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CASE REPORT

Supervised by:
dr. Arie Adrianus Polim, D.MAS, Sp.OG(K)

Presented by:
Sherynne Sulaiman (2013-061-081)
Kent Pradana (2014-061-131)
Emily (2014-061-132)
Marsha Desica (2014-061-136)
Department of Obstetrics and Gynecology
Medical Faculty of Atma Jaya Catholic University

2015

CHAPTER 1
CASE

1.1.

Patients Identity

Name

: Mrs. J

Age

: 57 years old

Nationality

: Indonesian

Address

: Pluit Dalam

Education

: Elementary school

Marital Status

: Married

Occupation

: Housewife

Religion

: Moslem

Date of Admission : November 2nd 2015

1.2.

Anamnesis

Chief Complaint
Feeling a lump in the vagina since 1 month ago
History of Present Illness
Patient came to the hospital because she feels a lump in her vagina since 1 month ago, the
lump size is about 5 cm in diameter. The lump protruding out when the patient is urinating
and resolves spontaneously after that. Patient also feeling a ball in her vagina while she is
3

walking and lifting heavy weight, but resolves when resting. Patient denied feeling any pain.
Patient also complained about having an urge to pee everytime she is coughing or lifting a
heavy weight. Patient had an increased frequency of urinating to more than 10 times a day
since 2 months ago. Patient denied feeling unsatisfied after urinating. Patient denied feeling
pelvic and back pain. Patient doesnt have any sexual activity since 10 years ago.
Patient had a history in difficulty on defecating since a long time ago but she doesnt
remember since when. Patient was diagnosed with bone tuberculosis for almost 1 year ago
and take medications for tuberculosis since then until now. Patient also had a history of
frequent coughing (more than 10 times a day) since more than 1 year ago. Patient also
diagnosed with hypertension and takes medication (amlodipine 1 x 5 mg) since 2 years ago.

moderatel
y

moderatel
y

moderatel
y

History of Past Illness

History of hypertension
History of spondylitis tuberculosis

: since 2 years ago (amlodipine 1 x 5 mg )


: since 11 months ago
(R/H/Z/E)

History of heart disease


History of diabetes mellitus
History of allergy
History of epilepsy
History of hematologic disease
History of urinary tract/ kidney disease
History of trauma
History of surgery

:
:
:
:
:
:
:
:

denied
denied
denied
denied
denied
denied
denied
denied

Family History
5

History of hypertension
History of pelvic organ prolapse
History of diabetes mellitus
History of allergy

:
:
:
:

denied
denied
denied
denied

Contraception History
Menstruation History

Menarche

: 15 years old
Menstrual cycle

First day of last menstrual cycle

Patient didnt

remember
: 5 years ago

Marital History
Married once, for 40 years.
Gestational History
First day of last menstrual period

No
.

Date

Gestational
Age
9 months

: 5 years ago

Breast

Labor History

Sex

Birth weight

Vaginal delivery

Male

3000 grams

yes

feeding

1980

1981

1982

9 months

Vaginal delivery

Male

3000 grams

Yes

1990

9 months

Vaginal delivery

Male

3500 grams

yes

Abortion

1993

Abortion

Physical Examination (November 2nd 2015)

1.3.

General condition

: moderately ill appearance

Consciousness

: compos mentis

Blood pressure

: 140/80 mmHg

Pulse

: 96 BPM

Respiratory Rate

: 20 breaths per minute

Temperature

: 36,7o C

Weight

: 56 kg

Height

: 144 cm

BMI

: 27.05 kg/m2

General Examination
Eye

: Palpebral edema -/Anemic conjunctiva -/Anicteric sclera

Oral

: Wet oral mucosa

Thorax
Cor

: Auscultation: irregular 1st and 2nd heart sound, gallop (-), murmur (-)

Pulmo

:
7

Inspection : Symmetric chest expansion in both static and dynamic breathing


Percussion : Sonor on both lungs
Auscultation : Vesicular breath sound +/+
Wheezing -/Crackles -/-

Mammae

: Hyperpigmentation of areola +/+


Nipple retraction -/-

Abdomen

Inspection : convex, striae gravidarum (-), linea nigra (-)


Palpation
: supple in all abdominal region, tenderness (-)
Auscultation : bowel sound (+), 3-4 x/ minute

Extremities

: Warm
Edema -/Physiological reflex ++/++/++/++
Pathological reflex --/--

Gynecology Examination
Perineal examination

Inspection
: vulvar atrophy -, vaginal atrophy -, lesions
Neurologic examination : bulbocavernosus reflex + (weak), anal wink reflex +
Speculum examination
:
o Protrusion come beyond the hymen
o Presenting part of the prolaps anterior
o Widen genital hiatus with increased intraabdominal pressure

Vaginal examination

POP-Q examination
8

o Genital hiatus
o Perineal body
o Total vaginal length
Speculum examination
o Valsava maneuver
o Descent of the apex
o Anterior vaginal wall
urethra o Posterior vaginal wall

: 5 cm
: 3 cm
:
: proplapse descends
:+
: cystocele +, vaginal sulci -, vaginal rugae -,
: rectocele -, enterocele

Picture 1. Vaginal & perineal examination

Picture 2. Vaginal & perineal examination

Bimanual examination
o Pelvic floor musculature

: muscle resting tone and strength (grade 3

oxford scale), muscle symmetry +

Workup:
EKG : ventricular extrasystole 10 times in 1 minute

1.4.

Laboratory Examination

Hematology

Hemoglobin
Hematocrit
Leukocyte

:
:
:

12 g/ dL
36%
7.900/ L
10

Thrombocyte
Blood group
Bleeding time
Clotting time
PT
APTT

:
:
:
:
:
:

239.000/ L
A/ Rh+
3 minutes
5 minutes
13,5 seconds
27,7 seconds

:
:
:
:

145 mmol/l
3.4 mmol/l
1.15 mmol/l
114 mmol/l

:
:
:
:
:
:

27 U/l
24 U/l
21 mg/ dL
0,5 mg/ dL
134 mg/ dL
-

Electrolyte

Sodium
Potassium
Calsium
Chloride

Blood Chemistry

1.5.

SGOT/ AST
SGPT/ ALT
Ureum
Creatinine
One time blood glucose
HbsAg

Admitting Diagnosis

P5A2, 57 years old, with second degree uterine prolapse and third degree cystocele, uncontrolled
hypertension grade 1, spondylitis tuberculosis

1.6.

Therapy
Hysterectomy transvaginal
Consult to the department of internal medicine for the operation toleration:
- Medication from departement of internal medicine:
o Hysterectomy transvaginal postpone until ventricular extrasystole < 6 times in
1 minute
11

o Oxygen 2 lpm via nasal canule


o Cordarone 150 mg in 50 ml D5 bolus in 15 minutes (diluted to 50 cc via syringe
pump) Cordarone drip 300 mg in 500 ml in 12 hours
o Candesartan 1 x 8 mg P.O
o Tuberculosis regimen: R/H/Z/E 450/400/1000/750
o Alprazolam 2 x 0.5 mg
1.7.

