Pocket ObGyn – Pelvic Organ Prolapse (PoP)
See Abbreviations
Definitions
- Loss of support of the anter, apical, or post compartments of the vagina that result in protrusion of pelvic organs into or out of the vaginal canal (bladder, rectum, small bowel, sigmoid, colon, or uterus/cervix).
- Anter: Cystocele: Prolapse of bladder into the vagina
- Apical: Uterine prolapse: Prolapse of uterus & cervix into the vagina or vaginal vault prolapse: Prolapse of the vaginal vault or cuff after hysterectomy
- Post: Rectocele: Prolapse of rectum into the vagina
Epidemiology (Obstet Gynecol 1997;89:501)
- Risk of POP requiring Surg by the age of 80 is ~11%
- POP is the 3rd most common indication for hysterectomy following leiomyomata & endometriosis
Pathophysiology (Cochrane Database Syst Rev 2010;4:3)
- Risk factors – Preg, childbirth, congen or Acq connective tissue abnormalities, denervation or weakness of the pelvic floor, aging, hysterectomy, menopause & factors a/w chronically raised intra-abdominal pres, & race (Black & Asian w/ lowest risk, Hispanic w/ highest risk)
- 3 levels of support of the vagina (Am J Obstet Gynecol 1992;166:1717)
Level I: Apical & uterine support comprised of cardinal & uterosacral ligament attachment to the cervix & upper vagina ® defects in this support complex may lead to apical prolapse
Level II: Lateral support of the vagina including paravaginal attachments (pubo- cervical fascia & arcus tendineus fasciae pelvis) contiguous w/ the cardinal/utero- sacral complex at the ischial spine ® defects in this support may lead to lateral, paravaginal, & anter wall prolapse
Level III: Support of distal 3rd of the vagina comprised of perineal body, superficial & deep perineal muscles, & fibromuscular connective tissue ® defects in this support may lead to anter & post vaginal wall prolapse, gaping introitus, & perineal descent
Clinical Manifestations
- Assoc sx (Note: Many women may be asymptomatic):
Bulge, pelvic heaviness, backache, urinary incontinence, frequency or urgency, diffi- culty in initiating & maintaining urinary flow, incomplete emptying, sexual dysfxn, incontinence of stool or flatus, constip, or need for splinting
• Physical exam:
Perform a full physical exam to determine pathology outside of the pelvis
Vaginal exam:
Routine external & bimanual exam while in lithotomy position
Elicit bulbocavernosus reflex & anal wink reflex to determine if sacral pathways are nml
Ask the pt to Valsalva while gently spreading the labia to determine overall prolapse
Inspect each compartment of the vagina separately w/ the pt performing max Valsalva. Use 1 blade of the speculum to assist in visualizing the anter or post compartment individually. During assessment determine the location & degree of prolapse relative to the hymenal ring.
Perform a rectovaginal exam to assess post wall defects, enterocele, & deter- mine anal sphincter strength
A PVR by catheterized specimen will help determine adequate emptying. Will also provide opportunity for urinalysis.
