Transcript Pelvic Organ Prolapse

Katrina Marie D. Soto
General Data
 G.S.
 63 year old
 G3P3 (3003)
 Married
 Roman Catholic
 Housewife
Chief Complaint
Past Medical History
 No comorbids (hypertension, DM, Asthma, COPD)
 No previous surgeries
 No allergies
Personal and Social History
 Non-smoker
 Non-alcoholic beverage drinker
Family History
 (+) Bronchial Asthma- maternal side
 (-) Hypertension, Diabetes mellitus, asthma
Menstrual History
 Menarche: 17 years old
 Regular intervals (28-30 days)
 Duration: 3 days
 2 pads per day
 (+) occassional dysmenorrhea
 Menopause for the past 19 years (1981)
Gynecologic History
 Coitarche: 18 years old
 Sexual Partners: 2
 Denied sexual activity
 (+) occassional vaginal bleeding
 No foul smelling vaginal discharge
 Denied OCP or IUD use
 Pap Smear 2009: normal
OB History
 G3P3 (3003)
 1970 –full term- female- ~7lbs- NSD- Isabela hospital-
no fetomaternal complications
 1971 –full term- female- ~8lbs- NSD- Isabela hospitalno fetomaternal complications
 1981 –full term- female- ~7lbs- NSD- Isabela hospitalno fetomaternal complications
History of Present Illness
• (+) pea sized introital mass, spontaneously
reducible, more prominent on straining
3 yrs PTA
• (-) pain, fever, changes in urinary or bowel
habits, vaginal bleeding, vaginal discharge
• Consult done at Isabela hospital where patient
was given unrecalled medications (suppository)
HPI
• Patient followed up every 6 months, (+) persistence of
Interim introital mass
• Noted increase in the size of the mass (~size of a fist)
1 yr PTA • Manually reducible
• (+) feeling of incomplete voiding, incontinence,
frequency, minimal vaginal bleeding no bowel changes
HPI
• Consult with AMD
• TVS: normal
• Advised surgery but patient deferred due to
financial constraints
• (+) persistence of symptoms but with regular
follow up every 6 months  Admission
Review of Systems
 Unremarkeable
Physical Examination
 Conscious, coherent, not in cardio-respiratory distress,
 BP: 110/70mmHg CR: 68/min, regular RR: 20/min,
regular T: 36.8oC Wt 58 kg Ht 168cm BMI 22.7
 Skin: warm with good skin turgor
 Head: skull normocephalic, atraumatic
 Eyes: pink palpebral conjunctivae, anicteric sclerae
 Neck: supple neck, with no palpable neck mass, no
neck vein engorgement
Physical Examination
 Lungs: symmetrical chest expansion, no rib
retractions, clear and equal breath sounds
 Heart: adynamic precordium, normal rate, regular
rhythm, no murmurs
 Abdomen: Symmetrical, flabby , NABS, soft, no
direct/indirect tenderness, no masses palpated
 Full and equal pulses, no cyanosis
 External exam: (+) introital mass, smooth mucosa, no
ulcerations or bleeding noted.
Salient Features
Subjective
Objective
 (+) 63 year old G3P3 (3003)
 Conscious, coherent not in
 (+) 3 year history of gradually
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enlarging introital mass
(+) 1 year history of frequency,
incontinence, feeling of
incomplete voiding, occ vaginal
bleeding TVS: normal
No comorbids or previous
surgeries
Menopause for 19 years
G3P3 (3003) NSD, 7-8 lb babies
cardiorespiratory distress
 BP: 110/70mmHg CR: 68/min,
regular RR: 20/min, regular T:
36.8oC Wt 58 kg Ht 168cm BMI
22.7
 Abdomen: Symmetrical, flabby ,
NABS, soft, no direct/indirect
tenderness, no masses palpated
 External exam: (+) introital
mass, smooth mucosa, no
ulcerations or bleeding noted.