Follow Up

November 3rd 2015 (05.00 a.m)


S: feeling a lump in her vagina +, headache (-), palpitation (-)

O:

General condition

: Mildly ill appearance

Consciousness

: Compos mentis

Blood Pressure

: 140/90 mmHg

HR

: 88 BPM

RR

: 22 breaths/minute

: 36,5 C

Eye

: palpebral edema -/-, anemic conjunctiva -/-, icteric sclera -/-.

Oral

: Wet oral mucous

Thorax:

Cor

Pulmo :

: Auscultation: irregular 1st and 2nd heart sound, Gallop (-), Murmur (-)

Inspection : symmetrical in both static and dynamic breathing

Percussion : sonor on both lungs


12

Auscultation : vesicular breath sound +/+, wheezing -/-, crackles -/-

Mammae : hyperpigmentation of areola +/+, nipple retraction -/-

Abdomen

Inspection : convex, striae gravidarum -, linea nigra -,

Palpation : supple in all abdominal region, tenderness

Percussion: tympanic sound in all abdominal region

Auscultation : bowel sound +, 6-7 x/minutes

Extremities: Warm

Edema

Physiological reflex : ++/++/++/++

Pathological reflex

: Lower extremities -/-

: --/--

Workup:

EKG : ventricular extrasystole 5 times in 1 minute

A : P5A2, 57 years old, second degree uterine prolapse and third degree cystocele, with
uncontrolled hypertension grade 1, spondylitis tuberculosis

P:
- Hysterectomy transvaginal postpone until ventricular extrasystole < 6 (stabile)
- Medication from departement of internal medicine:
Oxygen 2 lpm via nasal canule
Monitor vital sign
Cordarone 2 x 200 mg P.O
Candesartan 1 x 8 mg P.O
Tuberculosis regimen: R/H/Z/E 450/400/1000/750
Alprazolam 2 x 0.5 mg

13

November 4th 2015 (05.00 a.m)


S: Feeling a lump in her vagina +, headache (-), palpitation (-)

O:

General condition

: Mildly ill appearance

Consciousness

: Compos mentis

Blood Pressure

: 138/82 mmHg

HR

: 66 BPM

RR

: 22 breaths/minutes

: 37 C

Eye

: palpebral edema -/-, anemic conjunctiva -/-, icteric sclera -/-.

Oral

: Wet oral mucous

Thorax:

Cor

Pulmo :

: Auscultation: irregular 1st and 2nd heart sound, Gallop (-), Murmur (-)

Inspection : symmetric in both static and dynamic breathing

Percussion : sonor on both lungs

Auscultation : vesicular breath sound +/+, wheezing -/-, crackles -/-

Mammae : hyperpigmentation of areola +/+, nipple retraction -/-

Abdomen

Inspection : convex, striae gravidarum -, linea nigra -,

14

Palpation : supple in all abdominal region, tenderness

Percussion: tympanic in all abdominal region

Auscultation : bowel sound +, 5-6 x/minutes

Extremities: Warm

Edema

Physiological reflex : ++/++/++/++

Pathological reflex

: lower extremitites +/+

: --/--

Workup:

EKG: ventricular extrasystole 5 times in 1 minute

A: P3A2, 57 years old, second degree uterine prolapse and third degree cystocele, with
uncontrolled hypertension grade 1, spondylitis tuberculosis
P:
- Hysterectomy transvaginal confirming for operation
- Medication from departement of internal medicine:
Cordarone 2 x 200 mg P.O
Candesartan 1 x 8 mg P.O
Tuberculosis regimen: R/H/Z/E 450/400/1000/750

Operation Report

Patient was in lithotomy position.


Aseptic and antiseptic procedure in vaginal region and cervix has been done
Area other than operation location covered by sterile fabric
Major labia dextra and sinistra was put aside then sutured outward to open the operation

site
Cervix was fixed with tenaculum and pulled outward, the operation site was opened by
hague and urinary bladder was identified
15

Incision in a cervical region acording to the vaginal rugae with inverted U shaped
incision and circumferential 2 cm proximal portio to identified uterus. Cauterization of

small blood vessels to control the bleeding.


Undermining the uterus from peritoneum by cutting the posterior peritoneum fold and

septum
Ligation and dissection of cardinal ligament, uterosacral ligament, and uterine artery
Evacuation of the uterus form pelvic cavity
Ligation and dissection of latum ligament. Cauterization of small vessels to control the

bleeding
Cutting of the fallopian tubes and evacuation of uterus from the vaginal introitus
Reconstruction of anterior wall of the vagina by suturing the anterior mucosal wall of the

vagina (anterior colporrhaphy)


Reperitonealization to closed the abdominal cavity
Suturing of proximal vaginal wall sagitally and transversally to close the hole in the

vagina
Incision of posterior vaginal wall. Identification of cul de sac and rectovaginal fascia for

posterior colporrhaphy procedure


Rectovaginal fascia is sutured in the midline
Sutured the posterior vaginal wall sagitally
Operation done.

Final Diagnosis
P3A2, 57 years old, second degree uterine prolapse and third degree cystocele, with uncontrolled
hypertension grade 1, spondylitis tuberculosis

16

CHAPTER II
CASE ANALYSIS

Compariso

Case

n
Diagnostic
Approach

Theory (Prolapsus

Commentary

uteri)

Anamnesis:
-Feeling a lump in the
vagina
-The lump protruding out

Evaluation patient

with prolapsus uteri : are 2 groups of


Symptoms :

especially when urinating,


walking and lifting heavy

- can be

weight and resolves while

asymptomatic

resting, pain (-)


-Polymiction (+)
-Urgency (+)
-unsatisfied urinating (+)
Physical examination :
BP : 140/90mmHg, HR : 88
x/min RR:20 x/min Temp :
36.7 C
COR : heart sound 1 and 2
irregular , murmur -, gallop
Gynecolog Examination :
1. Perineal

- buldge symptoms
- urinary symptoms

prolapse
- Widen genital hiatus with
increase intra-abdominal

symptoms that we can


find from anamnesis :
- Bulge symptoms
- urinary symptoms
Patients denied any
other symptoms

- Gastrointerstinal
symptoms
- Female sexual

Physical examination :

dysfunction

- Hypertension grade 1

- pelvic and back

- Irregular heart sound

pain

examination
- Protusion come beyond
the hymen
- Anterior wall vagina

From this patient, there

Gynecolog examination
Physical

shows that there are

examination should

uteri and anterior

be normal

vaginal wall Descent

pressure
2. Vaginal

halfway past the hymen


Gynecolog

Examination
POP-Q examination
-genital hiatus 5cm
-perineal body 3cm
Speculum examination
- Valsava maneuver :

examination :

prolapse descent
- Descent of the apex (+)
- Anterior vaginal wall :

