A pelvic organ prolapse occurs when there is a defect or weakness in the supporting structures or muscular structures of the pelvis. The pelvic floor muscle is a big hammock of muscles that supports the uterus, bladder and bowel. 1 in 9 women will develop a pelvic organ prolapse by the age of 80. There is a reported 29% recurrence rate of pelvic organ prolapse in women who have previous surgery for pelvic organ prolapse, with the surgical techniques of today this have been reduced.
Contributing causes of prolapses
- Childbirth or pregnancy
- Collagen deficiency (collagen is a natural protein that helps keep tissues plump and elastic)
- Ageing and menopause
- Being overweight
- Chronic cough
- Constant heavy lifting
- Previous pelvic surgery
- Chronic constipation
Symptoms:
- Common complaints with a prolapse are
- Sensation of "something coming down" when up and about, disappears when lying down.
- Backache
- Increased frequency of needing to void {which is probably due to incomplete emptying of the bladder.}
- Problem emptying bowel
- A feeling of fullness or pressure in the lower abdominal area, {which is probably due to venous congestion and pressure from the abdominal contents on a weak and inadequate pelvic floor}.
- Sexual dysfunction and discomfort during intercourse.
- Urinary stress incontinence.
While pelvic organ prolapses are not life threatening they can certainly have an effect on your overall wellbeing and quality of life.
Types of prolapse
Cystocele or anterior wall prolapse
A cystocele is when there is a defect in the anterior wall supports and causes, the bladder to prolapse into the vaginal wall. This contributes to inability to empty the bladder properly and stress urinary incontinence.
Rectocele or posterior vaginal wall prolapse
A rectocele is where the defect is in the posterior or back wall supports of the vagina and as a result the rectum bulges into the vagina. This can contribute to difficulty emptying the bowel as this causes a pocket to form and as a result faeces become lodged there, it is not uncommon for women with a rectocele to have to use perineal pressure to aid the emptying of their bowel. A rectocele can also cause a decreased stream when passing urine as the bulge presses up against the urethra (water pipe) thus obstructing the flow of urine.
Enterocele
This is where the small bowel prolapses into the top of the vagina between the vagina and rectum, most commonly seen with a rectocele and or uterine prolapse.
Uterine prolapse
This is where the defect is in the structure that supports the womb, resulting in the cervix and uterus to prolapse into the vagina.
There are varying degrees of this prolapse
- Grade 1: The uterus has dropped slightly and many women are unaware of the prolapse and are noticed during a routine pelvic check up.
- Grade 2: The cervix and uterus has dropped further and can be felt or seen just inside the vagina.
- Grade 3: The cervix and uterus can be seen or felt outside the vagina. This is the most severe of uterine prolapses and also knows as a procidentia.
Uterocervical Prolapse
Vaginal vault prolapse
The vaginal vault is the top of the vagina. With a vault prolapse this is where the vaginal wall loses its support from surrounding structure and the vagina falls in on it self. A vault prolapse can only occur to women who have had a previous hysterectomy. Vault prolapse statistics show increased risk of vault prolapse in women who had a hysterectomy for a uterine prolapse, the risk of this occurring are decreasing with new methods of surgery for prolapse repair.
There are varying degrees of prolapses and are graded as
- Grade 1: prolapse is evident on examination but patient usually unaware of prolapse
- Grade 2: Prolapse can be felt or seen at vaginal opening
- Grade 3: Prolapse protrudes through the vaginal opening.
Treatment of Vaginal vault prolapse
The treatment of pelvic organ prolapse is assessed on an individual basis, treatment may include:
- elvic muscle exercises,
- Use of intravaginal pessary to reduce prolapse or
- Surgical repair of prolapse.
- Your specialist will discuss the best treatment option with you.
Urogynaecology Education prepared by: Prof. A. Rane & A. Corstiaans CNC: January 2004.
Pelvic Organ Prolapse Quantitation
- Statge 0: No prolapse is demonstrated. Ponts Aa, Ap, Ba, and Bp are all at –3 cm and either point C or D is between –TVL cm and –(TVL-2) cm (i.e., the quantitation value for point C or D is ≦ -[TVL-2] cm
- Stage 1: The criteria for stage 0 are not met, but the most distal portion of the prolapse is > 1cm above the level of hymen (i.e., its quantitaion value is < -1 cm)
- Stage II: The most distal portin of the prolapse is ≦ 1 cm proximal to or distal to the plane of the hymen (i.e., its quantitation value is≧ -1 cm but ≦ +1 cm)
- Stage III: The most distal portion of the prolapse is > 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in cm (i.e., its quantitaion value is > +1cm but < +[TVL-2] cm
- Sgage IV: Essentially, complete eversion of the total length of the lower-genital tract is demonstrated. The distal portion of the prolapse protrudes to at least (TVL-2) cm (i.e., its quantitation value is ≧ [TVL-2] cm). In most instance, the leading edge of stage IV prolapse is the cervix or vaginal cuff scar.