Initial Assessment
 63 year old G3P3 (3003)
 Pelvic Organ Prolapse Stage III
Differential Diagnosis
 Pedunculated myoma
 Cervical Polyp
 Bartholin’s Duct Cyst
 Soft tissue tumors (lipoma, leimyomas, sarcomas)
Epidemiology
 3rd most common indication for hysterectomy
 estimated lifetime risk of 11% to undergo surgery for
prolapse or incontinence (Olsen, 1997)
 Prevalence increases with age (Olsen, 1997)
 there was a 100-percent increased risk of prolapse for
each decade of life (POSST)
 physiologic aging, degenerative processes and
hypoestrogenism
Risk Factors
 Multiparity
 Vaginal birth – most frequently cited risk factor (Swift,
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2005) risk of POP increased 1.2 times with each vaginal
delivery
Menopause (aging, hypoestrogenism)
Chronically increased intra abdominal pressure
(COPD, obesity, constipation)
Pelvic floor trauma
Race
Connective Tissue disorders
Definition
 Prolapse is the downward displacement of one of the
pelvic organs from its normal location that results in
vaginal wall protrusion or bulge
 cystocele, cystourethrocele, uterine prolapse, rectocele,
and enterocele have traditionally been used to describe
the protrusion location
POP-Q
POP-Q Staging
Stage 0 No prolapse; anterior and posterior points are all -3 and C
(cervix) or D (posterior fornix) is between - TVL (total Vaginal length)
and - (TVL - 2) cm.
Stage I The criteria for stage 0 are not met, and the most distal prolapse is
>1 cm above the level of the hymen (< -1 cm).
Stage II The most distal prolapse is between 1 cm above and 1 cm below
the hymeneal ring (at least one point is - 1, 0, or +1).
Stage III The most distal prolapse is between >1 cm below the hymeneal
ring, but no further than 2 cm less than TVL.
Stage IV Represents complete vault eversion; the most distal prolapse
protrudes to at least (TVL - 2 ) cm.
International Continence Society Stages of Pelvic Organ Prolapse Determined by Pelvic Organ
Prolapse Quantification System Measurements
Baden-Walker Halfway System
 Grade 0 Normal position for each respective site
 Grade 1 Descent halfway to the hymen
 Grade 2 Descent to the hymen
 Grade 3 Descent halfway past the hymen
 Grade 4 Maximum possible descent for each site
Pathophysiology
 Pelvic organ support is maintained by complex
interactions between the levator ani muscle, vagina,
and pelvic floor connective tissue
 the upper vagina lies nearly horizontal in the standing
female
 upper vagina is compressed against the levator plate
during periods of increased intra-abdominal pressure
(flap valve effect)
Relevant Anatomy
The axes of pelvic support
 Three support axes
 Upper vertical axis (cardinal-uterosacral ligament
complex)
 Horizontal axis leads to lateral and paravaginal supports
two platforms pubocervical fascia and rectovaginal
septum
 Lower vertical axis supports the lower third of the
vagina, urethra and anal canal
DeLancey’s three levels of vaginal
support
 Apical suspension
 Upper paracolpium suspends apex to pelvic walls and sacrum
 Damage results in prolapse of vaginal apex
 Midvaginal lateral attachment
 Vaginal attachment to arcus tendineus fascia and levator ani muscle
fascia
 Pubocervical and rectovaginal fasciae support bladder and anterior
rectum
 Avulsion results in cystocele or rectocele
 Distal perineal fusion
 Fusion of vagina to perineal membrane, body and levators
 Damage results in deficient perineal body or urethrocele
Clinical Evaluation
 Bulge Symptoms
 Urinary Symptoms - stress urinary incontinence (SUI),
urge urinary incontinence, frequency, urgency, urinary
retention, recurrent urinary tract infection, or voiding
dysfunction
 GI symptoms- constipation
 Sexual dysfunction
 Pelvic and back pain
Physical Examination
 full body systems evaluation to identify pathology
outside the pelvis
 Initial pelvic exam  dorsal lithotomy position
 vulva and perineum are examined for signs of vulvar or
vaginal atrophy, lesions, or other abnormalities
 neurologic examination of sacral reflexes is performed
using a cotton swab (bulbocavernosus reflex and anal
wink)
 Pelvic organ prolapse examination begins by asking a
woman to attempt Valsalva maneuver prior to placing
a speculum in the vagina  true anatomy
Physical Examination
 Speculum exam
 (1) Does the protrusion come beyond the hymen?; (2)
What is the presenting part of the prolapse (anterior,
posterior, or apical)?; (3) Does the genital hiatus
significantly widen with increased intra-abdominal
pressure?
