- Definition: descent of 1 or more aspects of the vagina and/or uterus (anterior/posterior vaginal wall, uterus/cervix or vaginal cuff)
- Cystocele most common (33%)
- Posterior wall 18%
- Apical 14%
- 78% have no progression over ~16%
- Peak at age 60-70; 50% anatomic prevalence in women over 50
- 10-20% of pts with prolapse will undergo POP surgery
Anatomy
- Coccygeus - covers sacrospinous ligament. Sacrospinous fixation - goes through coccygeus, can cause glute pain
- Piriformis - sciatic nerve goes through it
- Perineal body - external sphincter, superificial transverse perineus muscle, bulbocavernosus
3 levels of support
- Level 1 - Uterosacral/cardinal ligament complex (apical support)
- Level 2 - arcus tendineus fascia, extends to obturator muscle and ischial spine. Loss leads to cystocele/rectocele
- Level 3 - perineal body.
Risk factors
- Pregnancy alone - increased pressure on pelvic support structures
- Similarly - chronic constipation, COPD
- Forceps delivery, young age at first delivery, prolonged second stage of labor (causing ischemia), infant birthweight > 4500 g
- Age (11% lifetime risk of POP surgery by age 80)
- Parity
- SVD x1 - 4x risk
- SVD x2 - 8x risk
- SVD x3 - 9x risk
- SVD x4 - 10x risk
- Obesity - unclear if losing weight reduces risk
- Prior POP surgery
- Diabetes, smoking, connective tissue disorder
Symptoms
- "bulge/fullness/heaviness" (very specific)
- Difficulty voiding/defecating, needing to splint
- Irritation of prolapsed areas
Stage 1 - 20% symptomatic
Stage 2 - 50% symptomatic
- Reduce prolapse with half-speculum prior to cough stress test to reveal occult SUI
POP-Q (pelvic organ prolapse quantification)
- Objective, reproducible measuring system of pelvic prolapse
- All measurements are measured in cm relative to the hymen (which is approximately 1 cm proximal to the vaginal introitus) - eg -1 means 1 cm proximal to the hymen
- All measurements (except TVL) measured during valsalva
- No prolapse: Aa = Ba = Ap = Bp = -3
- B point is dynamic
| Anterior compartment (cystocele) | |||
| Aa (-3 to +3) -3 = 3cm proximal to the hymen anteriorly ~location of bladder neck |
Ba (-3 to +tvl ) lowest point of the prolapse anteriorly |
C Cervix lip or cuff |
Apical compartment |
| GH (genital hiatus) measure from mid-urethra to bottom of vagina *during valsalva* - helps to determine size of pessary |
PB (usually 2-3) measure from bottom of vagina to mid-rectum |
TVL determine if should avoid further vaginal shortening |
|
| Ap (-3 to+3) 3cm proximal to the hymen posteriorly |
Bp (-3 to +tvl ) lowest point of the prolapse posteriorly |
D Posterior fornix behind cervix Omitted or 'hyst' if s/p hysterectomy |
|
| Posterior compartment (rectocele) | |||
Stages of pelvic prolapse (Baden-Walker system)
- Stage based on most distal compartment
| Stage 0 | no prolapse | Aa = Ba = Ap = Bp = -3; C/D between tvl and (tvl - 2 cm) |
| Stage 1 | < -1 cm | prolapse remains above the hymen |
| Stage 2 | -1 to +1 | prolapse at introitus |
| Stage 3 | +1 to (TVL - 2) | prolapse past introitus |
| Stage 4 | Greater than (TVL - 2) | complete eversion; procedentia if uterus |
Pessaries
- 92% of women can be successfully fitted. Better for anterior/apical prolapse, doesn't work well for rectocele
- May not work if short TVL (e.g. prior hysterectomy for cancer) or large GH
- Ring pessary better for stage II/III. Can have sex with this in or pt can remove
- Size is generally GH measurement + 1.25 (to make sure it doesn't fall out). F/u 1-2 wks later to make sure comfortable
- Gelhorn may be needed for stage IV. Has a stem; works with suction, grab with a ring forcep and release the suction. Doesn't work with sexual activity
- Need to come in q3-6mo (maybe even a year) to wash/replace/examine
- Need regular exams to make sure no fissures, erosion etc. May need to start estrogen before placement
Surgical management
- Vaginal vs abdominal
- Abdominal (sacrocolpopexy) - better if higher risk of recurrence
- Mesh vs no mesh
- Hysterectomy vs hysteropexy
- Obliterative vs preserve sexual intercourse
- Overall success rate pretty high if going off of pt subjective improvement - rates of reoperation 6-10%
Level 1 - Apical management (preserving vaginal length)
- Apical prolapse is due to lack of ligamentous support - a vaginal hysterectomy alone will not fix it!
- All can be done with a hysteropexy
- Transvaginal uterosacral ligament suspension - easier to do at the same time as a hysterectomy; easier to identify ligaments. If pt has had prior hysterectomy very difficult to find the ligaments.
- Do a cystoscopy afterwards to rule out ureteral kinking (1.8%). If UOs without brisk efflux, remove the most lateral/distal suture
- Transvaginal sacrospinous ligament fixation - unilateral OK
- Avoid: pudendal n (medial), sciatic n (superior), internal pudendal artery. Err on the distal/inferior side.
- Complications: nerve injury. Immediate takeback (within 72h) if severe pain afterwards. If pelvic floor pain, remove most lateral suture (pudendal n). If sciatica symptoms radiating down leg, remove superior suture. "Normal pain" is Charlie horse-like pain in gluteal area for ~6 wks. Possible rectal injury.
- Both transvaginal approaches have similar success rate (5% risk repeat intervention)
- Abdominal sacrocolpopexy
- Mesh tacks vaginal cuff to sacral promontory
- Won't lose vaginal length if this is a concern
- Complications: bleeding from middle sacral artery, L common iliac; mesh erosion (~ 6%), rarely infection of sacral disk/osteomyelitis
- Video: hysterectomy + sacrocolpopexy
- Video: post-hysterectomy sacrocolpopexy
Level 2 middle compartment
- Cystocele/rectocele
Level 3 - perineorrhaphy
Obliterative (if no further sexual intercourse) - colpocleisis