Pelvic organ prolapse

PELVIC ORGANPROLAPSE
By Dr.Sai Sudha
Moderator- Dr.Sai Lakshmi M.P.A

REFERENCES
•Shaw’s textbook of gynaecology-16th edition
•Dutta’s textbook of gynaecology-7th edition
•Berek & Novak’s gynaecology- 16th edition
•Te Linde’s operative gynaecology- 10th edition
•Williams textbook of gynaecology- 2nd edition

The Latin meaning of
‘Prolapse’ means slipping out of place and
‘procidentia’ means to fall
•Prolapse was known since the time of Hippocrates, Soranus,
Dhanvantri and Charak.
•Earliest treatments- Vaginal packing, exercises, Labial suturing
•First vaginal hysterectomy was done in New Orleans by Samuel
Choppin in 1861
•Lefort’s colpocleisis- 1877
•Pessaries-19th century
•Manchester operation- Modified by fothergill- 1888
HISTORY

EPIDEMIOLOGY
•Prevalence is high in white Caucasians.
•Prevalance is high in developing countries.
•The global prevalence of uterine prolapse is 2-20%
among parous women below 45 years of age.
•In India the prevalence rate is 15-20% below for the
same age.
•In India more than 1 million women suffer from genital
prolapse and majority of them belong to reproductive age
group.

DEFINITIONS
•Pelvic organ prolapse:- It is a bulge or protrusion of pelvic organs
and their associated vaginal segments into or through the vagina.
•Rectocele:- Protrusion of rectum into the vaginal lumen resulting
from weakness in the muscular wall of the rectum and the
paravaginal musculoconnective tissue.
•Enterocele:- Herniation of peritoneum and small bowel (true
hernia among the pelvic support disorders).
•Cystocele:- Descent of urinary bladder with the anterior vaginal
wall.

•Uterine prolapse:- Downward protrusion of the cervix and
uterus towards the introitus.
•Procidentia- prolapse of entire uterus and vagina
•Total vaginal vault prolapse- eversion of the entire vagina
posthysterectomy

ANATOMY- SUPPORTS OF UTERUS
•The uterus is anteverted, anteflexed with cervix at right
angle to the axis of the vagina and the external os
situated at the level of ischial spines.
•The uterus is held in this position by supports that are
grouped under three tier systems.
•The objective is to maintain the uterus at it’s level and
to prevent descent through the natural urogenital hiatus
in the pelvic floor.

1. UPPER TIER:-
• Primarily maintain the uterus in anteverted position.
• Structures responsible-
Endopelvic fascia covering the uterus
Round ligaments
Broad ligaments with intervening pelvic cellular tissues.
2. MIDDLE TIER:-
• Constitute the strongest support of the uterus.
• Structures responsible are-
Pericervical ring
Pelvic cellular tissues (endopelvic fascia)

3. INFERIOR TIER:-
• Indirect support to the uterus.
• Principally given by levator ani, endopelvic fascia,
levator plate, perineal body and urogenital
diaphragm.
 The endopelvic fascia at places is condensed and
reinforced by plain muscles to form ligaments called
the Cardinal ligaments. Mackenrodt’s, uterosacral
and pubocervical.

ANATOMY- SUPPORTS OF VAGINA
1. Supports of ANTERIOR VAGINAL WALL:-
• The vagina is ensheathed by strong condensation of pelvic
cellular tissue called Endopelvic fascia.
• This fascia forms the posterior urethral ligament giving
strong support to the urethra, anchored to pubic bones.
• Laterally, forms pubocervical fascia or ligament.

2. Supports of POSTERIOR VAGINAL WALL:-
• Endopelvic fascia sheath covering the vagina and rectum.
• Attachment of Uterosacral ligament to the lateral wall of
the vault.
• Levator ani with its fascial coverings.
• Medial fibers of pubococcygeus part of Levator ani.
• Levator plate
• Perineal body
• Biomechanical basis of uterovaginal supports (Delancey)

ANATOMY- DELANCEY’S LEVELS OF
SUPPORT
•LEVEL I :-
Uterosacral and cardinal ligaments support the uterus
and vaginal vault. The cervix remains at or just at the
level of ischial spines and the vagina lies horizontally.
“Level I damage causes uterine descent, enterocele and
vault descent”

•LEVEL II:-
Pelvic fascias and paracolpos which connects the vagina
to the white line on the lateral pelvic wall. Includes
pubocervical fascia anteriorly, rectovaginal fascia and
rectovaginal septum posteriorly.
“Level II damage causes cystocele and rectocele”
•LEVEL III:-
Levator ani muscle supports the lower one third of the
vagina. It forms a platform against which the pelvic
organs get compressed during straining.
“Level III damage causes urethrocele, gaping introitus and
deficient perineum”

