine cultures, cystoscopy, urethroscopy, and urodynamic studies, if indicated. When a rectocele is suspected from a history of chronic constipation and difficulty passing stool, obstructive lesions should be ruled out using anoscopy or sigmoidoscopy. A defecography study (similar to a barium enema) may also help to show a rectocele or enterocele but is not essential to diagnosis.

Uterine prolapse

Repair Procedure: Hysterectomy (abdominal or vaginal) and McCall culdoplasty Hysterectomy followed by attachment of the resulting vaginal cuff to the uterosacral ligaments to decrease the risk of future vault prolapse

Rectocele

Repair Procedure: Posterior colporrhaphy Similar to anterior colporrhaphy, except the posterior endopelvic fascia is identified and reattached to the apical support or uterine cervix (if present) and distally to the perineal body

Enteroceles, which represent the herniation of small bowel into the vaginal canal, can be repaired along with the reinforcement of the rectovaginal fascia and the posterior vaginal wall.

The key to the repair of any and all compartments is the re-establishment of the normal connection of the respective fascial layers to each other and the support ligaments.

Pelvic relaxation is especially apparent in the postmenopausal population

This increase is attributed to decreased endog- enous estrogen, the effects of gravity over time, and normal aging in the setting of previous pregnancy and vaginal delivery. Atrophy is associated with compromised elasticity, diminished vascular support, and laxity in structural elements. Tissues become less resilient to forces of gravity and increased intra- abdominal pressure, and accumulative stresses on the pelvic support system take effect.

Women who are poor surgical candidates and who no lon- ger plan vaginal intercourse may be offered a colpocleisis.

This is a vaginal obliterative procedure closes off the vaginal canal as a means of treating symptomatic pelvic organ prolapse. These procedures are less invasive with a shorter operative time, fewer complications and recurrences and a high patient satisfaction rate.

normal structural support of the pelvic organs is provided by a complex interaction between the muscles of the pelvic floor and connective tissue attachments to the bony pelvis.

This network of muscles (e.g., levator ani muscles), fascia (e.g., urogenital diaphragm, endopelvic fascia including the pubocervical and rectovaginal), nerves, and ligaments (e.g., uterosacral and cardinal ligaments) provides support on which the pelvic organs rest.

Prolapse is generally a benign condition and further evalu- ation and treatment is guided by the patient's goals for improvement in her quality of life.

Thus, asymptomatic prolapse can be monitored but does not require any further treatment and expectant management is acceptable.

Symptoms That May Be Manifested in Pelvic Organ Prolapse

Vaginal/sexual symptoms Pelvic pressure and/or heaviness Palpable or visible vaginal bulging Backache Urinary symptoms Urinary frequency Urinary urgency Incomplete/interrupted voiding Difficulty starting urinary stream Urinary incontinence Bowel symptoms Obstructed defecation Constipation Painful defecation Incomplete defecation Splinting-a -aPlacing fingers in or around the vagina/perineum to aid in defecation.

the differential diagnosis for cys- tocele and urethrocele includes urethral diverticula, Gartner cysts, Skene gland cysts, and tumors of the urethra and bladder.

When a rectocele is suspected, obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas) should be investi- gated. Cervical elongation, prolapsed cervical polyp, prolapsed uterine fibroid, and prolapsed cervical and endometrial tumors may be mistaken for uterine prolapse as can lower uterine segment fibroids

The symptoms reported with pelvic relaxation vary depend- ing on the structures involved and the degree of prolapse

With small degrees of pelvic relaxation, patients are often asymptomatic; however, prolapse severity and symp- toms are not always well-correlated.

In motivated patients with mild symptoms,

a first-line ther- apy involves the use of Kegel exercises to strengthen the pelvic musculature. These exercises involve the tightening and releas- ing of the levator ani muscles repeatedly to strengthen the muscles and improve pelvic support. Pelvic floor physical ther- apy with biofeedback is often used in conjunction.

Risk factors for pelvic organ prolapse include

advancing age, menopause, and parity. The incidence of pelvic relaxation increases four- and eightfold with the first two vaginal deliver- ies, respectively. Obstructed labor and traumatic delivery are also risk factors for pelvic organ prolapse as are conditions that result in chronically elevated intra-abdominal pressure. This pressure differential can be seen in the setting of obesity, chronic cough, COPD, chronic constipation, repeat heavy lift- ing, and large pelvic tumors. Additionally, a surgical history of hysterectomy is associated with an increase in apical prolapse.

Similarly, rectoceles and enteroceles result in

an upward bulging of the posterior vaginal wall when the patient strains with the split speculum placed upside down retracting the anterior vaginal wall (Fig. 18-4). This laxity in the rectovaginal wall can also be demonstrated on rectal examination.

Defecatory issues can be associated with prolapse of the apical and posterior aspects of the vaginal wall and include

incomplete emptying, fecal urgency, or constipation. Some patients perform a maneuver known as "splinting" to aid in evacuation of stool. This refers to the application of manual pressure (usually by a finger) to the perineum or posterior vaginal wall. sexual dysfunction can occur as a consequence of embarrassment or fear of discomfort

The mainstay of conservative management

is the use of vaginal pessaries. Pessaries act as mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area. Pessaries are indicated for any patient that desires nonsurgical management and those in whom surgery is contraindicated. Pessaries are often used in pregnant and postpartum women as well. These devices are fitted in the vagina, positioned like a diaphragm, and serve to hold the pelvic organs in their normal position Studies suggest that certain physical characteristics like longer vagina, smaller introitus, and lower weight are associated with more successful pessary placement. The use of vaginal pessaries requires a highly motivated patient who is willing to accept an intravaginal device and the small risks of pain, ulcerations, bleeding, leukorrhea, and infection. Pessaries may be used intermittently (interval removal and self-replacement) or may remain inside the vagina for up to 3 to 6 months at a time. Close follow-up with removal, vaginal examination, cleaning, and replacement ensures proper placement and hygiene and minimizes the small associated risks.

Pelvic organ prolapse presents with a variety of symptoms including

pelvic pressure and discomfort, dyspareunia, dif- ficulty evacuating the bowels and bladder, and low back discomfort. These clinical symptoms are often associated with a visible or palpable bulge in the vagina.

After hysterectomy, some women may experience

prolapse of the small intestine (enterocele) or the apex of the vagina (vaginal vault prolapse) secondary to loss of the support structures upon removal of the uterus and cervix.