PELVIC ORGAN PROLAPSE
POP
HESHAM A F SALEM
ALEX. UNIV.
MD
POP
DESCENT OF ANY OF
THE PELVIC ORGANS
BELOW ITS NORMAL
POSITION IN THE
PELVIC CAVITY .
POP
 One of the commonest presentations in
gynecological practice.
 11.1% of 80 years old women have
been exposed to the risk of POP .
Olsen 1997.
 22.7 per 10000 women had one
operation for POP in one year in the
discharge list of American hospitals .
 SUBAK 1998 has estimated the direct
cost of POP surgery to be 1012 million
US $ / year in the USA.
POP
MORE THAN 50 % OF
WOMEN UNDERGOING
SURGERY FOR POP
PERFORMS MORE THAN
ONE PROCEDURE IN
SINGLE SURGERY .
ARAH RINGOLD ET AL 2005
POP
 29.2% RECURRENCES .
 Scaring and fibrosis produced by
conventional surgery restores
only 50% of tissue strenghth .
COSSON ET
AL 2003 .J GYN OBST BIOL REP .
 58% recurrence rate after I year
of surgery in a prospective study .
whiteside et al 2004 AM J OB/GYNE.
 GOAL OF TREATMENT IS TO
RESTORE ANATOMY ANF FUNCTION
.
Rectocele and mucosal prolapse of
the anus
Complete rectal and uterine prolapse
POP
1. ANTERIOR :
URETHRA , BLADDER . (central
2. CENTRAL :
UTERUS ,CERVICAL STUMP
and lateral )
,VAGINAL VAULT .
3. POSTERIOR :
(low ,mid , high) .
RECTUM ,LOOPS OF INTESTINE
Anatomy
 In upright or sitting position
 Bladder, upper two-thirds vagina and
rectum lie in a horizontal axis
 Urethra, distal one-third vagina and anal
canal are vertical in orientation
 Pelvic floor is horizontal and is like a
hammock – levator plate
THE PELVIS
WHAT IS SPECIAL ABOUT IT?
 NARROW BONY CONTAINER .
 CONTAINS 3 DIFFERENT
DISTENSIBLE SYSTEMS .
 THEY ARE DISTENSIBLE TO MANY
MULTIPLES OF THEIR ORIGINAL
SIZES .
 3 HIGH PRESSURE POINTS .
 ONE LOW PRESSURE (low resistence )
SYSTEM ( vagina ,anal canal, urethra )
.
THE PELVIS
WHAT IS SPECIAL ABOUT IT
 THE 3 SYSTEMS ARE IN VERY CLOSE
PROXIMITY TO EACH OTHER .
 THE 3 SYSTEMS ARE KEPT IN PLACE
AND IN PROPER INTERRELATIONS
BY THE ENDOPELVIC FASCIA .
 WHEN ONE SYSTEM WORKS THE
OTHER 2 ARE NEGATIVELY
AFFECTED .
THE PELVIS
WHAT IS SPECIAL ABOUT IT
 ONE HIGH PRESSURE SYSTEM CAN
INVADE THE OTHER LOW PRESSURE
ONE IF THE SUPPORTING ENDOPELVIC
FASCIA IS TORN OR LOST .
 THE PELVIC DIAPHRAGM ACTS ONLY
AS A SOUTH GATE FOR THE PELVIS,
AND HAS NOTHING TO DO WITH THE
INTERRELATIONS BETWEEN THE
DIFFERENT SYSTEMS .
 USING THE MUSCLE TO CORRECT
MALRELATIONS BETWEEN ORGANS
NEEDS REVISION .
NORMAL DEFECATION
Anatomy
 The levator complex is composed of the
pubococcygeus, the iliococcygeus, and the coccygeus
muscles. The most medial fibers of the pubococcygeus
make up the puborectalis. These fibers loop around
the posterior aspect of the rectum and create an
anterior displacement of the rectum known as the
anorectal angle.
 The pelvic surface of the levator complex is
innervated by sacral efferent from S2 through S4. The
inferior surface is supplied by the perineal and inferior
rectal branches of the pudendal nerve.
 The levator ani musculature is attached to the inner
sides of the bony pelvis by a condensation of pelvic
fascia called the arcus tendineus.
Supporting ligaments and
fascia
 The urethropelvic ligament is a
fibrous band of connective tissue that
lines the undersurface of the bladder
neck and attaches laterally to the
arcus tendineus. The urethropelvic
ligament provides the major support
to the bladder neck and proximal
urethra. Laxity of the urethropelvic
ligament results in SUI.