- Inspection : no

cystocele (+)
-Posterior vaginal

lesion or any

1. Perineal
examination

vaginal atrophy,
abnormalities

wall :rectocele (-),


enterocele (-)
3. Bimanual

- Neurologic
examination
decrease the reflex

Examination :
oxford grade 3,

-Inspeculo

muscle symmetry

examination

(+)

examine the
anatomical
2. Vaginal
examination
- POP-Q
examination
genital hiatus open
widely
- Speculum
examination
prolapse descent
while valsava,

examine the vaginal


wall

3. Bimanual
examination
examine
the pelvic
floor
musculature
Risk factors

- 57 years old, has already

Risk factors for

Risk factors for

menopause

prolapsus uteri are

prolapsus uteri

multiparity, vaginal

identified in this case

delivery, race, age,

are age, multiparity,

connective tissue

vaginal delivery, and

disorder, increase

increase abdominal

abdominal pressure

pressure

Anterior

Anterior collporhaphy
for manage the

collporrhaphy
Hysterectomy
transvaginal

hysterectomy

- Multiparity (P3A2 vagianl


delivery)
-Increase abdominal pressure
[chronic cough, constipation,
overweight]

Management Hysterectomy transvaginal

cystocele and
transvaginal for
manage the uterine
prolapse

CHAPTER III
LITERATURE REVIEW
Pelvic Organ Prolapse

3.1.

Definition
Pelvic organ prolapse (POP) is a global health problem, affecting adult women of all

ages. It decreases their quality of life considerably. POP is one of the most common reasons for
gynaecological surgery in women after the fertile period. The failure rate is relatively high, an
estimated 30% of women require re-operation.1
Pelvic organ prolapse is a condition of specific signs and symptoms that lead to
impairment of normal function and diminished quality of life. Signs include descent of one or
more of the following: the anterior vaginal wall, posterior vaginal wall, uterus and cervix, the
apex of the vagina after hysterectomy, or the perineum Symptoms include vaginal bulging,
pelvic pressure, and splinting or digitation. Splinting is manual bolstering of the prolapse to
improve symptoms, whereas digitation aids stool evacuation. 3
3.2.Epidemiology
Pelvic organ prolapse (POP) is a health concern affecting millions of women worldwide. The
prevalence of POP varies widely across studies, depending on the population studied and entry
criteria. Women of all ages may be affected, although it is more common in older women. 3,4
In the Women's Health Initiative study, investigators found a 41.1 percent prevalence of
pelvic organ prolapse at a standard physical assessment in postmenopausal women older than 60
years who had not had a hysterectomy. 4
In the United States, it is the third most common indication for hysterectomy. Moreover, a
woman has an estimated lifetime risk of 11 percent to undergo surgery for prolapse or
incontinence. 3

3.3.Support Of Uterus

The uterus is normally placed in anteverted and anteflexed position. It lies in between the
bladder and rectum. The cervix pierces the anterior vaginal wall almost at right angle to the axis
of the vagina.
The uterus is held in this position and at this level by supports conveniently grouped
under three tier systems. The objective is to maintain the position and to prevent descent of the
uterus through the natural urogenital hiatus in the pelvic floor
1. Upper tier
The responsible structure are endopelvic fascia covering the uterus and round ligament,
broad ligaments with intervening pelvic cellular tissues. The last two are actually acting as a guy
rope with a steadying effect on the uterus. They have no action in preventing descent of the
uterus.
2. Middle tier
This constitutes the strongest support of the uterus. The responsible structure are
Pericervical ring
It is a collar of fibroelastic connective tissue encircling the supravaginal cervix. It is

connected with the pubocervical ligaments and the vesicovaginal septum anteriorly,
cardinal ligaments laterally and the uterosacral ligaments and the rectovaginal septum
posteriorly. Function: It stabilizes the cervix at the level of interspinous diameter along
with the other ligaments.
Pelvic cellular tissues
The endopelvic fascia consist of connective tissues and smooth muscles. The blood
vessels and nerves supplying the uterus, bladder, and vagina pass through it from the
lateral pelvic wall. As they pass, the pelvic cellular tissues condense surrounding them
and give good direct support to the viscera.
The endopelvic fascia at places is condensed and reinforced by plain muscles to form
ligaments : Mackenrodts, uterosacral, and pubocervical. On the medial side, these are attached
to the pericervical ring covering the cervicovaginal junction and on the other end are attached to
the lateral, posterior, and anterior walls of the pelvis. These are anatomically, morphologically,
and functionally the same unit. This hammock-like arrangement of condensed pelvic cellular
tissues is the cardinal support of the uterus.
3. Inferior tier
This gives the indirect support to the uterus. The support is principally given by the
pelvic floor muscles (levator ani), endopelvic fascia, levator plate, perineal body, and the
urogenital diaphragm 6

3.4.Support of Vagina

1. Support of the Anterior Vaginal Wall

Positional support.
In the erect posture, the vagina makes an angle of 45 to the horizontal. Normal
vaginal axis is horizontal in the upper two-third and vertical in the lower-third . A wellsupported vagina lies on the rectum and the levator plate . Any raised intra-abdominal
pressure is transmitted exclusively to the anterior vaginal wall which is apposed to the
posterior vaginal wall.

Pelvic cellular tissue


The vagina is ensheated by strong condensation of pelvic cellular tissue called
endopelvic fascia.

Traced below, this fascia forms the posterior urethral ligament, which is anchored to the
pubic bones giving strong support to the urethra. Traced laterally, this fascia form the
pubocervical fascia or ligament which is the anterior extension of the Mackenrodts ligaments.
2. Support of the Posterior Vaginal Wall
These parts are include Endopelvic fascial sheath covering the vagina and rectum and
attachment of the uterosacral ligament to the lateral wall of the vault. The levator ani muscles
with its fascial coverings. This muscle is slug like a hammock around the midline pelvic
effluents (urethra, vagina, and the anal canal). This strong, robust, and fatigue-resistant striated
muscle guards the hiatus urogenitalis. It supports the pelvic viscera and counteracts the
downward thrust of increased intra-abdominal pressure. The medial fibers of the pubococcygeus
part of levator ani muscles, are attached mainly to the urethra, vagina and rectum. Few fibrous
pass behind the rectum, vagina, and the urethra forming a sling. These pubovisceral fibers of the
levator ani muscles squeeze the rectum, vagina, and urethra and keep them closed by
compressing against the pubic bone. 6
When the levator ani muscles are damaged, the pelvic floor opens and there is widening
of the hiatus urogenitalis. The vagina is then pushed down by the increased intra-abdominal
pressure. Eventually, the genital organs prolapse. 5
3.5.Risk Factors