Anterior Vaginal Wall
- Point Aa : Located at the midline of the anterior vaginal wall, 3 cm proximal to the external urethral meatus. It corresponds approximately to the urethrovesical junction. The range of position of point Aa relative to the hymen is –3 to +3 cm.
- Point Ba : Represents the most distal position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa. Without any prolapse, point Ba is –3 cm. In a woman with a complete vaginal vault prolapse, point Ba has a positive value equal to the position of the cuff.
- Posterior Vaginal Wall : Posterior vaginal wall points are measured with the woman straining after single speculum blade is turned to retract the anterior vaginal wall.
- Point Ap : Located in the midline of the posterior vaginal wall, 3 cm proximal to the hymen. The possible values range from –3 to +3.
- Point Bp : The most distal position of any part of the upper posterior vaginal wall from the vaginal cuff or posterior vaginal fornix to point Ap. Bp is –3 when there is no prolapse. In a woman with total vaginal vault prolapse, Bp is a positive number equal to the distance between the cuff and hymen.
Superior Vagina
- Points located on the superior vagina represent the most proximal location of the normally positioned pelvic organs. These points are assessed with the woman straining with an assembled speculum in place.
- Point C : The most distal (most dependent) edge of the cervix or the leading edge of the vaginal cuff after hysterectomy.
- Point D : Marks the location of the posterior fornix in a woman who still has a cervix and correlates to the position where the uterosacral ligaments attach to the posterior cervix. Measuring this point distinguishes between suspensory failure of the uterosacral-cardinal ligament complex and cervical elongation. Cervical elongation causes point C to be significantly more positive than point D. Point D is omitted in women who had total hysterectomy.
Additional Measurements
- Total Vaginal Length (TVL) : With an assembled speculum in place and point C or D reduced completely to its normal position, the total vaginal length is measured as the greatest depth of the vagina in centimeters.
- Genital Hiatus (GH) : measured from the middle of the external urethral meatus to the posterior midline hymen while patient is straining.
- Perineal Body (PB) : Measured from the posterior margin of the GH to the midanal opening.
http://emprocedures.com/obgyn/popq/measurement.htm
New Treatments for Pelvic Organ Prolapse
Helen D. Jones, MD
Volume 2530, No 8, pp. 4391-4455, January 22, 2009
With a cystocele, on physical exam you see the bulge in the anterior wall of the vagina. In the sagittal plane, you can see this bulge, which is what we are trying to fix back up in place. If the bladder is sitting on a hammock, which is the endopelvic connective tissue that sits between the vagina and the bladder, this hammock can be damaged either with a sagging, where the bladder can come right down – this would be a midline defect – and if this patient has a midline defect, you would want to fix that person with an anterior colporrhaphy. If you have paravaginal defects, the strings of the hammock actually break and the bladder falls down, because the hammock has broken down. In this case, you want to fix those attachments back up in place. The endopelvic connective tissue attaches to the white line – the arcus tendineus fascia of the pelvis. If you need to do a paravaginal repair, this is what you would attach back up in place. If you have a central defect, going into the anterior vaginal wall, you enter with a midline or inverted T incision and the white tissue is the endopelvic connective tissue that is dissected off of the vaginal epithelium. This is what you tighten up that hammock to get rid of that sag, to push the bladder back up into its normal position. In anterior colporrhaphy, you have vaginal epithelium all opened up and the endopelvic connective tissue is peeled off and then plicated across the middle. This can be done with absorbable sutures, the most common way that it is done and we usually use Vicryl for this.
