Pelvic Relaxation/Pelvic Organ Prolapse

Briana Robinson-Walton MD
Basics
Description
Pelvic organ prolapse (POP) is a condition in which descent of a pelvic organ
into or beond the vagina! perine"#! or anal canal has occ"rred$ %his
relaxation can occ"r in one or #"ltiple areas of the vagina$
%he following ter#s are "sed to describe where the prolapse can arise&
'nterior wall prolapse&
o (stocele (bladder)
o )rethrocele ("rethra)
Posterior wall prolapse&
o Rectocele (rect"#)
o *nterocele(s#all/large bowel)
'pical prolapse&
o )terine prolapse ("ter"s)
o +aginal va"lt prolapse (vaginal c"ff)
'ge-Related ,actors
'dvancing age is co##onl associated with POP! with an --. lifeti#e ris/ for
s"rger b age 01$
Pediatric (onsiderations
POP in adolescents #a warrant an eval"ation of a connective tiss"e disorder s"ch as
Marfan2s or *hlers-Danlos sndro#es$
3taging
Prolapse is assessed b the Pelvic Organ Prolapse 4"antification (POP4) exa#$ %he
staging sste# "tili5es ob6ective #eas"re#ents to assign severit (see 7Phsical
*xa#8)&
3tage 1& 9o prolapse is de#onstrated&
o 'a! Ba! 'p! Bp are -:
o ( and D are ;%+< = > c#
3tage -& Most distal portion of prolapse is ?- c# above the level of the
h#en&
o Points @-- c#
3tage >& Most distal portion of prolapse is within - c# of the h#en&
o Point A-- c# and ;B- c#
3tage :& Most distal portion of prolapse is - c# past the introit"s&
o ?B- c# and ;%+< = > c#
3tage C& (o#plete eversion of "ter"s or vaginal va"lt&
o ?%+< ->
*pide#iolog
POP is highl prevalent a#ong post#enopa"sal wo#en$ %he lifeti#e prevalence is
between :1. and D1.$ Most wo#en are not s#pto#atic$ Eowever! - in -1 wo#en
will reF"ire s"rger for this condition and G>H. will "ndergo reoperation$ %he act"al
incidence of POP is "n/nown$
Ris/ ,actors
Obstetric ris/s&
o M"ltiparit
o Operative vaginal deliver
3"rgical ris/s&
o Esterecto#
o Prolapse s"rger
o Prior colpos"spension
Biologic ris/s&
o Menopa"se
o Epoestrogene#ia
o Obesit
o Wea/ pelvic #"sc"lat"re
o <arge dia#eter of bon pelvis
o (ollagen abnor#alities
<ifestle&
o Occ"pational (heav lifting)
o (hronic constipation/straining
Ienetics
Pregnanc! part"rition! aging! and #enopa"se affect each wo#an differentl$ Ienetic
predisposition is one aspect of the develop#ent and severit of POP$ %he encoded
#etabolis# of extracell"lar #atrix proteins (collagen! elastin and fibronectin) and
en5#es (#atrix #etalloproteinases) #a help to explain wh prolapse occ"rs in
so#e wo#en and not others$
Pathophsiolog
Prolapse res"lts fro# a co#bination of anato#ical factors! pelvic floor tra"#a!
