Pelvic Organ Prolapse :
Overview of Causes and Surgical
Options
Vincent Tse
MB BS ( Hons ) MS ( Syd ) FRACS
Male and Female Incontinence Urodynamics
Neuro-urology Pelvic Floor Reconstructive Surgery
Department of Urology, Concord Hospital, Sydney, NSW
“Pelvic Floor Reconstructive Surgery”

Recent time becoming a cross-disciplinary field
– Gynaecologist
– Urologist
– Colorectal surgeon
the PELVIC FLOOR SURGEON

Common interest and training in pelvic floor
dysfunction

Various national and international societies
collaborating research in this growing area
What is POP ?
Herniation of adjacent structures into vagina
What is Pelvic Organ Prolapse ? (POP)

Herniation of various pelvic structures
adjacent to the vagina

Can be in the form of :
•
•
•
•
anterior compartment – cystocele
vault – enterocele/uterine prolapse
posterior compartment – rectocele
perineum – perineal descent
POP Prevalence

20-30% in multiparous

2% in nulliparous

20% in post-gynaecological surgery

10% in requiring POP surgery in lifetime
Pathophysiology of POP
•
Central is genetic predispositon
– Age
– Childbirth ( pudendal nerve injury denerevates levators)
• One birth doubles POP risk
• 10-15% increase every subsequent birth
– Nerves
– Collagen
– Abdo pressure
• BMI > 30 increases risk by 40-75%
– Surgery
• Burch
• Hysterectomy
Pathophysiology of POP
... Leading to herniation of various pelvic
structures adjacent to the vagina
from
DETACHMENT or DISRUPTION
Types of Defects
 Detachment
– vagina is broken away from the
pelvis and needs to be reattached
 Disruption
– vaginal structure is torn and needs
to be patched or repaired
Normal Pelvic Support

Muscle
• Levator ani ( ‘pelvic floor muscle’)
• Obturator muscles

Ligaments
• Endopelvic fascia
» Pubourethral, urethropelvic, vesicopelvic,
cardinal, uterosacral, rectovaginal septum …
Nerves
 Blood Supply

Level 1
support –
vault/uterine
prolapse
Level 2
Support –
cystocele,
enterocele,recto
cele
Level 3 Support –
Perineal
descent,low
rectocele
LEVEL 2 and LEVEL 3
SUPPORTS
Level 2 Support Defects - Anterior Compartment :
The Cystocele

2 types :
– CENTRAL DEFECT
– Defect in fascia between vagina and bladder
– Loss of central rugae
– Looks like a round bulge on Valsalva
– LATERAL DEFECT
– Defect in fascia supporting lateral bladder to pelvic side
wall
– Central rugae intact
– Flat sagging anterior vagina
– >80% are mixed
Anterior Compartment Prolapse :
Cystocele

Patient may present with :
–
–
–
–
–
–
–

Asymptomatic
‘bulge’ or pressure in vagina
Often worse at end of day
Back ache
Irritation from contact with underwear
Voiding difficulty and Recurrent UTIs
Obstructive uropathy
Cystocele are often accompanied by :
– Prolapse of other compartments prolapse ( eg. vault or rectocele )
– STRESS incontinence
Grading of Pelvic Organ Prolapse ( POP )

Baden-Walker ( older, more clinically useful )
•
•
•
•

Grade 1: minimal displacement with straining
Grade 2: towards introitus with straining
Grade 3: to and beyond level of introitus with straining
Grade 4 : outside introitus at rest
POP-Q ( newer … )
• Cumbersome and questionable clinical utility other than
for research ( standardisation ) purposes
Management

Conservative
• Simply observe
• Vaginal ring pessary
• Topical estrogen cream if indicated