Unfortunately, the anterior colporrhaphy has about an eighty percent success rate; it fails about twenty percent of the time, even up to thirty percent in some series. We have worked with different materials to see if we can increase the success rate of the anterior colporrhaphy. We did a prospective randomized trial of Vicryl mesh in our institution where we just folded over a piece of mesh and imbricated it in just underneath the endopelvic connective tissue closure and actually found that we had reduced the cystocele. Our pilot study reduced it from eleven percent to zero percent. Our prospective randomized trial is also showing good success with that. Other things have been used in the past but there have been problems with some of these materials in that they have been rejected by the vagina. An interesting thing about Gore-Tex is that the pores in the Gore-Tex mesh allow bacteria to get in, but the pores are not big enough for macrophages to get in; they get infected and it is rejected by the body. People have tried to use mesh and have actually placed it over to completely replace the endopelvic connective tissue that it there. Again, this has worked well, but we still haven't figured out the best material to use in the vagina. This is an area with a lot of bacteria and things do get infected and get rejected.
Paravaginal defects.
In paravaginal defects, you have a break in the endopelvic connective tissue on the sides. This is what you would find on examination. You can try to replace the paravaginal supports when doing an examination by having the patient strain. If things are actually held up when you are holding this up while doing a pelvic exam, you have a paravaginal defect that needs to be repaired. The arcus tendineus fascia of the pelvis, the white line, goes down from the pubic bone to the ischial spine; you have to replace it all the way down that support. This can be done vaginally also. You would enter the space of Retzius from the vagina, where you peel off the endopelvic connective tissue over to the attachment to the pubic ramus, open up that area and access the white line. You can use nice long retractors to access the white line from that area, use the anterolateral vaginal wall and place a stitch from there onto the white line. What is nice is to actually put a pulley stitch in, where you have a stitch on the endopelvic connective tissue, on the anterolateral vaginal wall and attach it to the white line, then tying the sutures down to pull the vagina back up to the arcus.
Rectocele
This is weakness (bulge) in the posterior vaginal wall and rectovaginal septum or endopelvic connective tissue, causing a relaxation and allowing the rectum to bulge through. There is direct contact of the rectal serosa with the posterior vaginal wall. Looking at this on exam in the operating room, you have opened up the vaginal epithelium posteriorly. We start off with a diamond-shaped incision right at the perineum and make an incision up on the midline, dissecting off laterally. You see the right underneath. Again, we can do a midline plication of the connective tissue on either side and more distally, we can plicate the levator muscles together to hold the rectum down in place. In the classic posterior colporrhaphy, we actually do try to plicate the levator muscles together. The levator muscles are not actually normally plicated over the perineal body and this seems to be a little bit nonanatomic. It works well about eighty percent of the time to treat a rectocele but unfortunately has problems with dyspareunia because you are pulling the levator muscles together over the midline. That would be putting the sutures together a cross. It is important to build up the perineal body if it is not well built up. We have to plicate the superficial and deep transverse perinei muscles together to build the perineal body up as you are doing the colporrhaphy. This is the site specific defect repair. This is the new way to approach the rectocele. What Dr. Richardson found was that there is a sheet of tissue called Denonvillier's fascia which supposedly used to be attached to the perineal body and at the time of a vaginal delivery this gets torn off the perineal body and gets retracted completely superiorly. So as you are dissecting endopelvic connective tissue off the vaginal epithelium, you go up to the apex and you should be able to identify this tongue of tissue that you can actually put an Allis clamp on and bring down to the perineal body. The whole thing comes over like a sheet or blanket and covers the rectocele. When it is reattached to the perineal body and perirectal support structures here, you have nicely reduced the rectocele. This seems to work about eighty to ninety percent of the time, even reports of up to one hundred percent. It seems to be a little bit more anatomic than midline plication. Again, you are attaching it to the perineal body here, so make sure you have a good perineal body here before you attach it. Because this seems to be a little more anatomic, it tends to have less problems with dyspareunia.
Enterocele.
As you can see, the enterocele is a problem of the peritoneum that comes down in between the rectum and vagina and herniates through. Bowel can frequently come down into this area also. Most of the enteroceles that you see are posterior and therefore you see them while you are doing the posterior colporrhaphy. As you go up higher into the apex of the incision and are dissecting the endopelvic connective tissue off there, often you will come across this tissue that just looks like peritoneum; there is no fascia there and no thick tissue that you are coming across. You can even identify bowel right behind it. A rectal examination can help if you have this bulge here and while you are doing the dissection you do a rectal exam and your finger is just not coming up, you can feel bowel in between your finger and the rectum. This would be a way to identify the enterocele and it is very important to identify the enterocele and fix it to prevent problems in the future. You open up the enterocele sac – you can open it up sharply – and you want to close it down to high ligation at the level of the rectal reflection and at the level of the fascia. Now if there is a uterus, you want to get up to the cervical fibers. If you do not have a uterus there, you want to get all the way up to the bladder reflection.