Supporting ligaments and
fascia
 The pubocervical fascia is a fibrous
sheet of connective tissue that lines
the base of the urinary bladder and
inserts laterally into the arcus
tendineus. An intact pubocervical
fascia prevents the herniation of the
bladder and the proximal urethra into
the vagina. Damage to the
pubocervical fascia may cause the
bladder to herniate through the
vagina, resulting in cystocele
formation and SUI
Supporting ligaments and
fascia
 The cardinal ligaments arise from
the arcus tendineus and anchor to the
uterine cervix. The cardinal ligaments
stabilize and support the uterus,
vagina, and bladder. Weakening of
the cardinal ligaments may cause a
cystocele and uterine descensus.
Supporting ligaments and
fascia
 The uterosacral ligaments originate
from condensation of the fibrous
connective tissue overlying the sacral
promontory and insert into the
uterine cervix. The uterosacral
ligaments stabilize the uterus in the
bony pelvis. Weakening of the
uterosacral ligaments may cause a
prolapsed uterus or vaginal vault
prolapse.
Vaginal ligaments
 The vagina can be anatomically divided into
the proximal, middle, and distal regions. The
proximal segment, called the vault or cuff, is
stabilized by the parametrium, which
includes the cardinal and uterosacral
ligaments. Uterine and vault prolapse are
both associated with damage to these
supportive structures.
 The mid portion of the vagina is attached
laterally to the pelvic sidewalls by the lower
portion of the paracolpium to the arcus
tendineus fascia pelvis (ATFP), which
creates the superior lateral vaginal sulcus
observed during a physical examination.
Vaginal ligaments
 The pubocervical fascia
stretches between the ATFP to
support the anterior vaginal wall
and bladder. A cystocele can
occur when damage to the
pubocervical fascia in the central
or lateral areas (or both) allows
the bladder to prolapse into the
vagina.
Vaginal ligaments
 In a similar fashion, the posterior
vaginal wall in the mid vagina is
supported centrally and laterally by
the rectovaginal fascia, which is
attached to the fascia of the levator
ani musculature. These attachments
prevent the rectum from prolapsing
into the vagina and causing a
rectocele.
Vaginal ligaments
 The distal vagina is firmly attached to
the surrounding structures, including
the urethra and symphysis pubis
anteriorly, levator ani laterally, and
perineal musculature posteriorly.
Damage to the perineal musculature
by childbirth or surgery are common
causes of a relaxed outlet.
NATURE OF PELVIC LIGAMENTS
 THEY ARE NOT TRUE LIGAMENTS .
 THEIR MAIN FUNCTION IS BALANCE OF PELVIC
ORGANS .
 THEY SUSPEND PELVIC ORGANS WHEN THE
LEVATOR SUPPORT FAILS .
 LEVATOR IS NOT REPAIRABLE NOR
REPLACABLE.
 LIGAMENTS ARE REPAIRABLE OR REPLACABLE .
 LIGAMENTS ARE CONDENSATIONS OF A
CONTINUM CALLED THE ENDOPELVIC FASCIA .
Boat in dock analogy
 Boat- pelvic organs
 Water- levator muscles
 Moorings- Endopelvic fascial
ligaments
 Problem is with the water or moorings
or both
 Result is sinking of the boat
 Really the boat itself is fine
Boat in dock analogy
 The main support for the pelvic viscera is
provided by a group of muscles collectively
called the levator ani. An intact pelvic floor
allows the pelvic and abdominal viscera to
"rest" on the levator ani, significantly
reducing the tension on the supporting
fascia and ligaments. These pelvic
ligaments are not true ligaments and are
simply condensations of endopelvic fascia
covering the pelvic structures.
Boat in dock analogy
 The pelvic floor musculature and the pelvic
ligaments work together to provide support to
the pelvic floor structures. Most of the weight
of the pelvic viscera is supported by the
levator ani, whereas the pelvic ligaments
stabilize these structures in position, much as
a ship's weight is supported by the water and
the moorings simply keep the ship from
straying from the dock. When the levator ani
is damaged, excessive force is placed on the
ligaments, creating a predisposition for pelvic
prolapse.
PROLAPSE
 Mutifactorial involving both
neuromuscular and endopelvic fascial
damage
 Relaxation of the tissues supporting
the pelvic organs may cause
 Downward displacement of one or more of
these organs into the vagina, which may
result in their protrusion through the
vaginal introitus.