PATHOPHYSIOLOGY
“The interaction between the pelvic floor muscles,
fibromuscular connective tissues and intact innervation are
key to maintaining support of pelvic organs in their normal
locations. “
•POP occurs from attenuation of the supportive structures,
whether by actual tears or breaks or neuromuscular
dysfunction or both

•Damage of levator ani (Medial fibres of pubococcygeus)---
pelvic floor opens--- widening of hiatus urogenitalis--
Raised inta-abdominal pressure-- Vagina is pushed down--
 genital organs prolapse.
•Damage of levator plate/anococcygeal raphe--
enlargement of the rectogenitourinary hiatus-- Genital
organ prolapse.
•Damage to perineal body-- Loss of vaginal axis

•Overstretching of Mackenrodt’s & Uterosacral
ligaments.
•Overstretching and breaks in the endopelvic fascial
sheath.
•Overstretching of the perineum
•Loss of levator function due to neuromuscular damage
during childbirth
•Subinvolution of the supporting structures.

ETIOLOGY OF PELVIC ORGAN PROLAPSE

CLINICAL TYPES OF POP
The genital prolapse is classified into:-
VAGINAL PROLAPSE
UTERINE PROLAPSE
Vaginal prolapse can occur independently without
uterine descent, whereas Uterine prolapse is usually
associated with variable degrees of vaginal descent.

SHAW’S CLASSIFICATION
Anterior vaginal wall:-
Upper 2/3rd- CYSTOCELE
Lower 1/3rd- URETHROCELE
Posterior vaginal wall:-
Upper 1/3rd- ENTEROCELE (pouch of douglas hernia)
Lower 2/3rd- RECTOCELE
Uterine descent:-
Descent of cervix into vagina
Descent of cervix up to introitus
Descent of cervix outside introitus
Procidentia- All of uterus outside the introitus

• Procidentia involves prolapse of the uterus with eversion
of the entire vagina.
•Complex prolapse is associated with other defects like
urinary or fecal incontinence, nulliparous prolapse,
recurrent prolapse, vaginal and rectal prolapse or prolapse
in a frail women.

CLASSIFICATIONS
FRIEDMANS CLASSIFICATION (1961):-
IA- Descent to half way to hymen
IB- Descent until hymen
II- Descent until the introitus
III- Outside the introitus
IV- Complete procidentia

JEFFCOATES- UV PROLAPSE
I- Descent of the uterus but cervix remains with in
introitus
II- Descent to the extent that the cervix projects
through the vulva when woman is straining or standing.
III- Complete procidentia- The entire uterus prolapses
outside the vagina. The whole vagina or atleast the
whole of its anterior wall is everted.

UTERINE DESCENT
I- Descent of cervix into vagina
II- Descent of the cervix upto introitus
III- Descent of cervix outside the introitus
IV- Procidentia- All of the uterus outside the introitus

BADEN’S SYSTEM OF GRADING
Urethrocele, Cystocele, Rectocele
0- Normal
1-Descent to halfway to hymen
2-Progression to hymen
3-Progression to halfway through hymen
4-Maximal progression through hymen
Enterocele
0-Normal-Maximum 2cm of cul-de-sac between post cervix and
rectum.
1-Herniation of cul-de-sac to 1/4th of distance to hymen
2-Herniation to 2/4th of distance towards hymen
3-Herniation to 3/4th of distance towards hymen
4-Herniation to hymen

SYMPTOMATOLOGY
• The feeling of mass per vaginum causing discomfort
while walking or moving about.
•Backache or dragging pain in pelvis which is relieved on
lying down.
•Dyspareunia
•Excessive white or blood stained discharge per vaginum is
due to associated vaginitis or decubitus ulcer.

• In the presence of Cystocele :-
oDifficulty in evacuating the bladder. Patient has to
elevate the anterior vaginal wall to do so.
oIncreased frequency due to incomplete evacuation
oUrgency and frequency due to cystitis
oDysuria due to infection
oStress incontinence ( Urethrocele )
oRarely, retention of urine.
•In the presence of Rectocele :-
oDifficulty in defecating. Patient has to push the posterior
vaginal wall to evacuate.
oFecal incontinence may be associated.