You are trying to unite the pubocervical fascia and rectovaginal septum to prevent the enterocele from herniating through again. Then you can excise the remainder of the peritoneum and then you can do your plication of the endopelvic fascia over it. Again, if present, it is very, very important to try to search and look for this enterocele if you have any question that it is present. This is something that if it is not fixed, you are still leaving a fascial defect there and this can herniate through again in the future. If you have any questions or any thoughts that there may be an enterocele here and you are not sure with your exam, you can certainly go ahead and do some imaging studies. In approaching an enterocele from the abdomen, say you've done an abdominal hysterectomy and you know there is an enterocele or even prophylactically, if you are doing a Burch procedure or retropubic suspension where people can get anterior enteroceles or recurrent enteroceles after retropubic suspension, you want to do an enterocele repair. If the peritoneal cavity is open, we frequently do this right after abdominal hysterectomy. In the Hallban culdoplasty, you are closing down the peritoneum to the nadir and then up along the rectum. The peritoneum is closed down with vertical sutures. The Moskowitz culdoplasty is purse-string sutures. Again, you are starting at the level of the cervix or cuff and going all the way down to the nadir to completely close off the enterocele sac.
Uterine prolapse.
You see the cervix down at the level of the introitus and when you are done with the hysterectomy, what can be used well to close off the enterocele is the McCall culdoplasty. You take sutures from one uterosacral all the way to the other. We usually do a cystoscopy after we finish with the culdoplasty to make sure the ureters are okay. We actually do take the anterior peritoneum in the modified McCall culdoplasty and close this area off before we close the cuff.
For uterine prolapse, you want to support the cuff back in place and before you are done, you need to reattach the cuff to the uterosacral-cardinal ligament complex so that the vault does not prolapse afterwards. Your culdoplasty is going to get your enterocele and then you reattach that cuff to the connective tissue supporting system that is there so that you do not have prolapse again. Hysterectomy is a common cause for recurrent vaginal prolapse. The external McCall culdoplasty is described to try to attach the cuff to the uterosacral ligaments proximally and use that as our supporting system. Internally, we have the culdoplasty sutures, the enterocele sac sutures that are closing off the enterocele and then we take two sutures which were plicating the uterosacrals together and actually take them out through the posterior vaginal cuff and tie one back. This attaches the cuff up very high on the uterosacral ligaments. Then you can close off the cuff. We usually close the cuff first and then tie the McCall culdoplasty sutures down; these are the external sutures. Again, we go into the posterior vaginal wall, incorporating the two uterosacral ligaments and come right out. When tied back, you have nice elevation of the cuff. A plea to take care of that enterocele when you are doing hysterectomy.
Some people want to keep their uterus when being treated for uterine prolapse. You can attach it to the sacrum with mesh, so this would be a cervicosacral colpopexy, which works pretty well and you can also attach the uterosacrals to the sacrospinous ligaments, which can also work very well. Kovac and Krukschank did this and actually had people deliver after they suspended their uteri up and they delivered successfully vaginally. Eighty percent of them actually did not have recurrent prolapse of their uterus after that. I would probably do a cesarean section on that person, but certainly it can work.
Now let's say you have a person who has had a hysterectomy and now they have a prolapse of their vault. There are different surgical options, including the abdominal sacral colpopexy, abdominally, you can plicate the uterosacrals; you can attach the vagina back to the sacrospinous ligament; and you can do a McCall culdoplasty. The things you want to remember when you are trying to replace the vaginal vault back in place is that you are trying to maintain their normal vaginal axis and trying to maintain a functional vagina. These are the patients that you are doing the sacral colpopexy or sacrospinous suspension on, because they are still sexually active. You are not doing a colpocleisis on this patient. You want to repair all defects at the same time; you do not want to have problems with recurrent prolapse. You have to identify each defect separately and fix each defect separately. You really want to make sure that they do not have any stress incontinence. Whether it be a vault prolapse or a cystocele or rectocele that is third degree or beyond, you do have a chance that this patient has potential stress incontinence that they are not giving you a history about, but when you replace those tissues back in place, they will have incontinence. These patients need to have studies done before you actually go back for surgery.
Sacral colpopexy.
