Pelvic Organ Prolapse

Is the descent of the pelvic organs as a result of the loss of muscular and fascial structural support .

Pathophysiology

·         Direct Trauma to pelvic soft tissues

·         Neurological injury

·         Connective tissue disorders

Predisposing factors

Vaginal Delivery

Increasing Parity

Age

Obesity

Family History/race

connective tissue disorder – Ehlers –Danlos syndrom

Constipation/chronic cough/heavy lifting which increase intra abdominal pressure

Prolonged 2nd stage/forceps delivery/macrosomia

Endocrine – increases after menopause /pregnancy /during menstruation

Types of pelvic organ prolapse

1. Urethra – urethrocele

2. Bladder- cystocele

3. Uterus- uterine prolapse

4. Small Bowel  with POD – enterocele

5. Rectum- rectocele

6. vault – vault prolapse

Compartments

Anterior  vaginal wall :  Cystocele- upper 2/3

                                          Urethrocele- lower 1/3

Middle(apical) :    Uterine prolapse

                                vault prolapse

Posterior : enterocele (prolapse of POD with small bowels) – upper 1/3

                  Rectal prolapse- lower 2/3

Grading uterine descent

1^st degree – descent of the cervix into the vagina

2^nd degree – descent of the cervix upto the intritus

3^rd degree – descent of the cervix outside the introitus

Procedentia – prolapse of entire uterus outside the introitus.

Symptoms

Lump

Pain/discomfort in pelvis/vagina/buttocks/

    lower back 

Often vague ‘ache’ or ‘dragging’

Sexual dissatisfaction

Excoriation/bleeding from protruding tissue

Urinary

Stress incontinence  

Hesitancy

Poor Flow

Incomplete emptying

Recurrent UTI’s

Gastro intestinal

Constipation

Incomplete emptying

Tenesmus

Complications

Bleeding

Infection

Recurrent UTI’s

Urinary obstruction

Renal failure

Elongation of cervix

Decubitus ulcer – keratinization and pigmentation of vaginal mucosa as well as ulceration of the prolapsed tissue are caused by friction and congestion.

Associated conditions

Urinary Incontinence : Stress

                                    Urge

                                    Mixed

Fecal Incontinence : sphincter injury

Differential diagnosis

Vulvul cyst or tumor

Cyst  of the anterior vaginal wall

Urethral diverticula

Congenital elongation of the cervix

Cervical fibroid polyp

Chronic inversionof uterus

Rectal prolapse

Managements

Treat associated conditions

Constipation

Overactive bladder

Vulval irritation/atrophy

Back-pain/Pelvic pain

Conservative

1.      General lifestyle changes

Smoking cessation

Routine use of Kegel pelvic floor exercises

Regular physical activity

Weight loss

Avoid constipation by increase water intake ,fibre content and laxative

Hormone replacement therapy

2.       Pelvic floor exercises/physiotherapy

3.       Vaginal pessary

Ring pessary – allows sexual intercourse

Shelf pessary – preclude sexual intercourse

Limitations of pessaries

Often not acceptable to patients

Need to change regularly atleast 6 monthly

Discomfort

Sometimes not retained

Especially if previous vaginal hysterectomy

Can cause urinary retention/constipation if displaced

Erosions

Vaginal Discharge (non infective)

Of limited help in reducing posterior wall prolapse

Surgical Treatment

Cystocele – anterior colporrhaphy

Rectocele – posterior colporrhaphy

Uterine descent – vaginal hysterectomy

                                  Le Fort`s repair

                                  Colpocleisis

Vault prolapse – sacrospinous colpopexy

                               Sacral colpopexy

                              Le Fort`s repair

                                  Colpocleisis

Post-operative complications

Early

Haematoma’s, infection

Urinary Retention

Vaginal Discharge (Non infective)

Early failure of repair

Late      

Recurrence (20-30%)

Mesh erosions

Progression of prolapse in other compartments

Dyspareunia (especially posterior)

Stress incontinence/unstable bladder (5%)