inadeF"ate s"rveillance! and li#ited intervention$
'nato#ical/Ienetic factors&
o (ollagen disorder/defect
Pelvic floor tra"#a fro# vaginal deliver or s"rger&
o Jn6"r to tiss"e! #"scles! and nerves
JnadeF"ate s"rveillance&
o <ac/ of recognition of earl stage/grade POP
<i#ited intervention&
o )n#odified ris/ factors (i$e$! "ntreated constipation)
o Pessar or s"rgical #anage#ent
'ssociated (onditions
POP can occ"r in con6"nction with other pelvic floor disorders and res"lt in a
detri#ental effect on F"alit of life$
Jncontinence&
o )rinar
o ,ecal
Diagnosis
3igns and 3#pto#s
Eistor
Patients are generall as#pto#atic with earl stages of POP$ 's the prolapse
progresses! the patient #a present with a n"#ber of co#plaints
Prolapse&
o Press"re/pain&
+agina
<ower bac/
)rinar&
o Jncontinence
o Eesitanc/Retention
Bowel&
o ,ecal incontinence
o (onstipation/J#paction
3ex"al&
o Dspare"nia
o Decreased pleas"re/satisfaction
Phsical *xa#
Perfor# a general exa# to eval"ate health stat"s and i#pact of co#orbidities$
Pelvic exa# incl"des&
o +agina&
3"b"rethral #ass/tenderness (divertic"l"#)
Bladder #ass/tenderness (interstitial cstitis)
'troph (#ild! #oderate! severe)
Pelvic #"sc"lat"re& atroph! Kegel exa#
o (ervix (#ass! elongation)
o )ter"s (enlarge#ent! #obilit! descent)
o 'dnexa
o Rectal (#ass! exacerbation of rectocele! presence of enterocele)
o Prolapse eval"ation and staging
Perfor# exa# d"ring +alsalva! with a half spec"l"# and in the
standing position$
POP4 #eas"re#ents are #ade relative to the h#en in 1$D c#
incre#ents$
PointMeasurement Range
'a 'nterior vaginal wall : c# proxi#al to "rethral
#eat"s
-: to B:
Ba Most distal point on the anterior wall prolapse B: to
tvl
( Most distal edge of cervix or c"ff B/- tvl
D Most distal position of posterior fornix B/- tvl
'p Posterior vaginal wall : c# proxi#al to h#en -: to B:
Bp Most distal point on the posterior wall prolapse B: to
tvl
ghL Middle "rethral #eat"s to posterior #idline of
h#en
9o
li#it
pb

Posterior #idline of h#en to #id-anal opening 9o

li#it
tvlM Posterior h#en to the posterior fornix or vaginal
c"ff
9o
li#it
Lgenital hiat"s

perineal bod
Mtotal vaginal length
o Points #eas"red inside of the h#en are negative! whereas points
o"tside the h#en are positive$
o %he h#en is assigned a val"e of 5ero$
o 'll #eas"re#ents! except the total vaginal length are obtained with
+alsalva$
o %he #eas"re#ents recorded on H point grid&
'a Ba (
gh pb tvl
'p Bp DL
LJs not #eas"red in patients witho"t a cervix
P$-DD
%ests
)rinar incontinence&
o )rodna#ic testing
o B/- (stoscop (he#at"ria! s#o/ing histor)
(onstipation&
o (olonoscop
o Mar/er st"dies for transit ti#e
o Defecograph
,ecal incontinence&
o 'nal sonograph
o Mano#etr
o P"dendal nerve #otor latenc
J#aging
(onsider contrast (% of "pper "rinar tract with abnor#al cstoscop findings&
9egative exa# for he#at"ria eval"ation
<ac/ or abnor#al "reteral patenc
Differential Diagnosis
)rethral divertic"l"# or s"b"rethral cst
,ibroids in the lower "terine seg#ent
(ervical elongation
Rectovaginal #ass
%reat#ent
Ieneral Meas"res
Observation is appropriate for stage - prolapse or as#pto#atic stage >
prolapse&
o Jnterval POP4 exa#s repeated to eval"ate for progression! regression!
or stabilit
o %opical estrogens and pelvic floor exercises
Pessaries if nons"rgical #anage#ent is desired or poor operative candidate$
o Prior to fitting! a POP4 exa# and correction of vaginal atroph are
perfor#ed$
o Pessar selection based on location and severit of POP$ ' /nob with
the pessar addresses conc"rrent stress incontinence$
Anterior PosteriorApical
Ring Ring Ring
Iehr"ng Iehr"ng Ielhorn
Mar-<and Don"t
Jnitial fitting&
o 'ssess vaginal length and select pessar si5e (i$e$! "se pessar with
length ;N1 ## for %+< 0 c#)
o 'ssess co#fort! abilit to retain d"ring +alsalva! a#b"lation! and
voiding after place#ent$
o Jnstr"ct patient to re#ove nightl to wee/l independentl
o Provider-dependent chec/s ever -=: #onths
o )se %ri#o-3an oint#ent to decrease discharge
o *val"ation of infection! lacerations/erosions! and satisfaction at ever
visit
Medication (Dr"gs)
Most patients who have POP will reF"ire treat#ent of vaginal atroph$
+aginal crea#s&
o *stradiol crea# 1$1-. (*strace)
o (on6"gated estrogens 1$O>D #g/g# (Pre#arin)
+aginal tablet&
o *stradiol >D Pg (+agi,e#)
+aginal ring&
o *stradiol > #g (*string)
3"rger
%he goals of s"rgical correction are to restore anato# and correct s#pto#s
while respecting desire for sex"al f"nction$
%he tpe of repair is based on these goals as well as conc"rrent incontinence
iss"es$
Ienerall! POP is approached thro"gh the vaginaQ however! abdo#inal and
laparoscopic approaches #a be appropriate in certain cases$
Biologic #aterials and snthetic #eshes are proposed to decrease the ris/ of
rec"rrence$
3"ccessf"l repair addresses each defect and involves selection of the
appropriate s"rger$
Perfor#ance of hsterecto# and/or incontinence proced"re is based on
conc"rrent conditions! patient preference! and s"rgical ro"te$
(o#part#ent defect/co##on proced"res&
o 'nterior prolapse (cstocele! "rethrocele)&
'nterior repair
Paravaginal repair
o Posterior prolapse (rectocele/enterocele)&
Posterior repair/colporrhaph
*nterocele repair (c"ldoplast)
o 'pical prolapse ("terine prolapse! vaginal va"lt prolapse or
enterocele)&
)terosacral liga#ent s"spension (Mc(all! #odified Mc(all!