• Vaginal mucosa  Keratinization  Pigmentation
•Keratinization cracks infection  sloughing
Ulceration Decubitus ulcer found on the dependant part of
the prolapsed mass lying outside the introitus.
•Dependant position  Venous stasisTissue anoxia 
Decubitus ulcer (rarely undergoes carcinoma)
•Vaginal part of the cervix becomes congested and bulky
•Supravaginal part becomes elongated due to the pull of the
cardinal ligaments
MORBID CHANGES

•Hypertrophy of bladder wall and trabeculation
•Cystitis
•Hydroureteric changes occur when ureters are carried
downwards along with elongated mackenrodt’s ligaments
and then obstructed by the hiatus of the pelvic floor.
•Pyelitis or pyelonephritis due to ascending infection.
•Rarely, peritoneal infection may occur through the
posterior vaginal wall.

MANAGEMENT OF DECUBITUS ULCER
Smear-Cervical cytology to exclude malignancy
Colposcopy and directed biopsy
Reduction of prolapse with tampoons or pessary helps
in healing the ulcer
Vaginal pack with roller bandage soaked with antiseptic
lotion, glycerin and acriflavin
Estrogen cream in postmenopausal women

CLINICAL EXAMINATION
To evaluate the pelvic organ prolapse, it is useful to divide
the pelvis into compartments, each of which exhibits
specific defects.
1. Apical compartment of vagina- Graves speculum or
baden retractor.
2. Anterior and posterior compartements- Univalve or
Sims speculum
3. Rectovaginal examination to evaluate the posterior
compartment to distinguish a posterior vaginal wall
defect from a dissecting apical enterocele or a
combination of both.
 Patient is encouraged to perform valsalva to evaluate the full
extent of the prolapse or a standing straining examination
with bladder empty is performed.

I. Pelvic organ prolapse quantification
system
II. Pelvic muscle function assessment
III. Bladder function evaluation
IV.Bowel function evaluation

Pelvic organ prolapse quantification system
•The ‘International incontinence society’ has approved the use
of POP-Q system.
•The system identifies 9 locations in the vagina and vulva in
centimeters relative to the hymen, which are used to assign a
stage of prolapse at its most advanced site.
•It allows the use of a standardized technique with
quantitative measurements at straining relative to a constatnt
reference point (hymen)
•It also has the ability to assess prolapse at multiple vaginal
sites.

•The genital hiatus is measured from middle of the external urethral
meatus to the posterior midline hymen.
•The perineal body is measured from the posterior margin of the
genital hiatus to the midanal opening.
•The total vaginal length is the greatest depth of the vagina in
centimeters when the vaginal apex is reduced to its full normal
position.

•The anatomic position of the six defined points
should be measured in centimeters. Proximal to the
hymen- negative number, distal to the hymen-
positive number and with the plane at the hymen-
zero.
•After collection of the site specific measurements,
stages are assigned according to the most dependant
portion of the prolapse.

PELVIC MUSCLE FUNCTION ASSESSMENT
•Pelvic muscle function should be assessed during the
pelvic examination.
•Patient in lithotomy position.
•Palpate the puborectalis and pubococcygeus muscles
along the pelvic side wall at 4 & 8 o cock positions.
•Basal muscle tone, tone with contraction, strength,
duration and symmetry of contraction should be
appreciated.
•Rectovaginal examination should be performed to assess
the tone of anal sphincter complex.
•Urethral mobility is measured with a goniometer.

•Many women with prolapse have urethral hypermobility, that is the
resting angle being more than 30* or maximum strain angle being more
than 30*

BLADDER FUNCTION EVALUATION
•Basic bladder testing with prolapse reduction should be
performed to mimic bladder and urethral function if the
prolapse were treated.
•Assessments to be performed- Clean catch or catheterised
urine sample to test for infection, postvoid residual volume
and assessment of bladder sensation

BOWEL FUNCTION EVALUATION
•If the patient has defecatory dysfunction with a rectocele
and symptoms of constipation, pain with defecation, fecal
or fecal incontinence or any signs of levator spasm or anal
sphincter spasm, conservative management of the
conditions could be initiated before repair of the rectocele
and continued postperatively.

INVESTIGATIONS
•Diagnostic imaging of the pelvis is not routinely performed.
•Test that may be performed are-
a. Fluroscopic evaluation of bladder function
b. Ultrasound of the pelvis
c. Defecography for patients with suspected intussusception
or rectal mucosa prolapse.