Pelvic Organ Prolapse Quantification (POP-Q)
- Provides an objective site-specific system for determining location & staging of POP w/ the hymen as the fixed point of reference
- Negative numbers indicate support above the hymen where a positive value indicates prolapse beyond the hymen
Figure 7.1 A (diagram on left): POP-Q.There are site points labeled Aa, Ba, C, D, Bp, and Ap that correspond to points above or below the hymenal remnants and are stated in centimeters above (negative) or below (positive) that point.The genital hiatus (gh), perineal body (pb), and total vaginal length (tvl) are also listed as lengths in centimeters.They are used to quantify pelvic organ support anatomy. B (grid on right): Grid for recording quantitative description of pelvic organ support
(From Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10)
Stages of Prolapse
- Stage 0: No prolapse is demonstrated
- Stage I: Most dependent portion of prolapse is >1 cm above the hymen
- Stage II: Most dependent portion of prolapse is £1 cm prox or distal to the hymen
- Stage III: Most dependent portion of prolapse is >1 cm below the hymen but extends no further than 2 cm £TVL – 2 cm
- Stage IV: >TVL – 2 cm
Diagnostic Workup/Studies
- Physical exam is generally suff to determine type & stage of prolapse
- Urodynamic studies may be useful to determine occult urinary incontinence
Treatment: Nonsurgical Management
- Assurance & observation
- Pelvic floor muscle exercises (Kegel exercises)
Minimal risk & low cost, but no high-quality evid supporting prevention or rx of prolapse
- Pessary
Indications – poor operative candidate, desire to avoid Surg, used as diagnostic tool to determine if urinary incontinence resolves w/ restoration of anatomy
Continuation rate 50–80% after 1 y of use (Int Urogynecol J 2011;22:637)
Treatment: Surgical Management
- Apical support (uterine or vault prolapse):
Sacrocolpopexy: Mesh (typically polypropylene) suspension of the vagina or uterus to the anter longitudinal ligament of sacrum via abdominal, laparoscopic, or robotic-assisted approach
Risks: Mesh erosion 2–11% (Obstet Gynecol 2004;104:805), GI complications including SBO, other abdominal surgical complications, de novo stress incontinence, thus need to consider concomitant anti-incontinence procedure (NEJM 2006;354:1557)
Sacrocolpoperineopexy: Same technique as above, w/ addition of post arm of mesh extending to the perineal body
Uterosacral ligament suspension: Suspension of the vaginal cuff after hyster- ectomy to the bilateral uterosacral ligaments at the level of the ischial spines Risks: Ureteral obst up to 11% (cystoscopy recommended)
Sacrospinous ligament fixation: Suspension of the vaginal apex to the sacro- spinous ligament either unilaterally or bilaterally, typically using an extraperito- neal approach
Risks: Anter prolapse rate 6–28%, pudendal & inferior gluteal vessels & nerves lie behind the sacrospinous ligament & may be injured during procedure caus- ing hemorrhage or postop gluteal pain
Iliococcygeal suspension: Attaches the vaginal apex to the fascia of the iliococ- cygeus muscles bilaterally
Risks: No randomized trials that support the use of this procedure & may shorten vagina
• Anter compartment defect:
Anter colporrhaphy: Midline plication of endopelvic fibromuscularis of the anter vagina w/ removal of excess vaginal mucosa, ± graft reinforcement Benefits: Easy to perform
Risks: Only 50% anatomic cure
Paravaginal repair: Same as above w/ addition of lateral dissection to the arcus tendineus or obturator fascia w/ reinforcement sutures placed in these struc- tures. Can be performed by laparoscopic, vaginal, or abdominal approaches.
• Post compartment defect:
Post colporrhaphy: Midline plication of the rectovaginal fibromuscularis in the post vagina w/ removal of excess vaginal mucosa
Benefits: Cure rate is 76–96%
Risks: Excessive removal of vaginal mucosa can result in vaginal narrowing & dyspareunia, 25% rate of postsurgical dyspareunia alone
Site-specific repair: Identification of isolated defects in the rectovaginal fibro- muscularis & subseq repair
• Obliterative procedures in nonsexually active individuals:
Complete colpocleisis – removal of vaginal epithelium w/ suturing of the anter & post vaginal walls together, thus obliterating the vaginal lumen & effectively closing the vagina.
LeFort colpocleisis – partial excision of the anter & post vagina w/ closure of the vaginal lumen distal to the cervix (uterus in situ), lateral tracts left patent to allow for egress of cervical & vaginal mucus or discharge
• Mesh augmentation & mesh kit procedures:
Biologic: Autologous (self), allograft (donor), or xenograft (porcine/bovine)
Synthetic: Types I–IV based on pore size, type I monofilament most used due to large pore size & decreased rates of infxn
Mesh kits: Various types of kits: There is an FDA warning about the increased risk of complications including mesh erosion, GI involvement, pain, & need for reop- eration. ACOG recommends vaginal mesh be reserved for high-risk pts including those w/ recurrent prolapse &/or medical comorbidities precluding a lengthier Surg (Obstet Gynecol 2011;118:1459–1464).