The aetiology of pelvic organ prolapse is multifactorial. The pelvic organ support study
found age to be a risk factor for pelvic organ prolapse risk doubled with each decade of life.
Increasing parity was also associated with increasing severity of prolapse. Of the 17000
women in the Oxford family planning study, those with a history of two vaginal deliveries were
8.4 times more likely to have surgery for prolapse than those with no such history. 2

Figure 1. Risk Factors2

Obstetric Related Risks


1. Multiparity
Vaginal childbirth is the most frequently cited risk factor. Although there is some evidence
that pregnancy itself predisposes to pelvic organ prolapse. In the Reproductive Risks for
Incontinence Study at Kaiser (RRISK) study, Rortveit and colleagues (2007) found that the risk
of prolapse increased significantly in woman with one vaginal delivery. Other obstetric related
risks are macrosomia, prolonged second-stage labor, episiotomy, anal sphincter laceration,
epidural analgesia, forceps use, and oxytocin stimulation of labor. 3
2. Elective Cesarean Delivery
Controversy has arisen over the topic of elective cesarean delivery to prevent pelvic floor
disorders such as pelvic organ prolapse and urinary incontinence. Theoretically, if all women

underwent cesarean delivery, there would be fewer women with pelvic floor disorders. But most
women do not develop pelvic floor disorders, elective cesarean delivery would subject many
women to a potentially dangerous intervention who would otherwise not develop the problem. At
this point in time, recommendations regarding elective cesarean delivery to prevent pelvic floor
disorders must be individualized. 3
3. Age
In women aged 20 to 59 years, the incidence of POP roughly doubled with each decade. As
with other risks for POP, aging is a complex process. The increased incidence may result from
physiologic aging and degenerative processes as well as hypoestrogenism. Clinical and basic
investigations clearly demonstrate an important role for reproductive hormones in the
maintenance of connective tissues and the extracellular matrix necessary for pelvic organ
support. Estrogen and progesterone receptors have been identified in the nuclei of connective
tissue and smooth muscle cells of both the levator ani stroma and uterosacral ligaments.

4. Connective Tissue Disorder


The vaginal wall is composed of four layers: a superficial layer of stratified squamous
epithelium, a subepithelial dense connective tissue layer, composed primarily of collagen and
elastin, a layer of smooth muscle referred to as the muscularis and an adventitia, which is
composed of loose connective tissue. The vaginal subepithelium and muscularis together form a
fibromuscular layer beneath the vaginal epithelium, providing longitudinal and central support.
The connective tissue underlying the vagina contains relatively few cells. Beside fat cells and
mast cells, mainly fibroblasts are found, producing components of the extracellular matrix
(ECM). The ECM contains fibrillar components (collagen and elastin) embedded in a nonfibrillar ground substance. This ground substance consists of non-collagenous glycoproteins,
proteoglycans and hyaluronan. In addition, with the exception of the arcus tendineus fasciae
pelvis, these tissues contain a significant amount of smooth muscle cells . The fibrillar
component is thought to contribute the most to the biomechanical behaviour of these tissues. The
quantity and quality of collagen and elastin are regulated through a precise equilibrium between
synthesis, maturation and degradation. This process results in a dynamic process of constant
remodelling.1 Women with connective tissue disorders may be more likely to develop POP. This

relative decrease in well organized dense collagen is believed to contribute to weakening of


vaginal wall tensile strength and an increased susceptibility to vaginal wall prolapse. 3
5. Race
Racial differences in POP prevalence have been demonstrated in several studies. Black and
Asian women show the lowest risk, whereas Hispanic and white women appear to have the
highest risk. Although differences in collagen content have been demonstrated between races,
racial differences in the bony pelvis may also play a role. For instance, black women more
commonly have a narrow pubic arch and an android or anthropoid pelvis. These shapes are
protective against POP compared with the gynecoid pelvis typical of most white women. 3
6. Increased Abdominal Pressure
Chronically elevated intraabdominal pressure is believed to play a role in POP pathogenesis.
This condition is present with obesity, chronic constipation, chronic coughing, and repetitive
heavy lifting. Higher body mass index (BMI) has been associated with POP.3 Women who are
overweight (body mass index 25-30) or obese (>30) are at high risk of developing prolapse.2
3.6. Description and Classification
Visual Descriptors
Pelvic organ prolapse is descent of the anterior vaginal wall, posterior vaginal wall,
uterus (cervix), the apex of the vagina after hysterectomy, or the perineum, alone or in
combination. The terms cystocele, cystourethrocele, uterine prolapse, uterine procidentia,
rectocele, and enterocele have traditionally been used to describe the structures behind the
vaginal wall thought to be prolapsed 3

Pelvic Organ Prolapse Quantification (POP-Q)

In 1996, the International Continence Society defined a system of Pelvic Organ Prolapse
Quantification (POP-Q). This system contains a series of site specific measurements of a
womans pelvic organ support. Prolapse in each segment is measured relative to the hymen,
which is a anatomic landmark that can be identified consistently. Six points are located with
reference to the plane of the hymen: two on the anterior vaginal wall (points Aa and Ba), two in
the apical vagina (points C and D), and two on the posterior vaginal wall (points Ap and Bp) The
genital hiatus (Gh), perineal body (Pb), and total vaginal length (TVL) are also measured. All
POP-Q points, except TVL, are measured during patient Valsalva and should reflect maximum
protrusion. 3

The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support
Stage 0

No prolapse is demonstrated. Points Aa, Ap, Ba and Bp are all at -3 cm, and either
point C or D is between -TVL (total vaginal length) cm and - (TVL-2) cm (i.e., the
quantitation value for point C or D is -[TVL-2] cm).

Stage I

The criteria for stage 0 are not met, but the most distal portion of the prolapse is
>1cm above the level of the hymen (i.e., its quantitation value is <-1 cm)

Stage II

The most distal portion of the prolapse is 1 cm proximal to or distal to the plane of
the hymen (i.e., its quantitation value is -1 cm but +1 cm)

Stage III

The most distal portion of the prolapse is >1 cm below the plane of the hymen but
protrudes no further than 2 cm less than the total vaginal length in centimeters (i.e.,
its quantitation value is >+1 cm but < + [TVL-2] cm).

Stage IV

Essentially, complete eversion of the total length of the lower genital tract is
demonstrated. The distal portion of the prolapse proturdes to at least (TVL-2) cm
(i.e., its quantitation value is +[TVL-2] cm). In most instances, the leading edge of

stage IV prolapse will be the cervix or vaginal cuff sac.

Baden Walker Halfway System


This descriptive tool is also used to classify prolapse during phys- ical examination and is in
widespread clinical use. Although not as informative as the POP-Q, it is adequate for clinical use

if each compartment (anterior, apical, and posterior) is evaluated. 3

Table 24-3. Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse During
Physical Examination
Grade
Normal position for each respective site

Grade 1

Descent halfway to the hymen

Grade 2

Descent to the hymen

Grade 3

Descent halfway past the hymen

Grade 4

Maximum possible descent for each site

3.7.