MANAGEMENT
PREVENTIVE CONSERVATIVE SURGERY
•Adequate antenatal and
intranatal care
Avoid injury to supporting
structures during delivery
•Adequate postnatal care
Early ambulance and pelvic
floor excercises (Kegel
excercises)
•General measures-
a. Avoiding strenuous
activities, chronic
cough, constipation and
heavy weight lifting.
b. Maintain adequate
inter-pregnancy interval
•Indications-
1. Asymptomatic
women
2. Mild degree prolapse
3. POP in early
pregnancy
•Measures-
a. Improvement of
underlying factors
b. Estrogen replacement
in postmenopausal
women
c. Kegel excercises
d. Pessary treatment
•Guidelines-
a. When conservative
management has
failed in
symptomatic
prolapse.
b. Meticulous
examination under
anasthesia is
required to diagnose
the organ prolapsed.
c. These Surgical
procedures depend
on the type of
prolapse and are of
many types.

Voluntary contraction of the muscles innervated by the
pudendal nerve was popularized by Arnold Kegel
• Patient is taught to voluntarily contract the sphincters
• Initially 15 times each of 3 seconds, 6 times per day for 3
weeks
• Then less frequently for 6 months
• Contract leavtor ani and pubococcygeus
KEGEL’S EXCERCISE

The Kegel contraction should be confirmed during a pelvic
examination to ensure that the patient understands the
correct muscles to contract.
• The proper time to Kegel is after micturition. After the
bladder is emptied, the patient is instructed to lean as far
forward as her stability allows.
• While leaning forward, she performs three or more
isometric Kegel exercises by tightening the muscles until
they voluntarily relax on their own.
• The muscular action of the Kegel contractions also aids the
process of emptying.

•Pessaries cannot cure prolapse but can relieve the
symptoms by stretching the hiatus urogenitalis and
preventing vaginal and uterine descent.
INDICATIONS:-
•Early pregnancy- Pessary should be placed inside up to
18 weeks (Till the uterus becomes sufficiently enlarged to
sit on the brim of the pelvis)
•Puerperium- To facilitate involution
•Patients unfit for surgery, especially with short life
expectancy.
•Patient’s unwillingness for the surgery
•While waiting for the surgery
•Additional benefits- Improvement of urinary symptoms.

Types of pessary:
1. Support pessary- stage 1 and 2
2. Space filling pessary- stage 3 and 4
1.Support pessary
•Used to treat SUI and pelvic organ prolapse
• Easy to insert and remove
• Sexual intercourse possible with pessary in situ
• Theoretically use a spring mechanism
• Rest between the pubic symphysis and posterior vaginal fornix
Types:-
a) Ring
b) Gehrung
c) Shaatz
d) Lever- Hodge, Smith, Risser

4. LEVER PESSARY
1. Smith
2. Hodge
3. Risser
Used for uterine retroversion
and POP
• Rarely used
3. SHAATZ PESSARY
• Rigid ring pessary
• Insertion is done vertically and
then turned to horizontal position
inside the vagina
2. GEHRUNG PESSARY
• To treat cystocele and
rectocele
1. RING PESSARY
• Most commonly used pessary
• 4 types:
1. Ring
2. Ring with support
3. Incontinence ring
4. Incontinence ring with support

2. SPACE FILLING PESSARY
• Used in severe POP especially post hysterectomy vaginal vault prolapse
• Large apex to support vaginal apex
• Difficult to insert and remove
• Intercourse not possible with pessary in situ
• Either occupy space within vagina or create suction
• And adhere to the vaginal tissue
• In standing position, these pessaries also sit just inside the vaginal
introitus
Types:
1. Gellhorn Pessary
2. Donut pessary
3. Cube pessary
4. Inflatoball pessary

2. DONUT PESSARY
• Large, thick and hollow
• Difficult to insert and remove
• Insertion: vertical- rotate to horizontal position in vagina
• Removal: facilitated by a Kelly’s clamp
1. GELLHORN PESSARY
• Most commonly used
• Parts: broad base and stem
• Broad base supports vaginal apex
• Stem keeps circular base from rotating and being expelled
• Holes in stem and base allow vaginal discharge drainage
• Self care is difficult

4. INFLATOBALL PESSARY
• Air filled ball and stem with port
• Made of latex– needs to be removed daily
• Sizes: small, medium, large and extra large
3. CUBE PESSARY
• Supports 3rd degree uterine prolapse by holding vaginal
wall with suction
• Nightly removal and cleaning because of risk of vaginal
erosion and discharge
• No drainage capability
• Insertion: squeeze and insert at vaginal apex

Steps:
1. Measure the distance between the top of posterior fornix and
the lower border of the pubic symphysis
2. The long diameter of the pessary should be 1.5 cm less than this
distance
3. Patient should be in dorsal position
4. Non dominant hand separates labia and depresses perineal body
5. Leading edge of pessary is lubricated
6. Pessary inserted by dominant hand
7. Able to insert 1 finger between pessary and vaginal side wall
8. After insertion ask patient to move around and ask for
discomfort

Criteria for well fitting pessary:-
1. Patient should feel comfortable after insertion
2. Should be retained despite ambulation and straining
3. It should allow for adequate emptying of the bladder
4. Digital palpation around the periphery ensures that a
finger can be easily inserted in between the pessary and
vagina.

