Pelvic Organ Prolapse FNAC
- 1. Pelvic Organ Prolapse Francis Niño A. Cañedo
- 2. Pelvic Organ Prolapse (POP) Bulge or protrusion of pelvic organs common and costly affliction of older women
- 3. Pathophysiology Attenuation of pelvic support structures tears or breaks neuromuscular dysfunction both
- 4. Pelvic support structures Endopelvic connective tissue cardinal uterosacral ligament complex Pelvic diaphragm - levator ani and coccygeus muscles provides basal tonicity and support of the pelvic structures - when contracted (increased abdominal pressure), the rectum, vagina and urethra are pulled anteriorly toward the pubis
- 5. A saggital view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic floor.
- 6. RECTOCELE protrusion of the rectum into the vaginal lumen weak muscular wall of rectum and paravaginal connective tissue (holds rectum posteriorly)
- 8. ENTEROCELE herniation of the peritoneum and small bowel true hernia occurs downward (bet. uterosacral ligament and rectovaginal space) apically (previous hysterectomy)
- 11. CYSTOCELE herniation of the urinary bladder through the anterior vaginal wall weak pubocervical musculoconnective tissue at midline or detaches from its lateral or superior connecting points occurs downward (bet. uterosacral ligament and rectovaginal space) apically (previous hysterectomy)
- 13. Uterine prolapse Poor cardinal or uterosacral ligament apical support downward protrusion of cervix and uterus towards the introitus Procedentia – prolapse of uterus and vagina Total vaginal vault prolapse – after hysterectomy EVERSION OF VAGINA
- 14. Increased intraabdominal pressure -> ascites, large pelvic or intraabdominal tumors Sacral nerve disorders (S1-S4), Diabetic neuropathy Chronic respiratory disease -> chronic bronchitis, asthma, bronchiectasis Severe obesity Congenital
- 15. First degree – upper barrel of vagina Second degree – vaginal barrel to the introital region Third degree / Total – cervix and uterus prolapse out through the introitus
- 16. Uterine prolapse with apical detachment from the uterosacral ligament complex and lateral wall detachment from the endopelvic connective tissue.
- 17. Procidentia of the uterus and vagina
- 18. Evaluation Women 50 yo and above 50% fewer than 20% seek treatment
- 19. Symptoms Voiding dysfunction (urinary incontinence) obstructive voiding symptoms urinary urgency and frequency urinary retention and upper renal compromise (pain and anuria)
- 20. Pelvic pain Defecatory problems (constipation, diarrhea, tenesmus, fecal incontinence) back and flank pain overall pelvic discomfort dyapareunia
- 21. Physical Examination - divide into compartments Univalve / Sim’s speculum anterior and posterior rectovaginal examination posterior open ring forceps anterior lateral detachment defect Baden retractor Valsalva manuever Standing straining examination with empty bladder
- 22. Pelvic Organ Prolapse Quantitation System Anatomic descriptions of specific sites of vagina are used in place of traditional terms identifies nine locations in the vagina and vulva in centimenters relative to the hymen stage of prolapse graded on a scale of 0-3 or 0-4 with increasing severity of prolapse
- 23. six points along the vagina (two-anterior, middle, posterior) measured in relation to the hymen proximal – negative number in cms. distal – positive number in cms. zero – plane of the hymen
- 24. genital hiatus > middle of external urethral meatus to the posterior midline hymen - perineal body > posterior margin of genital hiatus to the midanal opening total vaginal length (TVL) > greatest depth of vagina (cms) when the vaginal apex is reduced to its full normal position
- 25. Standardization of terminology for female pelvic organ prolapse (POPQ classification)
- 27. Anterior wall (Aa and Ba) – anterior compartment prolapse Middle compartment (C and D) – suspensory failure / cervical elongation Posterior compartment (Ap and Bp) – posterior compartment prolapse
- 28. Aa -3 Ba -3 C -8 D -10 Ap -3 Bp -3 TVL 11 Genital hiatus 4 Perineal body 3
- 30. Clinical setting > most advanced extent of prolapse in cms. relative to the hymen anterior vagina posterior vagina cervix / vaginal apex
- 31. Pelvic Muscle Function Assessment Px in lithotomy position – bimanual examination – palpate puborectalis (4 and 8 o’ clock) basal muscle tone, strength, duration and symmetery of contraction rectovaginal examination -assess basal and contraction muscle tone of the anal sphincter complex
- 32. Urethral mobility hypermobility - resting urethral angle greater than 30 degrees or a maximal strain angle greater than 30 degrees - (+) urethral mobility + stress incontinence incontinence procedure Goniometer - measures baseline urethral angle and maximal strain angle of the urethra
- 34. Bladder Evaluation Clean catch or catheterized urine sample – infection postvoid residual volume assessment of bladder sensation reduction stress test
- 35. Imaging not routinely performed fluoroscopic evaluation of bladder function pelvic USG defecography (intussusception, rectal mucosal prolapse) MRI (pelvic pathology)
- 36. Treatment Nonsurgical Therapy conservative behavioral management mechanical devices