 Displacement of one or more of pelvic
organs into the rectum or onto the
perineum.
Factors promoting prolapse
 Erect posture causes increased stress on
muscles, nerves and connective tissue
 Acute and chronic trauma of vaginal delivery
 Aging
 Estrogen deprivation
 Intrinsic collagen abnormalities
 Chronic increase in intraabdominal pressure
 heavy lifting
 coughing
 constipation
Factors promoting prolapse
 More recently, an association between
collagen and connective tissue disorders and
pelvic floor relaxation has been established.
 Some vaginal prolapse conditions may even
be caused by prior pelvic surgery. For
example, a hysterectomy may cause an
enterocele or vault prolapse to form if the
vault is not adequately resuspended and the
cul-de-sac is not prophylactically obliterated.
Factors promoting prolapse
 A rectocele is a prolapse of the rectum into
the vagina through a damaged rectovaginal
septum. The most likely etiology for
rectocele formation and perineal relaxation
presumably is improper childbirth because
these conditions are essentially confined to
parous women.
 In some cases, a relaxed outlet may be
caused by an inadequately or incompletely
healed episiotomy performed at the time of
childbirth.
Factors promoting prolapse
 A cystocele is a prolapse of the
urinary bladder into the vagina
through a damaged urethropelvic
fascia . The most likely etiology for
cystocele formation presumably is
improper childbirth because these
conditions are essentially confined
to parous women.
Factors promoting prolapse
 Uterine prolapse is descent of the
uterus due to laxity or damage of the
maine uterine ligaments during
improper childbirth .
 Pelvic organ displacements are
usually the result of disruption of the
endopelvic fascia in between the
maine pelvic ligaments .
STRATEGY OF TREATMENT
1.MUSCLE DEFECT .
2.FASCIAL DEFECT
STRATEGY OF TREATMENT
 EXERCISE IS THE ONLY WAY TO
STRENGHTHEN A MUSCLE .
 MUSCLE APPROXIMATION IS HELPFUL
ONLY IN DIVARICATION DEFECTS .
 REPAIRE OR REPLACEMENT OF FASCIA
AND LIGAMENTS IS THE IDEAL WAY TO
CORRECT PROLAPSE .
 HYSTRECTOMY TO TREAT UTERINE
PROLAPSE IS AN UNWISE CHOICE .
FASCIA REPLACEMENT SURGERY







EASIER THAN CONVENTIONAL SURGERY .
SHORTER LEARNING CURVE .
LESS INVASIVE .
ORGAN SAVING . eg uterus , levator ani.
LESS LAPAROTOMIES .
FASTER RETURN TO USUAL LIFE ACTIVITIES .
SOME NEW PROBLEMS HAS EVOLVED AND NEED
SOME TIME FOR BUILDING UP EXPIERIENCE TO
MANAGE THEM .
 EQUAL OR BETTER RESULTS .
FASCIA REPLACEMENT SURGERY
 Uterine prolapse : replacement of the
uterosacral ligament by plication or mesh
promontofixation , sacrospinous fixation ,P IVS
.
 Rectocele : replacement of the rectovaginal
fascia .
 Cystocele , urethrocele : replacement of the
pubocervical fascia and urogenital triangle .
 Gsi : replacement of the pubocervical fascia by
TOT ,TVT A IVS , TVT SECURE .
Perineology
Perineology is the result of the fusion between
urogynecology and coloproctology. This "threeaxis approach" is now becoming widely
accepted.
The aim of Perineology is the understanding of the
anatomy in the respect of biomechanics and
physiology.
The functional state of the perineum can be
summarized with a T.A.P.E. (Three Axis Perineal
Evaluation).
Perineologist
 This approach has to be interdisplinary and
not multidisciplinary. There is only one boss
who must be the "architect of the
perineum", somebody who knows a lot
about the anatomy and the physiology of
the three axis.
 This new specialist is called "perineologist".
He could be the surgeon or somebody who
tells the surgeon what to do. The
perineologist must have a holistic view
(integration of the psychology, the way of
life, the abdominal wall muscles... in the
approach).
MESSAGE
 REPAIR SHOULD BE COMPREHENSIVE .
 MUSCLE EXERCISE IS IMPORTANT .
 TORN LIGAMENTS MAY BE REPAIRED
OR REPLACED .
 WE ARE IN NEED OF A PERINEOLOGIST
WHO CAN HANDLE THE PROBLEM OF
POP IN A WIDER ANGEL OF VISION .