PELVIC ORGAN PROLAPSE

Dr. Hazem Al-Mandeel

481 GYN

Department of Obstetrics & Gynecology

كمرجع كافي الساليدالدكتور – لكالم طبقا

التيم من نوت اضافه تم

Objectives

• To define pelvic organ prolapse

• Recognize pelvic anatomy

• Determine the Pathophysiology

• Discuss the predisposing factors

• Understand the grading systems

• Be aware of the options of management

Pelvic Organ Prolapse

• Is the descent of the pelvic organs as a result of the loss of muscular and fascial structural support .

• The only orifice for prolapse is the vagina

• Cause : destruction of one or more of the Anatomical support

Anatomic Supportsاسئله – ) ( محل جدا مهمه

• Muscular : Levator Ani (Pelvic Floor Ms.)

• Ligaments : Uterosacral-Cardinal Complex

• Fascial : Endopelvic (Pubocervical & Rectovaginal)

1- Levator Ani

• Major structure of pelvic floor

• Anterior/posterior orientation

• Perforated by urogenital hiatus

• Consists of : Pubococcygeus

Iliococygeus

Puborectalis

Coccygeus

اثنين اولشي اهم

2- Endopelvic Fascia

• Fibromuscular layer

• Local condensations are ligaments

• Principal ligaments are Uterosacral

Cardinal

• Pubocervical and Rectovaginal Fascia important in specific surgical correction

Pathophysiology

• Direct Trauma to pelvic soft tissues

• Neurological injury

• Connective tissue disorders

Predisposing Factorsمهمه

• Hereditary (genetic) predisposition

• Race: White > Black > Asian

• Pregnancy and Vaginal Childbirth

• Age and Menopause

• Raised intra-abdominal pressure (e.g.: obesity, cough, constipation, lifting, etc)

• Iatrogenic: surgical procedure

Types of Pelvic Organ Prolaopse

1. Urethra

2. Bladder

3. Uterus/ Vaginal Vault

4. Small Bowel

5. Rectum

6. Perineum body ( between the vagina and the uterus )

Compartmentsaccording to the relation to the vagina

• Anterior : Cystocele

Urethrocele

• Middle : Uterine prolapse

Enterocele/vault prolapse

• Posterior : Rectocele

Rectal prolapse

middle

The pt had hysroectomy

Rectocele

Classification of Prolapse

• Baden Walker (1972)

• Each site graded from 1 – 4

• POPQ: quantifies using specific points

• Measured relation to the hymenal ring

• More widely used

Symptoms of Prolapseاسئله – مهمه

• Pelvic pressure

• Pelvic pain

• Feeling of a “lump”

• Back pain

• Urinary dysfunction

• Bowel dysfunction

Complications of Prolapse

• Bleeding

• Infection

• Recurrent UTI’s

• Urinary obstruction

• Renal failure

Associated conditions

• Urinary Incontinence : Stress

Urge

Mixed

• Fecal Incontinence : sphincter injury

Options of Management it is not emergency

• No Treatment ( pelvic floor exercise)

• Conservative: such as

Physiotherapy or Pessary ( انظرالقادمه الشريحه

• Surgical Treatment

Aims of prolapse surgery

• Alleviate symptoms

• Restore normal anatomy

• Restore normal visceral function

• Avoid new bladder or bowel symptoms

• Preserve sexual function

• Avoid surgical complications

Classisfication of prolapse surgery

• Vaginal

PrimaryVaginal hysterectomyAnterior/Posterior repair

SecondarySacrospinous fixationIliococcygeus fixationUterosacral fixation

Recurrent+/- reinforcementSynthetic mesh/autologous/

donor/Xenograft

• Abdominal

Primary

Paravaginal repair

Hysteropexy

Secondary +- reinforcement

Sacrocolpopexy

Uterosacral/Sacrospinousfixation

• Laparoscopic

All of the Abdominal procedures +/-reinforcement

Conclusions

• Pelvic organ prolapse is common• Results from injury to soft tissue and nerves• Childbirth most significant association• Treatment requires understanding of anatomic

relationships• Treated with a combination of physio/pessary

and often complex surgery