Pelvic Organ Prolapse

Obstetrics & Gynecology 2005;106:615-634

OBGY R2 LEE EUN SUK

Abstract
Pelvic organ prolapse, including anterior and posterior vaginal
prolapse, uterine prolapse, & enterocele, is a common group of
clinical conditions affecting millions of American women.
Pathophysiology of prolapse is multifactorial and may operate under
a "multiple-hit" process in which genetically susceptible women are
exposed to life events that ultimately result in the development of
clinically important prolapse.
Evaluation of women with prolapse requires a comprehensive
approach, with attention to function in all pelvic compartments
based on a detailed patient history, physical examination, and
limited testing.
Treatment is warranted based on specific symptoms, prolapse
management choices fall into 2 broad categories: nonsurgical,
which includes pelvic floor muscle training and pessary use; &
surgical, which can be reconstructive (eg, sacral colpopexy) or
obliterative (eg, colpocleisis).

Clinical Importance
Based on projections from the United States Census Bureau, the
number of American women aged 65 years and over will double in the
next 25 years, to more than 40 million women by 2030
Demand for health care services related to pelvic floor disorders
will increased at twice the rate of the population itself
Although the overall rate of prolapse surgery has dropped, this
represents a substantial drop in the rate of surgery for women less
than 50 years old & a moderate increase for women aged 50 years
and greater

Clinical Importance
Fig 1

Pathophysiology
Table 1

Symptoms

Diagnostic Approach
Women with prolapse often have urinary symptoms
Some women have stress incontinence symptoms due to urethral
incompetence, but many women, particularly those with advanced
anterior vaginal prolapse, are continence
Defecatory symptoms such as excessive straining, incomplete rectal
emptying, or the need for perineal or vaginal pressure to accomplish
defecation
Influence of prolapse on sexual functioning should be addressed in
women of all ages

Physical Examination

Diagnostic Approach
The extent of prolapse should be systematically assessed
With advanced prolapse, determining the extent of prolapse
& its constituents ( anterior and posterior vagina; cervix or
vaginal apex ) is usually not difficult
The use of vaginal speculums or retractors is very helpful in
determining what vaginal sites are affected by prolapse
An unidentified vaginal bulge can be clearly identified as the vaginal
apex, once the anterior and posterior vagina are retracted

Physical Examination

Diagnostic Approach
fig2

Physical Examination

Diagnostic Approach
fig3

Diagnostic Approach
fig4

Physical Examination

Diagnostic Approach
The maximal extent of prolapse is demonstrated with a standing
straining examination when the bladder is empty
Pelvic muscle function should be assessed after the bimanual
examination palpate the pelvic muscles a few centimeters
inside the hymen, along pelvic sidewalls at the 4 & 8 oclock
Resting tone & voluntary contraction of the anal aphincters should
be assessed during rectovaginal examination

Testing

Bladder Testing
At minimum, for all patients with prolapse, 3 pieces of information
should be obtained;
Screening for urinary tract infection
Postvoid residual urine volume
Presence or absence of bladder sensation

Women with prolapse and urinary incontinence should have stress

testing performed with the prolapse reduction because this will mimic
bladder and urethral function when the prolapse is treated
In the setting of a positive reduction stress test recommend
that as incontinence procedure should be performed at the time of
prolapse surgery

Therapeutic Approach

Indications for Treatment

Choice of treatment for prolapse depends on symptoms severity and
severity of prolapse
Symptoms associated with stage I or II prolapse require careful
evaluation, especially if surgery is being considered
Many women with stress urinary incontinence have stage I or II ,
although stress incontinence is not a symptom of prolapse
; it is simply a coincident symptom

Therapeutic Approach

Observation
Observation is appropriate for women whose symptoms are not
sufficiently bothersome to warrant active management
There is no indications for treatment, particularly surgery, for women
with asymptomatic prolapse before the problem gets any worse
Occasionally a patient will present with advanced prolapse, yet she
will say that shes asymptomatic is observation still qppropriate?
An important consideration is her efficiency of bladder emptying
Other risks : exposed vaginal epithelium & evisceration

Therapeutic Approach

Nonsurgical Management
Includes adjunct therapy to address concomitant symptoms,
pelvic floor muscle training, and pessaries
Ideally, nonsurgical management will decrease the frequency
and severity of symptoms, delay or avoid surgery & potentially prevent
worsening the prolapse

Therapeutic Approach

Adjunct Therapy
Addresses symptoms of urinary, defecatory & sexual dysfunction
Patient often present with defecatory symptoms, such as excessive
straining at stool and a feeling of incomplete evacuation, and physical
examination reveals stage II or early stage III posterior vaginal prolapse
(rectocele) evaluation from the GI perspective
Age-appropriate screening for colorectal cancer
: diet history (fiber and fluid intake), exercise history, review of
medications for GI adverse effects, and bowel movements
Adjunct therapy includes advice on lifestyle alterations, weight loss,
and a general exercise program