Pre-operative measures:
1. Daily vaginal douching to prevent infection
2. Tampooning to reduce prolapse. This increases blood flow.
3. In case of atrophic vaginal walls, topical oestrogens are
given.
4. Correction of anaemia and stabilization of medical
conditions

ANTERIOR COMPARTMENT DEFECT REPAIR
Indications:
1. Anterior colporrhaphy for central cystocele
2. Repair of paravaginal defects if there is lateral cystocele
3. Anterior colporrhaphy with paravaginal fascial defect repair
if there is combined cystocele and paravaginal defects
General considerations:
1. Antibiotics
• Within 60 mins of incision
• 1st generation cephalosporins
• Combination (500mg metronidazole+ 400mg ciprofloxacin)

1.Anterior colporrhaphy
OBJECTIVE:-
Plicate layers of vaginal muscularis and adventitia
overlying the bladder (Pubocervical fascia)
Plicate and reattach the paravaginal tissue to reduce
the central protrusion of bladder and vagina

Traction of cervix
Expose anterior vaginal wall
Transverse incision on the bladder sulcus
Vertical incision from midpoint extending till the midurethra
Vaginal walls reflected to expose the bladder and vesicovaginal fascia
The vesicovaginal fascia is tightened by plicating the vaginal
muscularis & adventitia medial to the vaginal flaps in midline without
excessive tension
Excess vaginal wall is excised
Laxicity is corrected
Vaginal wall sutured

2.Paravaginal defect repair:
• To correct lateral cystocele
• AIM:
Reattach pubocervical fascia to fascia overlying obturator
internus at the level of ATFP on both sides
• Types of approaches:-
1. Open retropubic approach
2. Transvaginal approach
3. Laparoscopic approach

Transvaginal approach:
1. Anterior vaginal wall is opened in the midline– if needed
anterior colporrhaphy is done
2. Dissection extended laterally beneath inferior pubic ramus
to expose fascia over obturator internus at level of white line
3. Paravaginal defect can be palpated
4. 1cm proximal to ischial spine a series of non-absorbable
sutures is placed in white line
5. The sutures pass through white line, lateral edge of
pubocervical fascia and through underside of vaginal skin
6. Sutures are tied
7. After trimming excess vaginal skin, vagina is closed in same
way as anterior colporrhaphy

Retropubic Approach:
STEPS:
1. Retropubic space is entered through open method
2. Low transverse incision made
3. Bladder & vagina depressed & pulled medially to visualise lateral
retropubic space
4. Blunt dissection pulling badder medially
5. Surgeon’s non-dominant hand inserted into vagina– to gently elevate
anterolateral vagina
6. Defect in attachment of vaginal fascia to ATFP revealed
7. Suture is put at vaginal apex– 1st full thickness of vagina (excluding
vaginal epithelium)
8. Then deep into fascia over obturator muscle at ATFP
9. Sutures from 1-2cm anterior to ischial spine, to anterior limit of fascial
defect

3.ABDOMINAL SLING SURGERY
INDICATIONS:
1. Ligaments are extremely weak as in nulliparous and young
women
2. Preserve reproductive function
Aim/Advantages of conservative surgery
• To relieve the symptoms
• To restore the anatomy to normal
• To restore the functions to normal
• To prevent recurrence in future
• To maintain child bearing potential
• To maintain menstrual function

PRINCIPLE:
• With a fascial strip / prosthetic material (Merselene tape or Dacron)
the Cervix is fixed to the abdominal wall / sacrum / pelvis.
• Cystocele/ rectocele repair if needed can be done vaginally before or
after.
TYPES OF SURGERY
1. Abdominocervicopexy
2. Shirodkar’s abdominal sling operation
3. Khanna’s abdominal sling operation
4. Virkud’s procedure
5. Purandare’s procedure
6. Joshi’s sling
7. Soonawala’s sling

I.Shirodkar’s sling:
• Dr. V.N. Shirodkar (pioneer) used fascia lata femoris to strengthen the
uterosacral ligaments and fixation to sacral promontory
retroperitoneally, now replaced by mersilene tape
• Mersilene tape has a definite advantage over fascia lata as it is inert
material, non-absorbable, non irritant with predictable tensile strength
• Tape is fixed to posterior aspect of isthmus and sacral promontory
• Anatomically correction done
• Difficult to perform

CLOSED LOOP POSTERIOR SLING
• One end of mersilene tape is anchored to anterior longitudinal
ligament over sacral promontry.
• Other end is then passed subperitoneally on the right side and then
through the right broad ligament.
• It is anchored to the posterior aspect of isthmus passed to left broad
ligament then through the psoas loop(made using 5 cm long tape
passed through psoas muscle).
• The tape then passes under sigmoid mesentry to be fixed back to
sacral promontry.