Surgical
• Most pts need pre-operative urodynamics to exclude
occult stress incontinence
– Anterior colporraphy ( central defect )
– Paravaginal repair ( lateral defect )
• +/- TVT or fascial pubovaginal sling
Type of Surgery Depends on …
 Detachment
– vagina is broken away from the
pelvis and needs to be reattached
 Disruption
– vaginal structure is torn and needs
to be patched or repaired
Anterior Compartment
• To Replace
– Add mesh/biologic
(graft augmentation)
Mesh Use in PRIMARY Cystocele Repair
Author
Year
Mesh
N
F- up
mths
Anatom.
success %
Infection%
Vaginal
erosion %
Julian
1996
Marlex
12
24
100
0
8.3
Flood
1998
Marlex
142
36
94.4
3.5
2.1
Adhoute
2004
Gynemesh
52
27
95
0
3.8
Shah
2004
Prolene
29
25
93.3
0
6.7
Dwyer
2004
Atrium
47
29
94
0
7
Milani
2004
Prolene
63
17
94
0
13
de Tayrac
2007
Polypropylene
132
13
92.3
0
6.3
Hiltunin
2007
Polypropylene
104
12
93.3
(vs 61.5 AR)
0
17
Sivaslioglu
2008
Polypropylene
90
12
91
0
(vs 72% AR)
6.9
Nieminen
2008
Polypropylene
105
24
89
0
(vs 59% AR)
8.0
Level 2 Support Defects - Posterior Compartment:
The Rectocele

May present with :
•
•
•
•
•
•
Asymptomatic
Defecatory difficulty/constipation
Digital manipulation of posterior vaginal wall
Deep pelvic pain
Back pain
Urinary difficulty
Entero-Rectocele
Management

Conservative
• Bowel softeners
• Exclude other possible low rectal conditions (eg. cancer)
• Ring Pessary

Surgical
•
•
•
•
Pre-operative defecatory rectoproctography
Posterior colporraphy
Transanal Delorme repair
Perineorraphy if perineal descent present
Level 1 Support Defects :
Vault / Uterine Prolapse

Presentation often similar to cystocele

Often co-exist with cystocele/rectocele

Beware of the little old lady with unexplained back
pain, recurrent UTIs, or renal failure – exclude
PROLAPSE
Procidentia
Management

Conservative
• Observe
• Ring pessary
• Topical Estrogen if required

Surgical
• In general,
– YOUNGER and SEXUALLY ACTIVE
» Suspend to the sacrum
– OLDER and NON-SEXUALLY ACTIVE
» Suspend to the sacrospinous ligament
Surgical Management : Level 1
FUNCTIONAL
• To sacrum
– Sacrocolpopexy/hysteropexy
» Open, laparoscopic, robotic
– Uterosacral ligament
• To other level 1 sites
– Sacrospinous ligament
– Iliococcygeal fascia, etc
NON-FUNCTIONAL
• colpocleisis
Open Sacrocolpopexy
sigmoid
Sacral promontory
rectum
vault
bladder
Transvaginal Sacrospinous
Ligament Fixation
Open vs Transvaginal Sacrocolpopexy

Open
•
•
•
•
•

Level 1 evidence – most durable and effective
Preserves vaginal axis hence less dyspareunia
Lower complication profile
Rx of choice for recurrence
Longer stay and return to activity
Transvaginal
•
•
•
•
Equally effective but …
Alters vaginal axis, hence higher dyspareunia rate ( 15%)
May be more appropriate for the older, less sexually active
Shorter stay and less invasive
CONCLUSION
Conclusion

Causes of POP

Level 1 and 2 support defects

Overview of conservative and operative
management of cystocele, rectocele and
vault prolapse
Take Home Messages

Aetiology is multifactorial

CAVEAT : pelvic examination in the elderly female with
confusion, recurrent UTIs, unexplained renal impairment !

Conservative management with pessary

Pelvic floor exercises may retard the progression of POP,
but will not reverse any existing POP

Management of pelvic prolapse are now managed by pelvic
floor reconstructive surgeons who have had special
training and may be a gynaecologist, urologist or colorectal
surgeon !
Thank You for your Patience !