 Pop Q examination
 Bimanual examination is performed to identify other
pelvic pathology
 Assessment of pelvic floor musculature
Anterior compartment defects
 Urethral hypermobility
 Distal 4 cm of anterior vaginal wall
 Cotton swab test
 If describes an arc greater than 30 degrees from
horizontal with valsalva
 Results in genuine stress incontinence
 Cystocele
Evaluation of a cystourethrocele
Cystocele
 Main support of urethra and bladder is the pubo-vesical-
cervical fascia
 Essentially a hernia in the anterior vaginal wall due to
weakness or defect in this fascia
 Symptoms include pelvic pressure and bulge or mass in the
vagina
 Surgical repair is the treatment of choice
Posterior compartment defects
 Rectocele
 Perineal deficiency
 Bulbocavernous and superficial transverse muscle heads
retracted
 Perineal descent
 Sagging and funneling of the levator ani around the
perineum such that anus becomes most dependent
 Difficulty with defecation
Rectocele
 Chiefly a hernia in the posterior vaginal wall secondary
to weakness or defect in the rectovaginal septum
 Symptoms include difficulty evacuating stool, a
vaginal mass, and fullness sensation
 Rectovaginal exam confirms diagnosis
Evaluation of a rectocele
Rectocele
 Damage generally due to excessive pushing in
childbirth or chronic constipation
 Surgical treatment if symptomatic
 Posterior Colporrhaphy
 Laxatives and stool softeners

Temporary relief
Apical defects
 Uterine prolapse
 Normal cervix located in upper third of vagina
 Degree of prolapse measured by position of cervix at
maximum intraabdominal pressure, without traction
 Complete uterovaginal prolapse is called procidentia
 Vault prolapse
 Enterocele
Uterine prolapse
 Weakness of endopelvic fascia and detachment of
cardinal and uterosacral ligaments
 Complains of severe pelvic or abdominal pressure,
bulge or mass, and low back pain
 Surgical management includes hysterectomy and
vaginal cuff or apex suspension
 Estrogen replacement important
Enterocele
 A true hernia of the rectouterine or cul-de-sac pouch
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(pouch of Douglas) into the rectovaginal septum
Descent of bowel in a peritoneum-lined sac between
posterior vaginal apex and anterior rectum
Can occur anteriorly as well
Symptoms of fullness and vaginal pressure or palpable
mass
Bowel peristalsis confirms diagnosis
Enterocele
 Commonly found in association with other defects
 Surgical approach
 Vaginal
 Abdominal

Laparoscopic
 Ligation of hernia sac and obliteration of the pouch of
Douglas
Approach to Treatment
 asymptomatic or mildly symptomatic, expectant
management is appropriate
 for women with significant prolapse or for those with
bothersome symptoms, nonsurgical or surgical
therapy may be selected.