II.Purandare’s cervicopexy
• DYNAMIC, CLOSED LOOP, ANTERIOR SLING
• Merselene tape is anchored to anterior aspect of isthmus and anterior
abdominal wall
• Material used: rectus sheath or mersilene tape
STEPS:
1. Abdomen opened by pfannestiel incision
2. Uterus held by Shirodkar’s uterus holding forceps
3. Bonney’s round ligament holding forceps passed lateral to rectus
muscle, posterior rectus sheath is pierced and passed into same broad
ligament to emerge in uterovesical space
4. Tip of mersilene tape caught with forceps and tape drawn out

5. Other side same procedure done
6. Round ligament plication done
7. Uterovesical peritoneum and rectus closed
8. 2 ends of tape pulled such that top of uterus comes to lie
flush with top of pubic symphysis
9. Tape is sutured to rectus sheath on both side

Steps:
1. The mersilene tape is attached to the isthmus posteriorly and then
passed between two leaves of broad ligament then transversalis fascia
then internal inguinal ring and upwards upto anterior superior iliac
spine.
2. Originally tapes were fixed to periosteum of anterior superior iliac
spine but now fixed to inguinal ligament.
III.Khanna’s sling operation
• Tape is anchored to ant aspect of isthmus and ant sup. Iliac spine
• Easier to perform and safe.

IV.Joshi’s sling:
• Anterior surface of uterus at the level of internal os is suspended
to the pectineal ligament on both sides with mersilene tape.
ADVANTAGES:
1. Uterus elevated without compressive effect on any organ
2. Weight of uterus shared by 2 strong ligaments. So no chance of
recurrence
3. Dissection doesn’t involve important structures like sigmoid,
ureter or sacral veins
4. Caesarean can be done without cutting tape

V. Virkud’s composite sling operation
• Tape is anchored from the post aspect of isthmus to sacral promontory
on the rt. Side and ant. Abdominal wall on the left side
• Uterosacral ligament is plicated
• One end of mersilene tape is attached to sacral promontory
• Subperitoneally towards the right pelvic wall then right broad
ligament and posterior surface of the isthmus
• Then passed through the left broad ligament then towards left
inguinal ring and turned medially and sutured to rectus sheath.
Plication of uterosacrals to correct dextro rotation.

VI. Soonawala’s sling
• Anterior longitudinal ligament on S1 vertebra
• Along right uterosacral ligament of isthmus of uterus
• Retraced extra peritoneally to S1 vertebra
VII. Sacrocervicopexy
• posterior surface of isthmus is anchored to s1 vertebra.
Advantages:
1. Effective correction of descent
2. Anteversion
3. No compression on rectum or ureter

MIDDLE COMPARTMENT DEFECT
UTERINE PROLAPSE
1. VAGINAL HYSTERECTOMY
• Women more than 40 yrs
• Have completed her family
• No longer keen on retaining her childbearing & menstrual functions

• Circular insicion over cervix, below bladder sulcus & vagina
mucosa dissected off the cervix all around.
• POD identified post & peritoneum incised
• Bladder pushed upwards until uterovesical peritoneum is
visible & incised
• Mackenrodt & uterosacral ligament are clamped, cut &
pedicles transfixed
• Uterine vessels are identified, clamped,cut & ligated
•Upper portion of broad ligament holding uterus contains
round & ovarian ligament & fallopian tube identified,
clamped, cut & pedicle transfixed.

Complications:
• Hemorrhage
• Sepsis
• Anaesthesia risks
• UTI
• Rarely trauma to bladder and rectum.
• Vault prolapse as late sequela
• Dyspareunia caused by short vagina
• Uterus removed
• Peritoneal cavity is closed with purse-string suture
• Ant. Colporraphy & post colpoperineorraphy is performed
as required.
• Vaginal is packed with betadine pack for 24 hrs
• Cathetherize for 48 hrs.