Grade 0

Pathophysiology
Pelvic organ support is maintained by complex interactions among the pelvic floor muscles,
pelvic floor connective tissue, and vaginal wall. These work in concert to provide support and
also maintain normal physiologic function of the vagina, urethra, bladder, and rectum. Several
factors are believed to be involved in pelvic organ support failure. These include genetic
predisposition, loss of pelvic floor striated muscle support, vaginal wall weakness, and loss of
connective attachments between the vaginal wall and the pelvic floor muscles and pelvic viscera.
Although multiple mechanisms have been hypothesized as contributors to the development of
prolapse, none fully explain the origin and natural history of this process.
1. Change to the levator ani muscle
It is widely believed that the levator ani muscles sustain either direct muscle or denervation
injury during childbirth and that these injuries are involved in the pathogenesis of pelvic organ

prolapse. It is hypothesized that during second-stage labor, nerve injury from stretch or
compression or both leads to partial denervation of the levator ani. Denervated muscle loses tone
and the genital hiatus opens, thereby leading to pelvic viscera prolapse. Loss of skeletal muscle
volume and function occurs in virtually all striated muscles during aging. Results obtained from
young and older women with pelvic organ prolapse indicate that the levator ani muscle
undergoes substantial morphologic and biochemical changes during aging. Thus, loss of levator
tone with age may contribute to pelvic organ support failure in older women, possibly those with
pre- existing defects in connective tissue support. As striated muscles lose tone, ligamentous and
connective tissue support of the pelvic organs must sustain more forces conferred by abdominal
pressure. As connective tissues bear these loads for long periods, they stretch and may eventually
fail, resulting in prolapse.
2. Role of connective tissue
Connective tissues and ligaments surrounds the pelvic organs and attaches them to the levator
ani muscle and bony pelvis. The connective tissue of the pelvis is comprised of collagen, elastin,
smooth muscle, and microfibers, which are anchored in an extracellular matrix of
polysaccharides. The connective tissue that invests the pelvic viscera provides substantial pelvic
organ support.
The arcus tendineus fascia pelvis is a condensation of the parietal fascia covering the medial
aspects of the obturator internus and levator ani muscles. It provides the lateral and apical anchor
sites for the anterior and posterior vagina. The arcus tendineus fascia pelvis is therefore poised to
withstand descent of the anterior vaginal wall, vaginal apex, and proximal urethra. Loss of
connective tissue support at the vaginal apex leading to stretching or tearing of the arcus
tendineus fascia pelvis. The result is apical and anterior vaginal wall prolapse.
The uterosacral ligaments contribute to apical support by suspending and stabilizing the
uterus, cervix, and upper vagina. The ligament is comprised of approximately 20 percent smooth
muscle. Abnormalities in uterosacral ligament support of the pelvic organs contribute to the
development of prolapse.
The fascia and connective tissues of the pelvic floor may also lose strength consequent to
aging and loss of neuroendocrine signaling in pelvic tissues. Estrogen deficiency can affect the

biomedical composition, quality, and quantity of collagen. Estrogen influences collagen content
by increasing synthesis or decreasing degradation. Exogenous estrogen supplementation has
been found to increase the skin collagen content in postmenopausal women who are estrogen
deficient 3

Figure 2. Connective Tissues and Ligaments2

3. Role of vaginal wall


The vaginal wall is comprised of mucosa (epithelium and lamina propria), a fibroelastic
muscularis layer, and an adventitial layer that is composed of loose areolar tissue, abundant
elastic fibers, and neurovascular bundles. The muscularis and adventitial layers together form the
fibro muscular layer, which was previously referred to as endopelvic fascia. The fibromuscular
layer coalesces laterally and attaches to the arcus tendineus fascia pelvis and superior fascia of

the levator ani muscle. In the lower third of the vagina, the vaginal wall is attached directly to the
perineal membrane and the perineal body. This suspensory system, together with the uterosacral
ligaments, prevents the vagina and uterus from descent when the genital hiatus is open.
Abnormalities in the anatomy, physiology, and cellular biology of vaginal wall smooth muscle
may contribute to POP. Specifically, in fibromuscular tissue taken at the vaginal apex from both
the anterior and posterior vaginal walls, vaginal prolapse is associated with loss of smooth
muscle, myofibroblast activation, abnormal smooth muscle phenotype, and increased protease
activity.
4. The defect theory of pelvic organ prolapse
This theory states that tears in different sites of the endopelvic fascia surrounding the vaginal
wall allow herniation of the pelvic organs. The association of POP with vaginal delivery is
consistent with this theory. An attenuation of the vaginal wall without loss of fascial attachments
called distension cystocele or rectocele. In contrast, anterior and posterior wall defects due to
loss of the connective tissue attachment of the lateral vaginal wall to the pelvic side wall are
described as displacement (para- vaginal) cystocele or rectocele. With distension- type prolapse,
the vaginal wall appears smooth and without rugae, due to attenuation. With displacement-type
prolapse, vaginal rugae are visible. Both defect types could result from the stretching or tearing
of support tissues during second-stage labor.
5. Level of Vaginal support
Level I support suspends the upper or proximal vagina. Level II support attaches the
midvagina along its length to the arcus tendineus fascia pelvis. Level III support results from
fusion of the distal vagina to adjacent structures. Defects in each level of support result in
identifiable vaginal wall prolapse: apical, anterior, and posterior. 3
3.8. Evaluation of the Patient with Pelvic Organ Prolapse
Symptoms Associated with pelvic Organ Prolapse
There are some symptoms that appear in women with organs prolapse such as bulge
symptoms, urinary symptom, female sexual dysfunction, pelvic and back pain, or even
asymptomatic. In bulge symptoms, women may comment on feeling a ball in the vagina, sitting

on a weight, or noting a bulge rubbing against their clothes. These symptoms worsen with
prolapse progression. Patients with POP often have concurrent urinary symptoms. These may
include stress urinary incontinence (SUI), urge urinary incontinence, frequency, urgency, urinary
retention, recurrent urinary tract infection, or voiding dysfunction.
Female sexual dysfunction is present in women with dyspareunia, low libido, problems
with arousal, and inability to achieve orgasm. The etiology is frequently multifactorial and
includes psychosocial factors, urogenital atrophy, aging, and male sexual dysfunction. Sexual
dysfunction was worse in women with symptomatic prolapse versus those with asymptomatic
prolapse.
During symptom inventory, several tools may be useful in assessing severity. Two
commonly used questionnaires are the Pelvic Floor Distress Inventory (PFDI) and the Pelvic
Floor Impact Questionnaire (PFIQ)

Physical Examination
Initial pelvic examination is performed with a woman in lithotomy position. The vulva and
perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalities. A
neurologic examination of sacral reflexes is performed using a cotton swab. First, the
bulbocavernosus reflex is elicited by tapping or stroking lateral to the clitoris and observing
contraction of the bulbocavernosus muscle bilaterally. Secondly, evaluation of anal sphincter
innervation is completed by stroking lateral to the anus and observing a reflexive contraction of
the anus, known as the anal wink reflex. Intact reflexes suggest normal sacral pathways.
Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver
prior to placing a speculum in the vagina. Patients who are unable to adequately complete a
Valsalva maneuver are asked to cough. With speculum examination, structures are artificially
lifted, supported, or displaced. Importantly, this assessment helps answer three questions: (1)
Does the protrusion come beyond the hymen? (2) What is the presenting part of the prolapse
(anterior, posterior, or apical)? (3) Does the geni- tal hiatus significantly widen with increased
intraabdominal pressure?