s"spension)
3acrospino"s liga#ent fixation
Jleococcge"s s"spension
3acrocolpopex/3acrocervicopex
o Perineal prolapse&
Perineorrhaph
,ollow"p
Disposition
Jss"es for Referral
(ons"ltation with a "rognecologist is necessar for the following reasons&
(onc"rrent proble# with incontinence
Rec"rrent prolapse
)nable to properl assess POP
Jnabilit to properl #anage POP
Prognosis
Wo#en with pessaries #a discontin"e "se d"e to infection! discharge!
bleeding! or the desire for definitive therap$
Wo#en who elect s"rgical #anage#ent sho"ld be co"nseled that the
rec"rrence rates are variable depending on the proced"re perfor#ed&
o Rec"rrence in the anterior co#part#ent is the highest! >1=C1.! and
#ore co##on with vaginal proced"res$
o %he need for another proced"re is as high as :1.$
Patient Monitoring
Pessar eval"ation ever -=: #onths if wo#an doesn2t re#ove the pessar on
her own$
'nn"al reeval"ation of POP in wo#en who re#ove the pessar independentl$
%he POP4 eval"ation of s"rgical o"tco#es is exec"ted ann"all after the -st
ear$
Bibliograph
B"#p R(! et al$ *pide#iolog and nat"ral histor of pelvic floor dsf"nction$ Obstet
Inecol (lin$ -HH0Q>D&N>:=NCO$
B"#p R(! et al$ %he standardi5ation of ter#inolog of fe#ale pelvic organ prolapse
and pelvic floor dsf"nction$ '# R Obstet Inecol$ -HHOQ-ND&-1=-N$
Miscellaneo"s
3non#(s)
Pelvic or vaginal relaxation
(linical Pearls
S 3evere atroph&
= B"rning s#pto#s #a be initiall enco"ntered with "se of topical estradiol$
= Pretreat#ent with petrole"# 6ell #a help$
S Pessar "se&
= Deflate don"t pessar with -0-ga"ge needle and :1-cc sringe to ease insertion and
place#ent$
= Ma have higher fail"re rates with pessar with a large IE (AO c#) or shortened
vagina (%+< @0 c#)
S 3"rger&
= Bowel prep all patients prior to s"rger and prevent constipation postoperativel$
'bbreviations
S POPTPelvic organ prolapse
S IETIenital hiat"s
S PBTPerineal bod
S %+<T%otal vaginal length
(odes
J(DH-(M
S O-0$11 Prolapse! vaginal walls
S O-0$1- (stocele! #idline
S O-0$1> (stocele! lateral
S O-0$1: )rethrocele
S O-0$1C Rectocele
S O-0$1D Perineocele
S O-0$- Prolapse! "terine
S O-0$> )terovaginal prolapse! inco#plete
S O-0$: )terovaginal prolapse! co#plete
S O-0$D +aginal va"lt prolapse hsterecto#
S O-0$O *nterocele
Patient %eaching
Prevention
S POP is #"ltifactorial! and the inabilit to predict who will develop s#pto#atic
pelvic floor relaxation prevents #odification of inciting factors a#ong reprod"ctive-
age wo#en$
S %he strongest ris/ factors for develop#ent of POP are obstetric& M"ltiparit and
vaginal deliver$ Prevention of POP with cesarean deliver is controversial$ Once
recogni5ed! certain factors #a be #odified to i#prove or prevent worsening of POP&
= (onstipation
= Occ"pational and recreations stress
= Obesit
= (hronic l"ng disease
= 3#o/ing
= +aginal estrogen