2. LE FORT’S REPAIR
• Reserved for the very elderly menopausal pt with advanced prolapse
or for those considered unfit for any major surgical procedure.
• Flaps of vagina from ant & post vaginal walls are excised, the raw areas
apposed with catgut sutures
• Wide area of adhesion is created in the midline prevents uterus from
prolapsing, small tunnels on either side permitting drainage of
discharge.
• Operation limits marital function, not to be advised to women with
active married life.
• Contraindicated in menstruating woman, a woman with diseased
cervix and uterus.

3. SHIRODKER S PROCEDURE
• Modified Fothergill’s operation
• Anterior Colporraphy performed, attachment of Mackenrodt ligaments
to cervix on each side is exposed.
• Vaginal incision is then extended posteriorly round the cervix.
• POD is opened, uterosacral ligaments identified and divided close to
the cervix.
• The stumps of these ligaments are crossed and stiched together in
front of cervix.
• High closure of the peritoneum of POD is carried out.
• Cervix is not amputated, rest of operation similar to Fothergill’s
operation

STEPS
• Dialation and curettage
• Cervical amputation
• Shortening of mackenrodt and anterior plication in front of the
cervix
• Anterior colporrhaphy
• Posterior colpoperiniorrhaphy
NINE ESSENTIAL STEPS OF THE MODIFIED MANCHESTER OPERATION
• 1. Hydrodissection
• 2. Cervical circumcision
• 3. Cuff perparation; decollement
• 4. Bladder displacement
• 5. Uterosacral ligament plication: extraperitoneal Mc Call suture
• 6. Cardinal ligament plication
• 7. Colporrhaphy anterior
• 8. Cervix amputation: Sturmdorf suture
• 9. posterior Colporrhaphy

THE MANCHESTER (FOTHERGILL) OPERATION
The Manchester operation was first performed in 1888 by Archibald
Donald in Manchester.
One of his trainees, Edward Fothergill, modified the operation by adding
parametrial fixation.
It was performed extensively until the 1950s when it was replaced by
vaginal hysterectomy
Objectives
1. To amputate the cervix leaving approximately 7 cm of uterus.
2. Approximation of the uterosacral and cardinal ligaments in front of
the cervix.
This shortens these ligaments and thus elevates and displaces the cervix
posteriorly.
This backward displacement encourages anteversion and helps prevent
prolapse.

Fothergill’s/Manchester operation

POSTERIOR COMPARTMENT DEFECT
• Objectives of repair:-
1. Treatment of rectocoele by repair of the rectovaginal fascial
defect.
2. Reconstruction of the perineal body.
3. To reduce the size of the urogenital hiatus—not needed
very often.

1. Pre-operatively the lower rectum should be empty.
2. A thin layer of the stretched skin is excised with a scalpel, in a
diamond shape, extending on to the perineal skin.
3. A vertical rather than horizontal incision is used.
4. The midline vaginal incision is extended with scissors or a scalpel to 3
cm below the cervix. Using sharp dissection, the vaginal walls are
separated from the underlying rectovaginal fascia and the rectum, as far
laterally as the attachment to the fascia over the obturator internus.
5. The sac is then closed in a double layer of vicryl suture, If the
enterocoele is small (less than 3cm) there is no need to open the sac, as
long as it is possible to close the fascial defect over it.
1. PERINEORRHAPHY

• If a patient has a pelvic floor with almost no support, and a large
levator hiatus, it is necessary to add sutures laterally and further up the
vagina to create a levatorplasty.
• The posterior vaginal wall is now sutured down to the hymen.
• Perineoplasty is performed in three layers of interrupted vicryl
sutures.
6. To repair the fascial defect, start with the transverse defect, which is
almost always present where rectovaginal fascia is separated from the
uterosacral ligaments.

MANAGEMENT
VAGINAL CORRECTION:-
• Inverted T shaped incision
• Dissect and expose sac
• Sac opened and contents pushed away
• Peritoneum dissected and excised
• Purse string suture – neck of the sac
• Cervix pulled up ,interrupted suture around uterosaral ligaments
ENTEROCELE
• Herniation of upper third of posterior vaginal wall
• Contain omentum or even loop of small bowel
• Always look for and correct during prolapse repair
• Prophylactic correction during vaginal or abdominal hyterectomy

VAGINAL CORRECTION OF POST HYSTERECTOMY ENTEROCELE
1. Internal Mc call suture
ABDOMINAL CORRECTION OF POST HYSTERECTOMY ENTEROCELE
1. Vaginal vault – suspend to uterosacral ligament
2. Other procedures:-
• HALBAN PROCEDURE
• MOSCOWITZ PROCEDURE

MCCALL CULDOPLASTY
• A wedge of posterior vaginal wall and peritoneum removed
• Enterocole sac freed and excised
• Two internal sutures (permanent) placed approximating
both USL and posterior peritoneum.
• One external suture through USL , post peritoneum
& brought out through post vaginal wall.
• This obliterates cul-de-sac, supports vaginal apex &
lengthens posterior vaginal wall.