Therapeutic Approach

Pelvic Floor Muscle Training

Designed to increase the strength abd endurance of the pelvic
muscles, thereby improving support to pelvic organs
Kegel exercises
With virtually no adverse effects, its only negative is the cost of
providing instruction and follow-up for patients

Therapeutic Approach

Pessaries
To decrease symptom frequency and severity, delay or avoid surgery,
and potentially prevent worsening of prolapse
The most important relative contraindication for pessary use occurs
when the patient cannot comply with follow-up
Pessary use must be discontinued for persistent vaginal erosions
Unsuccessful fitting is associated with short vaginal length (less than
7cm) and wide introitus ( 4 finger-breadths)

Nonsurgical Management

Therapeutic Approach

Pessaries
Separated into 2 broad categories : support and space-filling
Ring pessary (with diaphragm) and other support pessaries are
commonly recommended for stage II and early stage III
Space-filling pessaries such as the Gellhorn are usually used for more
advanced prolapse
If some perineal support is preserved, a ring pessary ( without support
when cervix is present, with support after hysterectomy)
is good first choice

Nonsurgical Management

Therapeutic Approach

Pessaries
Gellhorn pessaries are useful for women with more advanced prolapse
and less perineal support because they sometimes
stay in place when ring pessaries do not
The Gellhorn is fitted so that the disk is centered in the upper vagina
& the stem points downward behind the perineal body

Nonsurgical Management

Therapeutic Approach

Pessaries
The goal of changing the pessary at frequent intervals to prevent
vaginal irritation that leads to discharge, infection, and erosion
If daily changing is too bothersome, a schedule of weekly or twiceweekly removal can be used
Vaginal estrogen is commly employed with pessaries
In women with vaginal atrophy at pessary initiation, local estrogen is
important to prevent vaginal erosions

Surgical Management - Approach

Approach to prolapse surgery include vaginal, abdominal, and
laparoscopic routes or combination of approaches
Vaginal approach results in fewer wound complications, less
postoperative pain, shorter hospital stay, and less cost than
abdominal surgery
Surgical procedures for prolapse : cathegorized into 3 groups
Restorative use the patients endogenous support structures
Compensatory replace deficient support with some type of graft
Obliterative close the vagina

Surgical Management

Prolapse Procedures Anterior Vaginal Repair

Traditionally repaired with anterior colporrhaphy
vaginal epithelium separated from the underlying fibromuscular
connective tissue, followed by midline plication of the vaginal
muscularis with interrupted stitches
excision of excess epithelium & closure
Richardson reintroduced the concept of paravaginal repair
reattaches the anterior lateral vaginal sulcus to the obturator
internus muscle and fascia at the level of the arcus tendineus
fasia pelvis (white line) via transvaginal or retropubic access

Paravaginal defects
-Loss of lateral vagina
attachment at the arcus
tendineus resulting in a
cystocele (bladder drop)

Surgical Management

Prolapse Procedures Posterior Vaginal Repair

Traditionally posterior colporrhaphy
vaginal epithelium separated from the underlying fibromuscular
connective tissue (rectovaginal septum, in between the vaginal
muscularis and the rectovaginal adventitia) followed by midline
plication of the vaginal muscularis with interrupted stitches
excision of excess epithelium & closure
Other procedures can be combined with posterior colporrhaphy, such
as levator ani plication and peroneorrhaphy
Dyspareunia after posterior colporrhaphy
blamed on levator ani plication
& narrowing can also occur with overzealous perineorrhaphy
The vaginal configuration is altered by the Burch procedure
the upward displacement of the anterior vaginal tube
create a transverse ridge in the posterior vagina

Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is
one of the two best cures for stress or activity related urine leakage

Surgical Management

Prolapse Procedures Posterior Vaginal Repair

Despite careful attention to ensure adequate introital caliber after
posterior repair, 38% of women after Burch and posterior repair
persistent dyspareunia 1 year or more after surgery
Levator ani plication is associated with postoperative dyspareunia
recommend not to be performed in sexually active women
In non-sexually active women, levator ani plication performed to
reinforce the repair, intentionally narrow the mid & lower vagina
; high perineorrhaphy can be added to further close the introitus

Surgical Management

Prolapse Procedures Vaginal Apical Repair

Apical vaginal prolapse includes uterine prolapse with or without
enterocele and vaginal vault prolapse, typically with enterocele
The standard treatment for symptomatic uterine prolapse
hysterectomy with procedure to suspend the vaginal apex,
address enterocele when indicated, repair coexisting anterior
& posterior vaginal prolapse
perform anti-incontinence procedure