- 37. Mild to moderate prolapse desire preservation of future childbearing surgery may not be an option do not desire surgical intervention
- 38. Conservative Management Lifestyle alteration physical intervention (PELVIC FLOOR MUSCLE TRAINING) GOALS: > prevent worsening prolapse > decrease severity of symptoms > increase strength, endurance and support of pelvic floor musculature > avoid or delay surgical intervention
- 39. Mechanical devices whom medical reasons cannot undergo surgery desire to avoid surgery significant degree of prolapse that makes other nonsurgical approaches unfeasible
- 40. Pessaries provide pelvic organ support within the vaginal vault support pessary (Ring pessary) – Stage I and II space filling pessary (Gelhorn pessary) – Stage III and IV
- 42. Possible complications: vaginal discharge and odor excoriation and irritation stress incontinence rare: vesicovaginal fistula, small bowel entrapment, hydronephrosis, urosepsis
- 43. patient is asked to stand, perform Valsalva and cough to ensure the pessary is retained desired support and leakage control and can void latex allergy remove and clean device every 2 to 3 days
- 44. Surgical Management relieve symptoms restore vaginal anatomy sexual function obliterative and constrictive surgery – sexual function not desired vaginal abdominal laparoscopic
- 45. Restorative - uses patient’s endogenous support structures Compensatory - attempts to replace deficient support with permanent graft material Obliterative - close or partially close the vagina
- 46. The Anterior Compartment anterior vaginal wall and its attachments urethra bladder
- 47. View of pelvic cavity with bladder, upper vagina and sigmoid colon removed
- 48. Defects: - tears or attenuation of the vaginal fibromuscular wall - detachment from pelvic sidewalls, the cervical or cardinal ligament complex - pubis
- 49. Physical examination may reveal the following findings: - presence of a central ballooning-type defect - Descent of the area of the vaginal wall below the bladder neck - Descent of the cervix or apical vaginal area - presence or absence of sulci extending lateroanteriorly, lateral detachment to the arcus is maintained or lost.
- 50. Anterior Vaginal Colporrhaphy - Anatomic correction of an anterior defect or cystocele Paravaginal Repair Reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia muscle at the level of the arcus tendineus pelvis women with anteriolateral detachments
- 51. Posterior Compartment Supports rectum and vagina pelvic floor musculature and connective tissue Denonvillier’s (pararectal) fascia- fibromuscular layer of the posterior vaginall wall and its lateral attachments to the lateral pelvic floor (levator) musculature and fascia
- 52. Saggital oblique view of the distal midvagina
- 53. Traditional Posterior Coloporrhaphy Preserve sexual function plication of the pubococcygeus muscles across the anterior rectum and perineal body reconstruction Denonvillier's fascia is mobilized from the vaginal epithelium, leaving as much of this tissue as possible attached laterally to the levator fascia superficial muscles of perineum and bulbocavernous fascia are plicated at midline and closed (episiotomy repair)
- 54. De novo dyspareunia (8-26%) - vaginal strictures, introital tightness, levator spasm, neuralgia
- 55. Defect Specific Posterior Repair restorative establish an intact plane of connective tissue that positions the rectum against the pelvic floor and obliterates any potential space between a well-supported cervix or vaginal cuff and the cephalad edge of the tissue plane and upper rectum.
- 56. Abdominal Approach to Posterior Repair Sacral colpoperineopexy replace the normal vaginal suspensory ligaments and to augment or replace the posterior fibromuscular plane with graft material that runs from the sacrum to the perineal body Prevents descent and opening of the genital hiatus Mersilene mesh and dermal allografts
- 57. Laparoscopic approach to posterior repair Dissection of the rectovaginal space to the perineal body plication of levator fascia permanent mesh
- 58. Transanal posterior repair remove or plicate redundant rectal mucosa, to decrease the size of the rectal vault, and to plicate the rectal muscularis defecatory function
- 59. The Apical Compartment Cardinal ligaments, upper paravaginal fibromuscular connective tissue, paracervical fascia defects: - loss of cardinal support -> vaginal cuff descent - detached fibromuscular vagina from anterior rectum -> enterocele , sigmoidocele - upper fibromuscular tissue tear -> central apical descent
- 60. A saggital view of the female pelvis with bladder and uterus removed (ureters, trigone, and cervix intact) illustrating anterior and posterior vaginal fibromuscular planes, their endopelvic fascial attachments, and a functional pelvic floor.
- 61. Transvaginal repairs (extraperitoneal) - sacrospinous - iliococcygeal - high paravaginal suspensions
- 62. Abdominal Procedures Abdominal Uterosacral Suspension Abdominal Sacrocolpopexy Laparoscopic Techniques
- 64. Vaginal Obliterative Procedures Colpocleisis For debilitated patients who do not desire vaginal function partial colpocleisis – total colpectomy