For vaginal examination, if the POP-Q examination is performed, the genital hiatus (Gh) and
perineal body (Pb) are measured during Valsalva maneuver The total vaginal length (TVL) is
then measured by placing a marked ring forceps, or a ruler, at the vaginal apex and noting the
distance to the hymen. A bivalve speculum is then inserted to the vaginal apex. It displaces the
anterior and posterior vaginal walls, and points C and D are then measured with Valsalva. The
speculum is slowly withdrawn to assess descent of the apex.
A split speculum is then used to displace the posterior vaginal wall and allow for
visualization of the anterior wall and measurement of points Aa and Ba. Attempts are made to
characterize the nature of the anterior vaginal wall defect. Sagging lateral vaginal sulci with
vaginal rugae still present suggest a paravaginal defect, that is, a lateral loss of support. A central
bulge and loss of vaginal rugae is called a midline or central defect. If loss of support appears to
arise from detachment of the anterior vaginal walls apical segment from the apex, it is termed a
transverse or anterior apical defect
The split speculum is then rotated 180 degrees to displace the anterior wall and allow
examination of the posterior wall. Points Ap and Bp are measured. If the posterior vaginal wall
descends, attempts are made to determine if rec- tocele or enterocele is present. Enterocele can
only definitively be diagnosed by observing small bowel peristalsis behind the vaginal wall. In
general, bulges at the apical segment of the posterior vaginal wall should implicate enteroceles,
whereas bulges in the distal posterior wall are presumed to be rectoceles. Further distinction may
be found during standing rectovaginal examination. A clinicians index finger is placed in the
rectum and thumb on the posterior vaginal wall. Small bowel may be palpated between the
rectum and vagina, confirming enterocele. 3
3.9.Approach to Treatment
Treatment for woman who have POP depends on the type and severity of symptoms, age
and medical comorbidities, desire for future sexual function and/or fertility, and risk factors for
recurrence. Often a combination of nonsurgical and surgical approaches may be selected. An
evidence-based appraisal of each options success rate should be included. In the simplest case, a
patient with prolapse of the vaginal apex beyond the hymen, whose only symptom is bulge or
pelvic pressure, could be offered pessary or surgical treatment. In a more complicated case, a

woman with prolapse beyond the hymenal ring may note a bulge, constipation, urge urinary
incontinence, and pelvic pain.
3.9.1. Non Surgical Treatment
Pessary
Pessaries are the standard nonsurgical treatment for POP. Pessaries are usually
made of silicone or inert plastic, and they are safe and simple to manage. The most
common indications for use pessaries is pelvic organ prolapse. Traditionally, pessaries
have been reserved for women either unfit or unwilling to undergo surgery. Women who
have undergone at least one previous attempt at surgical management without relief may
often choose a pessary over additional surgery. Pessaries may also help some women with
prolapse and associated incontinence. One multicenter randomized crossover trial
compared two pessary types for relief of prolapse symptoms and urinary complaints.
Pessaries may also be used diagnostically. A pessary may also be placed diagnostically to
identify which women are at risk for urinary incontinence after prolapse-correcting
surgery (Chaikin, 2000; Liang, 2004).
The types of pessaries are divided into two broad categories: support and spacefilling pessaries. Support pessaries, such as the ring pessary,the lever pessaries include
the Smith, Hodge, Risser, and Gehrung, Incontinence ring, and Mar-land, use a spring
mechanism that rests in the posterior fornix and against the posterior aspect of the
symphysis pubis. Vaginal support results from elevation of the superior vagina by the
spring, which is supported by the symphysis pubis. Ring pessaries may be constructed as
a simple circular ring or as a ring with support that looks like a large contraceptive
diaphragm. These are effective in women with first and second degree prolapse. Also, the
support rings diaphragm is especially useful in women with accompanying anterior
vaginal wall prolapse. When properly fitted, the device should lie behind the pubic
symphysis anteriorly and behind the cervix posteriorly. In contrast, space-filling pessaries
maintain their position by creating suction between the pessary and vaginal walls (cube),
by creating a diameter larger than the genital hiatus (donut), or by both mechanisms
(Gellhorn). The Gellhorn is often used for moderate to severe prolapse and for complete
procidentia. It contains a concave disc that fits against the cervix or vaginal cuff and has a

stem that is positioned just cephalad to the introitus. The concave disc supports the
vaginal apex by creating suction, and the stem is useful for device removal. Of all
pessaries, the two most commonly used and studied devices are the ring and Gellhorn
pessaries.

A patient must be an active participant in the treatment decision to use a pessary.


Its success will depend upon her ability to care for the pessaryeither alone or with the
assistance of a caretakerand her willingness and availability to come for subsequent
evaluations. Vaginal atrophy should be treated before or concomitantly with pessary
initiation. The type of device selected may be affected by patient factors such as
hormonal status, sexual activity, prior hysterectomy, and stage and site of POP. After a
pessary is selected, a woman should be fitted with the largest size that can be comfortably
worn. If a pessary is ideally fitted, a patient is not aware of its presence. As a woman ages
and gains or loses weight, alternate sizes may be required. Generally, a patient is fitted
with a pessary while in the lithotomy position after she has emptied both her bladder and
rectum. A digital examination is performed to assess vaginal length and width, and an
initial estimation of pessary size is made.

