Pelvic organ prolapse

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Chapter 18 Pelvic organ prolapse

Definition. Pelvic organ prolapse is the protrusion of pelvic organs into the vaginal canal. Prolapse of pelvic organs occurs when their attachments, neural connections and supports fail.

Incidence. Pelvic organ prolapse is common and affects about 1 in 3 women who have had one or more children.

Causes and risk factors

• age, parity, vaginal delivery, connective tissue dysfunction, chronic cough, constipation, size of genital hiatus, congenital factors, obesity

Examination

• general examination, including body mass index (BMI)

• abdominal: exclude mass lesion

• genital hiatus: widened

• cough with and without prolapse reduced: assess for urinary leakage

• use Sims’ speculum: left lateral or lithotomy, Valsalva

• POP-Q assessment (see below)

• vaginal examination for pelvic organ assessment

POP-Q (pelvic organ prolapse quantification) classification

The POP-Q system evaluates descent relative to a fixed reference point, the hymen. Six points are measured in centimetres above or below the hymen, and three further measurements evaluate the genital hiatus, perineal body and total vaginal length (see Fig 18.1). The six points are as follows:

1. Point Aa is located in the mid-line of the anterior vaginal wall, 3 cm above the external urethral meatus.

2. Point Ba is a point that represents the most dependent (distal) position of any part of the upper anterior vaginal wall down to point Aa.

3. Point Ap is located in the mid-line of the posterior vaginal wall, 3 cm above the hymen.

4. Point Bp is a point that represents the most dependent (distal) position of any part of the upper posterior vaginal wall down to point Ap.

5. Point C is the distal edge of the cervix or the vaginal cuff following a hysterectomy.

6. Point D is the location of the posterior fornix in women with a cervix present.

Figure 18.1 Reference points for the International Continence Society classification (1996) for vaginal prolapse

The three further measurements are:

1. Genital hiatus (GH) is measured from the middle of the external urethral meatus to the posterior mid-line hymen.

2. Perineal body (PB) is measured from the posterior margin of the genital hiatus to the mid-anal opening.

3. Total vaginal length (TVL) is the length of the vagina when points C or D are reduced to their normal positions.

Stages

• Stage 0: no prolapse is demonstrated.

• Stage 1: most distal portion of prolapse is >1 cm above the level of the hymen.

• Stage 2: most distal portion of prolapse is ≤1cm proximal to or distal to the plane of the hymen.

• Stage 3: most distal portion is >1 cm below the plane of the hymen, but protrudes to no further than 2 cm less than the TVL.

• Stage 4: complete eversion of total length of lower genital tract.

Investigations

• Urodynamics studies are useful to assess for preexisting voiding dysfunction and occult urodynamic stress incontinence.

Conservative management

• pelvic floor exercises: may reduce symptoms of prolapse

• mechanical support for prolapse inserted into vagina

• numerous types: ring, shelf, cube

Surgical management

Identify which compartments require repair, and repair all defects. Options are vaginal or abdominal approach; conserve uterus or hysterectomy; and native tissue repair or augment with biomaterials. Biomaterials are biological or synthetic. Biological materials are autografts, allografts or xenografts. Synthetic materials are mesh. The mesh should be a macroporous monofilamentous mesh.

Vaginal approach

• anterior compartment defects: anterior native tissue repair, anterior repair with biomaterial augmentation, vaginal paravaginal repair

• posterior compartment defects: posterior native tissue repair, posterior repair with biomaterial augmentation

• vault or uterine descent: sacrospinous colpopexy or hysteropexy with sutures or mesh, high uterosacral placation

• perineorrhaphy

Abdominal approach

• open or laparoscopic

• sacral colpopexy with mesh

• paravaginal repair

Risks and complications

• intraoperative complications: anaesthetic complications, bleeding and transfusion, damage to bladder, ureters or bowel

• immediate postoperative complications: infection, deep venous thrombosis, voiding difficulties, fistula formation

• long-term issues: recurrence of prolapse, dyspareunia

• mesh complications: vaginal mesh exposure, mesh erosion into bladder or bowel, mesh contraction and scarring

Long-term considerations

Depending on the type of pelvic organ prolapse repair performed, there can be significant prolapse recurrence rates of more than 30%. While traditional native tissue repairs do have significant recurrence rates, they do avoid the risks of mesh augmentation such as mesh exposure and erosion. Repair techniques using biomaterial augmentation aim to reduce recurrence rates and are continuing to be developed in order to try to reduce such risks.

When counselling patients regarding prolapse treatment, conservative and surgical options should be fully discussed. An important aspect of counselling is the realistic expectations of outcomes, in particular of surgery.

Further reading

Bump R.C., Mattieson A., Bo K., et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. American Journal of Obstetrics and Gynecology. 1996;175(1):10-17.

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