Conservative treatments
 Obstetric care to protect pelvic floor
 Decreased pushing times
 Avoid forceps, major lacerations
 Permit passive descent
 General lifestyle changes
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Smoking cessation and cough cessation
Routine use of Kegel pelvic floor exercises
Regular physical activity
Proper nutrition
Weight loss
Avoid constipation and repetitive heavy lifting
Hormone replacement therapy
Non Surgical
 Pessaries are the
standard nonsurgical
treatment for POP.
 reserved for women
either unfit or unwilling
to undergo surgery
 2 types
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Support
Space filling
Non Surgical
 Pelvic floor muscle exercise  limit progression and
alleviate prolapse symptoms (Kegel Exercises)
 women learn to consciously contract muscles before and
during increases in abdominal pressure, which prevents
organ descent
 regular muscle strength training builds permanent
muscle volume and structural support
Principles of reconstructive pelvic
surgery
 Site-specific repair
 Rebuild weakened endopelvic fascia, repair fascial
tears, and reattach prolapsed tissues to stronger sites
 Goal is a vagina of normal depth, width and axis
 Denervation or muscle trauma cannot be corrected
surgically
Surgical
 Obliterative
 Lefort colpocleisis and complete colpocleisis
 removing extensive vaginal epithelium, suturing
anterior and posterior vaginal walls together,
obliterating the vaginal vault, and effectively closing the
vagina.
 technically easier, require less operative time, and offer
superior success rates (91-100%)
 Reconstructive
 restore normal pelvic anatomy and are more commonly
performed than obliterative procedures for POP.
What was done to the patient
 Vaginal Hysterectomy with anterior and posterior
colporrhaphy
Based on good and consistent scientific
evidence (Level A)
 The only symptom specific to prolapse is the awareness of a
vaginal bulge or protrusion. For all other pelvic symptoms,
resolution with prolapse treatment cannot be assumed.
 Pessaries can be fitted in most women with prolapse,
regardless of prolapse stage or site of predominant
prolapse.
 Cadaveric fascia should not be used as graft material for
abdominal sacral colpopexy because of a substantially
higher risk of recurrent prolapse than with synthetic mesh.
 Stress-continent women with positive stress test results
(prolapse reduced) are at higher risk for developing
postoperative stress incontinence after prolapse repair alone
compared with women with negative stress test results (prolapse
reduced).
 For stress-continent women planning abdominal sacral
colpopexy, regardless of the results of preoperative stress testing,
the addition of the Burch procedure substantially reduces the
likelihood of postoperative stress incontinence without
increasing urgency symptoms or obstructed voiding.
 For women with positive prolapse reduction stress test results
who are planning vaginal prolapse repair, tension-free vaginal
tape (TVT) midurethral sling (rather than suburethral fascial
plication) appears to offer better prevention from postoperative
stress incontinence.
Based on limited or inconsistent scientific
evidence (Level B)
 Clinicians should discuss the option of pessary use with all
women who have prolapse that warrants treatment based
on symptoms. In particular, pessary use should be
considered before surgical intervention in women with
symptomatic prolapse.
 Alternative operations for uterine preservation in women
with prolapse include uterosacral or sacrospinous ligament
fixation by the vaginal approach, or sacral hysteropexy by
the abdominal approach.
 Hysteropexy should not be performed by using the ventral
abdominal wall for support because of the high risk for
recurrent prolapse, particularly enterocele.
 Round ligament suspension is not effective in treating
uterine or vaginal prolapse.
 Compared with vaginal sacrospinous ligament
fixation, abdominal sacral colpopexy has less apical
failure and less postoperative dyspareunia and stress
incontinence, but is also associated with more
complications.
 Transvaginal posterior colporrhaphy is recommended
over transanal repair for posterior vaginal prolapse
Based primarily on consensus and expert
opinion (Level C)
 Clinicians should discuss with women the potential risks
and benefits in performing a prophylactic antiincontinence procedure at the time of prolapse repair.
 Women with prolapse who are asymptomatic or mildly
symptomatic can be observed at regular intervals, unless
new bothersome symptoms develop.
 For women who are at high risk for complications with
reconstructive procedures and who no longer desire vaginal
intercourse, colpocleisis can be offered.
 Cystoscopy should be performed intraoperatively to assess
for bladder or ureteral damage after all prolapse or
incontinence procedures during which the bladder or
ureters may be at risk of injury