For ring pessary placement, the device is held in the clinicians dominant hand in
a folded position. Lubricant is placed on either the vaginal introitus or the pessarys
leading edge. While holding the labia apart, the pessary is inserted by pushing in an
inferior, cephalad direction against the posterior vaginal wall. Next, an index finger is
directed into the posterior vaginal fornix to ensure that the cervix is resting above the
pessary. The clinicians finger should barely slide between the lateral edges of the ring
pessary and the vaginal sidewall. The pessary should fit snuggly but not tightly against
the symphysis pubis and the posterior and lateral vaginal walls. Too much pressure may
increase the risk for pain. Following pessary placement, a woman is prompted to perform
a Valsalva maneuver, which might dislodge an improperly fitted pessary. She should be
able to stand, walk, cough, and urinate without difficulty or discomfort. Instruction on
removal and placement should then follow. For removal of a ring pessary, an index finger
is inserted into the vagina to hook the rings leading edge. Traction is applied along the
vaginal axis to bring the ring toward the introitus.
Here, it may be grasped by the thumb and index finger and removed. Ideally, a
pessary is removed nightly to weekly, washed in soap and water, and replaced the next
morning. Women are sent home from their initial fitting session with instructions
describing the management of commonly encountered problems (Table 24-7). After
initial placement, a return visit may follow in 1 to 2 weeks. For patients comfortable with
their pessary management, return visits may be semiannual. For those unable or unwilling
to remove and replace a device themselves, a pessary may be removed and the patients
vagina inspected at the providers office every 2 or 3 months. Delaying visits longer than
this may lead to problematic discharge and odor.

Serious complications such as erosion into adjacent organs are rare with proper
use and usually result only after years of neglect. At each return visit, the pessary is
removed, and the vagina is inspected for erosions, abrasions, ulcerations, or granulation
tissue (Fig. 24-20). Vaginal bleeding is usually an early sign and should not be ignored.
Pessary ulcers or abrasions are treated by changing the pessary type or size to alleviate
pressure points or by removing the pessary completely until healing occurs. Prolapse
ulcers have the same appearance as pessary ulcers, however, the former result from the
prolapsed bulge rubbing against patient clothing. Alternatively, water-based lubricants
applied to the pessary may help prevent these complications. All pessaries tend to trap
vaginal secretions and obstruct normal drainage to some degree. The resultant odor may
be managed by encouraging more frequent night time device removal, washing, and
reinsertion the next day.

Pelvic Floor Muscle Exercise


These exercises have been suggested as a therapy that might limit progression and
alleviate prolapse symptoms, also known as Kegel exercises. There are two hypotheses
that describe the benefits of pelvic floor muscle exercise for prolapse prevention and
treatment (B, 2004). From these exercises, women learn to consciously contract muscles
before and during increases in abdominal pressure. This prevents organ descent.
Alternatively, regular muscle strength training builds permanent muscle volume and
structural support. However, pelvic floor exercise has minimal risk and low cost. For this
reason, it may be offered to asymptomatic or mildly symptomatic women who are
interested in prevention of progression and who decline other treatments.

3.9.2. Surgical Treatment


For pelvic organ prolapse, there are two choices of surgeries. The two approaches to
prolapse surgery are obliterative and reconstructive.

Obliterative Procedures
Obliterative approaches include Lefort colpocleisis and complete. These
procedures involve removing vaginal epithelium, suturing anterior and posterior vaginal
walls together, obliterating the vaginal vault, and effectively closing the vagina.
Obliterative procedures are only appropriate for elderly or medically compromised
patients who have no future desire for coital activity. Obliterative procedures are
technically easier, require less operative time, and offer superior success rates compared
with reconstructive procedures. Latent stress urinary incontinence can be unmasked with
colpocleisis due to downward traction on the urethra.

Reconstructive Procedures
These surgeries attempt to restore normal pelvic anatomy and are more commonly
performed for POP than obliterative procedures. Vaginal, abdominal, laparoscopic, and
robotic approaches may be used, and selection is individualized. The decision to proceed
with a vaginal, abdominal, or minimally invasive approach depends on multiple factors
including the patients unique characteristics and surgeons expertise. An abdominal
approach appears to have advantages in certain instances (Benson, 1996; Maher,
2004a,b). These include women with prior failure of a vaginal approach, those with a
shortened vagina, or those believed to be at higher risk for recurrence, such as young
women with severe prolapse. In contrast, a vaginal approach typically offers shorter
operative time and a quicker return to daily activities.
Laparoscopic and robotic approaches to prolapse repair are becoming more
common. Procedures include sacrocolpopexy, uterosacral ligament vaginal vault
suspension, paravaginal repair, and rectocele repair. However, surgeons with
advanced laparoscopic skills who can perform the same operation laparoscopically
should have equivalent results.
If apical or uterine prolapse is present, hysterectomy will more readily allow
the vaginal apex to be resuspended with the previously described apical suspension
procedures. If hysterectomy is not performed in the context of apical prolapse, these
procedures must be modified or specific uterine suspension procedures performed.

Alternatively, if apical or cervical prolapse is not present, hysterectomy need not be


incorporated into prolapse repair.
a. Anterior Compartment
Historically, anterior colporrhaphy has been the most common operation, yet
long-term anatomic success rates are poor. In a randomized trial of three anterior
colporrhaphy techniques (traditional midline plication, ultralateral repair, and
traditional plication plus lateral reinforcement with synthetic mesh), Weber and
associates (2001b) found a low rate of anatomic success. The poor rates of anatomic
success with traditional anterior colporrhaphy have prompted reevaluation of repair
concepts and development of other procedures. Despite these limitations, if a central
or midline defect is suspected, anterior colporrhaphy may be performed. Mesh or
biomaterial may also be used in conjunction with anterior colporrhaphy or by itself. Mesh
is used to reinforce the vaginal wall and is sutured in place laterally. Recent studies show
improved anatomic success when mesh is used for anterior wall repair, there are
significant risks. These include mesh erosion, pain, and dyspareunia. In many cases,
anterior vaginal wall prolapse results from fibromuscular defects at the anterior apical
segment or transverse detachment of the anterior apical segment from the vaginal apex. In
these situations, an apical suspension procedure such as an abdominal sacrocolpopexy or
uterosacral ligament vaginal vault suspension will resuspend the anterior vaginal wall to
the apex and reduce anterior wall prolapse. With these procedures, continuity is also
reestablished between the anterior and posterior vaginal fibromuscular layers to prevent
enterocele formation. Alternatively, if a lateral defect is suspected, paravaginal repair can
be performed through a vaginal, abdominal, or laparoscopic route. Paravaginal repair is
performed by reattaching the fibromuscular layer of the vaginal wall to the arcus
tendineus fascia pelvis.
b. Vaginal Apex
There is a growing appreciation that support of the vaginal apex provides the
cornerstone for a successful prolapse repair. Some experts believe that isolated
surgical repair of the anterior and posterior walls is doomed for failure if the apex is
not adequately supported (Brubaker, 2005a). The vaginal apex can be resuspended
with a number of procedures including abdominal sacrocolpopexy, sacrospinous
ligament fixation, or uterosacral ligament vaginal vault suspension.

Abdominal Sacrocolpopexy.
This surgery suspends the vaginal vault to the sacrum using synthetic
mesh. Advantages include the procedures durability over time and conservation
of normal vaginal anatomy. This procedure may be used primarily or as a second
surgery for women with recurrences after failure of other prolapse repairs.
Sacrocolpopexy may be performed as an abdominal, laparoscopic, or robotic
procedure. When hysterectomy is performed in conjunction with sacrocolpopexy,
consideration should be given to performing a supracervical rather than a total
abdominal hysterectomy. With the cervix left in situ, the risk of postoperative
mesh erosion at the vaginal apex is believed to be diminished. This results from a
lack of exposure of the mesh to vaginal bacteria that occurs when the vagina is

opened with total abdominal hysterectomy.


