Medical Archive

C27 Pelvic Organ Prolapse

Pathophysiology

Risk factor
- Muscle weakness
- Vaginal delivery, Old age
- Extra abdominal pressure
- Overweight, chronic coughing, heavy lifting
- Nerve, tissue damage
- History of hysterectomy, prolapse op.

Definitions

Apical compartment

Normal apical support includes the integrity of the cardinal/uterosacral ligaments, the upper paravaginal ?bromuscular connective tissue, and, when the uterus is present, the paracervical fascia. The ?bromuscular tissue of the upper vagina blends in with the paracervical fascia. Both of these are attached laterally and posterior laterally to the cardinal ligaments and uterosacral ligaments.

Anterior compartment

Figure 27.7 View of the pelvic cavity with bladder, upper vagina, and sigmoid colon removed. The ?bromuscular wall of the anterior vagina is attached to the arcus tendineus fascia pelvis by endopelvic connective tissue and supports the bladder. The pararectal fascia (Denonvillier�s fascia) includes the ?bromuscular tissue of the posterior vagina and its lateral attachment to the fascia levator ani.

Posterior compartment

Figure 27.8 Sagittal oblique view of the distal midvagina illustrating lateral connection of the posterior musculoconnective tissue wall to the fascia levator ani and anterior wall to the arcus tendineus pelvis. The attachment sites fuse together at a point closer to the ischial spine where the vagina assumes a more oval shape.

Evaluation

Symptoms

Physical examination

Pelvic organ prolapse quantitation system

Figure 27.9 Standardization of terminology for female pelvic organ prolapse (POP-Q) classi?cation. This diagram demonstrates the anatomic position of the POP-Q sites, including six sites involving the anterior (Aa, Ba), middle (C, D), and posterior (Ap, Bp) compartments with the genital hiatus (gh), perineal body (pb), and total vaginal length (tvl).

Pelvic muscle function assessment

Bladder function evaluation

Bowel function evaluation

Rectocele ?? tenesmus? ??? ? ??. ? anal manometry

Imaging

Treatment

Surgery – Colporrhaphy(????), Sacrocolpopexy

?? ?? ? ??? ?? ?? sling ?? ??. Stage 3?? Kegel? ?? ??.

Nonsurgical therapy

Conservative management

??????? ???? ??. Reassurance and observation!
Alteration of lifestyle
Pelvic floor muscle training (PFMT)

Mechanical devices

Pessary – ??? ??? ?. ????? ?? ? estrogen cream 4-6? ??.

Surgical management

Colpocleisis(?? ???)
- ???? ?? ???? ???? ????.
- In which the�vagina�is closed off or narrowed to provide more support for pelvic organs.
Vaginal hysterectomy with colporrhaphy(?? ???)
- Anterior colporrhaphy for cystocele
- Posterior colporrhaphy for rectocele
Sacrocolpopexy
- (?? ??) with�vaginal vault suspension�and�hysterectomy: fixation of the vaginal apex to the�sacrum�for the repair of apical or�vaginal vault prolapse, with suspension and�hysterectomy