MOSCHOWITZ OPERATION
• Through abdominal route 3-4 successive purse string
sutures are taken starting from the bottom of the cul de sac
so as to obliterate it
• Sutures pass through the peritoneum, serosa of the rectum
and uterosacrals.

VAGINAL OPERATIONS TO SUPPORT THE VAULIT
SACROSPINOUS FIXATION
• The following description is for a patient who has had a previous total
abdominal hysterectomy.
• The vagina is incised in the midline. If anterior vaginal repair is
needed, this is carried out first,
• The mobilisation of the right para-rectal space to gain access to the
sacrospinous ligament.
• The tissue between the lateral side of the rectum and the
sacrospinous ligament is the rectal pillar, and it is necessary to create a
window in the rectal pillar to gain access to the ligament.
• The dissection continues until the glistening fibres of the ligament are
clearly visible

• The sacrospinous ligament runs posteromedially from the ischial spine
to the lateral border of the sacrum and coccyx.
• Suture is passed through the ligament is therefore two fingers’
breadth medial to the spine, without allowing the suture to go deep to
the ligament or superior to the ligament.
• One end of each of the sutures is brought through the complete
thickness of the vaginal vault. The other end is sutured and tied into the
underside of the vaginal vault skin/fascia and is then brought through
the vaginal skin
• Two sutures will act like a pulley.
• The skin of the vagina is pushed upwards towards the sacrospinous
ligament and the sutures
are tied without tension,

HIGH UTEROSACRAL LIGAMENT SUSPENSION
• This procedure to support the vaginal apex is rarely performed but is
frequently used as an alternative to sacrospinous fixation.
• The uterosacral ligament is identified and the ureter is palpated
laterally and the rectum medially.
• Two or three delayed absorbable sutures are placed in each
uterosacral ligament but not tied.
• The distal 2 cm of the uterosacral ligaments are sutured together in
front of the rectum to obliterate the Pouch of Douglas.
• Previously placed delayed absorbable sutures are then brought
through the fascia and full thickness of the vagina and tied.

ILIOCOCCYGEUS FASCIA SUSPENSION
• Repair any anterior compartment defect if present
• Iliococcygeus muscle identified lateral to rectum & anterior
to ischial spine
• Sutures placed anterior to ischial spine
• Passed through vaginal apex

ABDOMINAL SACROCOLPOPEXY
• Suspension of the vaginal vault from the sacrum using mesh can be
done laparoscopically or through laparotomy.
• Adhesions throughout the pelvis are freed. The vaginal vault is
identified and the peritoneum is opened in order to mobilise the
bladder.
• the peritoneum over the sacral promontory is divided and the incision
in the peritoneum is continued across the right side of the pelvis to the
vaginal vault.
• The mesh is placed over the vaginal vault and sutured using at least
three pairs of interrupted prolene sutures posteriorly, one pair of
sutures at the vault and two pairs of sutures anteriorly.

VAGINAL
• McCall’s culdoplasty
• Sacrospinous ligament fixation
• High Uterosacral ligament suspension with fascial reconstruction
• Iliococcygeus fascia suspension
• Meshplasty
ABDOMINAL
• Abdominal sacral colpopexy
• High uterosacral ligament suspension
• Laproscopic approach
OBLITERATIVE
• LeFort’s Partial Colpocleisis
• Introital tightening

UTERINE PRESERVATION OPERATIONS FOR APICAL
PROLAPSE
CAN BE PERFORMED IN CASES
• with complete collapse of the pelvic floor,
• associated with ulceration of the skin,
• with or without previous hysterectomy in an elderly patient who is no
longer having intercourse
TWO TYPES
• PARTIAL COLPOCLEISIS
• TOTAL COLPOCLEISIS

MANAGEMENT OF POP USING MESH
Synthetic and biological mesh have been used.
Found to be better than traditional methods of repair.
Absorbable- Fascia lata, dermis, rectus sheath and
polygalactin(Synthetic)
Non absorbable- Synthetic- Polypropylene,
polytetrafluroethylene.
Prolene mesh are commonly used- synthetic,
macroporus and monofilament
Absorbabale mesh are less likely to cause complications
but failure rates are high.
Non absorbable have low failure rate but higher rate of
complications.

Pelvic organ prolapse

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