Escolar Documentos
Profissional Documentos
Cultura Documentos
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
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 hypertension
History of spondylitis tuberculosis
:
:
:
:
:
:
:
:
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
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
1.3.
General condition
Consciousness
: compos mentis
Blood pressure
: 140/80 mmHg
Pulse
: 96 BPM
Respiratory Rate
Temperature
: 36,7o C
Weight
: 56 kg
Height
: 144 cm
BMI
: 27.05 kg/m2
General Examination
Eye
Oral
Thorax
Cor
: Auscultation: irregular 1st and 2nd heart sound, gallop (-), murmur (-)
Pulmo
:
7
Mammae
Abdomen
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
Bimanual examination
o Pelvic floor musculature
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
Follow Up
O:
General condition
Consciousness
: Compos mentis
Blood Pressure
: 140/90 mmHg
HR
: 88 BPM
RR
: 22 breaths/minute
: 36,5 C
Eye
Oral
Thorax:
Cor
Pulmo :
: Auscultation: irregular 1st and 2nd heart sound, Gallop (-), Murmur (-)
Abdomen
Extremities: Warm
Edema
Pathological reflex
: --/--
Workup:
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
O:
General condition
Consciousness
: Compos mentis
Blood Pressure
: 138/82 mmHg
HR
: 66 BPM
RR
: 22 breaths/minutes
: 37 C
Eye
Oral
Thorax:
Cor
Pulmo :
: Auscultation: irregular 1st and 2nd heart sound, Gallop (-), Murmur (-)
Abdomen
14
Extremities: Warm
Edema
Pathological reflex
: --/--
Workup:
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
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
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
Incision of posterior vaginal wall. Identification of cul de sac and rectovaginal fascia for
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
- can be
asymptomatic
- buldge symptoms
- urinary symptoms
prolapse
- Widen genital hiatus with
increase intra-abdominal
- Gastrointerstinal
symptoms
- Female sexual
Physical examination :
dysfunction
- Hypertension grade 1
pain
examination
- Protusion come beyond
the hymen
- Anterior wall vagina
Gynecolog examination
Physical
examination should
be normal
pressure
2. Vaginal
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
- 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,
3. Bimanual
examination
examine
the pelvic
floor
musculature
Risk factors
menopause
prolapsus uteri
multiparity, vaginal
connective tissue
disorder, increase
increase abdominal
abdominal pressure
pressure
Anterior
Anterior collporhaphy
for manage the
collporrhaphy
Hysterectomy
transvaginal
hysterectomy
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
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.
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
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.
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
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
Grade 2
Grade 3
Grade 4
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
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.
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.
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.
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
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
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.
BIBLIOGRAPHY
1. Kerkhoff M., Hendriks L. Changes in connective tissue in patients with pelvic organ
prolapsea review of the current literature. International Urogynecology Journal. 2009
Apr;(4):46174.
2. Doshani A, Teo
R,
Mayne
C.
Uterine
prolapse.
Biomed
Journal.
2007
Oct;335(7624):81923.
3. Cunningham G. Williams Obstetrics 24th edition. McGrawHill Education; 2014.
4. Kuncharapu I, Majeroni BA, Johnson DW. Pelvic organ prolapse. Am Fam
Physician. 2010 May 1;81(9):1111-1117.
5. Jones KA, Harmanli O. Pessary use in pelvic organ prolapse and urinary incontinence.
Reviews in Obstetrics and Gynecology. 2010;3(1):3.
6. Dutta DC, Konar H. DC Duttas textbook of gynecology: including contraception. 2014.
7. Spiegel M. Schaums mathematical handbook of formulas and tables [Internet]. McGrawHill
Osborne
Media;
1999
[cited
http://ir.nmu.org.ua/handle/123456789/125091
2015
Nov
4].
Available
from: