Pelvic Organ Prolapse : Overview of Causes and Surgical Options

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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

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Pelvic Floor Reconstructive Surgery

• Recent time becoming a cross-disciplinary field
• Gynaecologist
• Urologist the PELVIC
  FLOOR SURGEON
• Colorectal surgeon
• Common interest and training in pelvic floor
  dysfunction
• Various national and international societies
  collaborating research in this growing area

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What is POP ?
Herniation of adjacent structures into vagina
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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

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POP Prevalence

• 20-30 in multiparous
• 2 in nulliparous
• 20 in post-gynaecological surgery
• 10 in requiring POP surgery in lifetime

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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 gt 30 increases risk by 40-75
• Surgery
• Burch
• Hysterectomy

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Pathophysiology of POP

• ... Leading to herniation of various pelvic
  structures adjacent to the vagina
• from
• DETACHMENT or DISRUPTION

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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

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Normal Pelvic Support

• Muscle
• Levator ani ( pelvic floor muscle)
• Obturator muscles
• Ligaments
• Endopelvic fascia
• Pubourethral, urethropelvic, vesicopelvic,
  cardinal, uterosacral, rectovaginal septum
• Nerves
• Blood Supply

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Level 1 support vault/uterine prolapse
Level 2 Support cystocele, enterocele,rectocele
Level 3 Support Perineal descent,low rectocele
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LEVEL 2 and LEVEL 3 SUPPORTS
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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
• gt80 are mixed

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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

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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

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POP-Q System
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• POPQ

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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

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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

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Anterior Compartment

• To Replace
• Add mesh/biologic
• (graft augmentation)

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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 (vs 72 AR) 0 6.9
Nieminen 2008 Polypropylene 105 24 89 (vs 59 AR) 0 8.0
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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

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Entero-Rectocele
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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

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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

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Procidentia
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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

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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

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Open Sacrocolpopexy
sigmoid
Sacral promontory
rectum
vault
bladder
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CLOSURE OF CUL-de-SAC prevents ENTEROCELE
FORMATION
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Transvaginal Sacrospinous Ligament Fixation
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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

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CONCLUSION
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Conclusion

• Causes of POP
• Level 1 and 2 support defects
• Overview of conservative and operative management
  of cystocele, rectocele and vault prolapse

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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 !

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Thank You for your Patience !