Vaginal Apical Repair

Enterocele Repair
Whether by vaginal, abdominal, of
laparoscopic access, enterocele
repair is traditionally performed by
sharply dissecting the peritoneal
sac from the rectum and bladder
A purse-string suture can be used
to close the peritoneum
as high as possible

Vaginal Apical Repair

Sacrospinous Ligament Suspension

Sacrospinous ligament fixation
entails attachment of the
vaginal apex to the
sacrospinous ligament, the
tendinous component of the
coccygeus muscle

Vaginal Apical Repair

Iliococcygeal vaginal suspension

Iliococcygeal vaginal suspension
involves attachment of vaginal
apex to the iliococcygeus muscle
and fascia, usually bilaterally

Vaginal Apical Repair

Uterosacral Ligament Suspension

Used prophylactically at
hysterectomy or therapeutically
for vaginal apical suspension
Once access to the posterior culde-sac has been attained, the
uterosacral ligament remnant
can be found
Sutures in each ligament and
incorporated into the ant & post
fibromuscular layer of vagina

Nonsurgical Management

Prolapse procedure

Comparison of Vaginal Approaches to Apical Repair

Sacrospinous ligament suspension may leave the anterior vaginal at

greater risk for subsequent failure & because the procedure is
extraperitoneal rare ureteral and rectal injury
Iliococcygeal suspension is straightforward procedure to learn and
teach. It carriers virtually no risk of ureteral or small bowel injury,
there are no vital structures nearby at risk for surgical injury
Uterosacral ligament suspension traditionally requires peritoneal entry
challenging in posthysterectomy prolapse, especially in the setting
of bowel adhesions engendering the rare occurrence of bowel injury
Uterosacral ligament suspension carreies a risk of ureteral injury
(usually kinking due to medial displacement or suture ligation that impedes
urinary flow)

Prolapse procedure

Abdominal Apical Repair

Abdominal Sacral Colpopexy uses graft material attached to the

anterior and posterior vaginal apex and suspended to the anterior
longitudinal ligament of the sacrum for repair of apical prolapse
Peritoneal closure over the graft & obliteration of the cul-de-sac for
treatment or prevention of enterocele
The cure rate range from 78% to 100%
Complications
: intra-operative hemorrhage, laparotomy (adhesion & small bowel
obstruction) , and graft infection or erosion

Prolapse procedure

Comparison of Abdominal and Vaginal Approaches

to Apical Repair
Success rates appear to favor the abdominal approach to apical
vaginal prolapse
Abdominal sacral colpopexy is more durable in providing apical
support, but at the cost of increased complications
Younger women benefit more also likely to be more from durability,
with the reduced chance they will need prolapse surgery in future

Nonsurgical Management

Prolapse procedure

Colpocleisis
In a healthy, sexually active woman the vagina may be
surgically attached to the sacrospinous ligament, sacrum or
fascia support system. But, they can be associated with
occasional serious complications such as severe hemorrhage
or major nerve injury
In those frail elderly women who do not wish to be sexually
active in the future total colpocleisis is a simple, safe, and
effective surgical procedure that reliably relieves these women
of their symptoms
Total colpocleisis procedure often coupled with a tension free
vaginal tape (TVT) sling procedure for urinary incontinence

Surgical Management

Diagnosis and Treatment of Stress Incontinence

with Pelvic Organ Prolapse
Stress Incontinence (activity leakage)
Loss of urine during coughing, sneezing, laughing or
lifting something heavy. These activities cause an
increase in "belly pressure
forces the urine out of the bladder
Stress incontinence occurs almost exclusively in women
& thought to be due to "pelvic (vaginal) relaxation"
from childbirth or aging.

Surgical Management

Diagnosis and Treatment of Stress Incontinence

with Pelvic Organ Prolapse
Stress Incontinence - Treatments
Conservative Therapy
Pelvic Floor Exercises
Urinary Meatal Occlusion Devices
Collagen Injections
Urinary Incontinence Surgery
Anterior Repair and Kelly plication
Pubovaginal Sling Procedures
TVT Sling Surgical Procedures
Burch Urethropexy Procedures

In an attempt to support the urethra, actually the vagina under

and beside the urethra is the area which the operation takes
place. The two most successful operations described
Pubovaginal Sling procedure & Burch urethropexy
(colposuspension)

Surgical Management

Adjunctive Materials
The most common prolase procedures using ajunctive materials are
abdominal sacral colpopexy and anterior & posterior vaginal repairs
The ideal adjunctive material should be biocompatible yet inert,
nonallergenic, noninflammatory, resistant to mechanical stress and
conveniently available
It is critically important for surgeons to discuss the use of adjunctive
materials with patients before surgery so patients are well-informed of
risks and benefits and participate in the decision to use materials