Sacrospinous Ligament Fixation.
This is one of the most popular procedures for apical suspension. The
vaginal apex is suspended to the sacrospinous ligament unilaterally or bilaterally
using a vaginal extraperitoneal approach. After sacrospinous ligament fixation
(SSLF), recurrent apical prolapse is uncommon. Complications associated with
SSLF include buttock pain from nerve involvement with supporting ligatures in 3
percent of patients and vascular injury in 1 percent (Sze, 1997a,b). Although
infrequent, significant and life-threatening hemorrhage can follow injury to blood

vessels located behind the sacrospinous ligament


Uterosacral Ligament Vaginal Vault Suspension.
With this procedure, the vaginal apex is attached to remnants of the
uterosacral ligament at the level of the ischial spines or higher. Performed
vaginally or abdominally, the uterosacral ligament vaginal vault suspension is
believed to replace the vaginal apex to a more anatomic position than SSLF,

which deflects the vagina posteriorly (Barber,2000; Maher, 2004b; Shull, 2000).
c. Posterior Compartment
Enterocele Repair.
Posterior vaginal wall prolapse may be due to enterocele or rectocele.
Enterocele is defined as herniation of the small bowel through the vaginal
fibromuscular layer, usually at the vaginal apex. Discontinuity of the anterior and
posterior vaginal wall fibromuscular layers allows for this herniation.
Accordingly, enterocele repairs have as their goal reattachment of these

fibromuscular layers. If posterior wall prolapse is due to enterocele, repair of this

defect should reduce the posterior wall prolapse.


Rectocele Repair.
Posterior vaginal wall prolapse due to rectocele is repaired with one of
several techniques. Traditional posterior colporrhaphy aims to rebuild the
fibromuscular layer between the rectum and vagina by performing a midline
fibromuscular plication. To narrow the genital hiatus and prevent recurrence,
some surgeons plicate the levator ani muscles concurrently with posterior repair.
However, this practice may contribute to dyspareunia. Thus, it is best avoided in

women who are sexually active.


Site-Specific Posterior Repair.
This repair is based on the assumption that specific tears exist in the
fibromuscular layer, which can be identified and repaired in a discrete fashion.
Defects may be midline, lateral, distal, or superior (Fig. 24-21). This approach is
conceptually analogous to a fascial hernia, in which the fascial tear is identified
and repaired. Thus, its theoretical advantage lies in its restoration of normal

anatomy rather than plication of tissue in the midline.


Mesh Reinforcement.
In an effort to reduce prolapse recurrence, graft augmentation with
allograft, xenograft, or synthetic mesh has been used in conjunction with posterior
colporrhaphy and site-specific repair. Generally, the graft is placed after
colporrhaphy or site-specific repair is completed. Moreover, in situations in which
the fibromuscular layer cannot be identified to perform a midline plication or sitespecific repair, graft augmentation may be the only surgical option. Mesh is
sutured in place laterally with a minimum number of sutures. If technically
possible, the graft is attached to the vaginal apex and the uterosacral ligament.

Distally, the graft is attached to the perineal body.


Sacrocolpoperineopexy.
This modification of sacrocolpopexy may be selected for correction of
posterior vaginal wall descent when an abdominal approach is employed for other
prolapse procedures or if treatment of perineal descent is necessary (Cundiff ,
1997; Lyons, 1997; Sullivan, 2001; Visco, 2001). With this procedure, the
posterior sacrocolpopexy mesh is extended down the posterior vaginal wall to the

perineal body. In several case series, anatomic cure rates were greater than 75
percent.

d. Perineum
The perineum provides distal support to the posterior vaginal wall and anterior
rectal wall and anchors these structures to the pelvic floor. A disrupted perineal body will
allow descent of the distal vagina and rectum and will contribute to a widened levator
hiatus. Perineorrhaphy is often done in conjunction with posterior colporrhaphy to
recreate normal anatomy. During surgery, the perineum is rebuilt through midline
plication of the perineal muscles and connective tissue. Importantly, overly aggressive
plication can narrow the introitus, create a posterior vaginal wall ridge, and lead to entry
dyspareunia. However, in a woman who is not sexually active, high perineorrhaphy with
intentional introital narrowing is believed to decrease the risk of posterior wall prolapse
recurrence.
e. The Use of Mesh and Materials in Reconstructive Pelvic Surgery
Synthetic mesh for sacrocolpopexy and midurethral slings has been widely
studied and is safe and eff ective. Mesh erosion occurs in a small percentage of cases but
can be managed with local estrogen therapy and limited vaginal wall mesh excision.
Therefore, synthetic mesh is recommended for sacrocolpopexy and midurethral slings.

Some surgeons routinely use graft or mesh augmentation, others never use it, and some
use it only for limited indications. Selective use may include:
1. the need to bridge a space
2. weak or absent connective tissue
3. connective tissue disease
4. high risk for recurrence (obesity, chronically increased intraabdominal
pressure, and young age)
5. shortened vagina
Biologic grafts may be autologous, allograft, or xenograft. Autologous grafts are
harvested from another part of the patients body such as rectus abdominis fascia or thigh
fascia lata. Morbidity is low, but may include increased operative time, pain, hematoma,
or weakened fascia at the harvest site. Allografts come from a human source other than
the patient and include cadaveric fascia or cadaveric dermis. Xenografts are biologic
tissue obtained from a source or species foreign to the patient such as porcine dermis,
porcine small intestinal submucosa, or bovine pericardium. Biologic materials have
varying biomechanical properties and as noted earlier, are associated with high rates of
prolapse recurrence. Synthetic mesh is classified as types I through IV, based on pore size
(Table 24-8) (Amid, 1997). Pore size is the most important property of synthetic mesh.
Bacteria generally measure less than 1 m, whereas granulocytes and macrophages are
typically larger than 10 m. Thus, a mesh with pore size < 10 m may allow bacterial but
not macrophage infiltration and thereby predispose to infection. Accordingly, type I mesh
has the lowest rate of infection compared with types II and III. Pore size is also the basis
of tissue ingrowth, angiogenesis, flexibility, and strength. Pore sizes of 50 to 200 m
allow for superior tissue ingrowth and collagen infiltration. Meshes are either
monofilament or multifilament. Multifilament mesh has small intrafiber pores that can
harbor bacteria, therefore, monofilament mesh is recommended. From these findings,
consensus suggests that if synthetic mesh is used, type I monofilament is the best choice
for reconstructive pelvic surgery. Mesh or graft augmentation will undoubtedly persist
due to the current poor cure rates with traditional transvaginal repairs.

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