The sacral colpopexy is done abdominally; it is a suspension of the vaginal vault where you are attaching the cuff back to the sacrum via a transit, because the vagina will not stretch that far. You are using a bridge; this is usually a synthetic bridge, although cadaveric fascia has also been used. Again, when using synthetic materials, there are problems with some erosion of mesh and materials through this area. This is one of the disadvantages of the sacral colpopexy. The nice thing about the colpopexy is that we are not using the patient's native structures; we are not using her uterosacral ligaments, which we know have failed in the past and we bypass that system altogether.
Sacral colpopexy and sacrospinous suspension are the two most commonly used procedures for replacing the vaginal vault. They work well and have a good success rate. The problem with the sacral colpopexy is that there can be problems with mesh erosion and it is abdominal surgery. Again, vaginal surgery can certainly be done a lot more commonly for patients with multiple medical problems. Recovery is lower with abdominal surgery and hospital stay is longer with abdominal surgery than with vaginal surgery. Therefore, the sacrospinous suspension is nice in the sense that it can work just as well. It is also using a structure separate from the uterosacral ligaments – it is using the sacrospinous ligament, which is a nice, strong structure and it is done vaginally.
When you are doing vaginal surgery, you can correct all the other problems at the same time and it is extraperitoneal; abdominal surgery is intraperitoneal. Sacral colpopexy has problems with bleeding over the sacrum, which can be a problem. You can just as well encounter bleeding problems with the sacrospinous suspension as well. In sacral colpopexy, we take the vaginal vault up to the sacral promontory and attach it to the periosteum over the sacrum here. We take a piece of mesh and fold it over so it is anterior and posterior and then take it back up. You can fold this in half or cut it in half and take a piece over on each side and then attach that back up in place. The problem here is that you see how the vagina should really be deviating back towards the sacrum and it is important to really be careful in taking hour length of mesh so that there is movement here and you are not tightening up too much here.
For sacrospinous suspension, you need to have good visualization and nice long retractors that will keep other structures away from the ligament while you are trying to take a stitch into it. The Capiodevice is an auto-suture device that is actually very easy to use. We have now moved towards permanent sutures. We use Gore-Tex sutures for our suspensions. The way we get to this space is to identify the spine on the right side when working for a right sacrospinous suspension. You locate the spine and move medially. You will come across the sacrospinous ligament. This is done classically through the rectovaginal space. If you are doing a posterior colporrhaphy, you go lateral enough for your perirectal supports and perforate through the perirectal fascia at the level of the spine and access that space. Once you are down at the spine and have perforated through, you retract the rectum medially and there will be the sacrospinous ligament. The space can also be accessed when you are doing an anterior colporrhaphy for the anterior sacrospinous suspension. So when you have made your dissection, taken the endopelvic connective tissue off the vaginal epithelium to the level of the pubic ramus, you perforate through into the paravesical space. You sweep down and find the ischial spine and then go medially and you will find the sacrospinous ligament. The nice thing about this is that when you are going through the perirectal space, it is a small space that you are working through and the vagina can get narrowed when it is taken through that space to the sacrospinous ligament.
What we have started doing at our center is to try to get through to the sacrospinous ligament anteriorly and the vagina really has a nicer caliber and has just as good function afterwards. We use a pulley stitch on the vagina so that when we have these sutures placed here, they are attached to the vagina and we can tie this down. The pulley suture in effect keeps the knot on the other side of the vagina, not inside the vagina, where it could get infected very easily. It is very nice to decide where you are going to place your stitch before you start the procedure. If you put a marking suture there, when you do the dissection you will not get confused as to what actual part of the vagina should go down to the sacrospinous ligament. It is very confusing once things are completely splayed open and you've pulled the vagina every which way with Allis clamps all over the place. It is really nice to place that stitch to get a nice repair out of it. You want to place these about 2 cm apart if possible. This helps to maintain the vaginal caliber so it doesn't get narrowed up at the apex.
We just did an anterior sacrospinous suspension study. Because we are not going through the posterior plane, which can get very narrowed and pulling the vagina down a little more posterior than it should be, there were many cystoceles occurring because of the tension on the anterior vaginal wall and we actually found that we had better rates for recurrence of prolapse altogether with this technique.
Things that you need to be careful of include hitting vessels, which can happen with either procedure. The pudendal artery and vein are the big things that you are going to hit here. They are just medial to the ischial spine. You want to use the medial two-thirds of the sacrospinous ligament for your suspension.
McCall culdoplasty is repairing the vault back up and attaching it to the uterosacral ligaments like we did after the hysterectomy, but in this case you don't have the open peritoneal space already for you. You need to dissect out, find this area, enter the area, open up into the peritoneal cavity, find the uterosacral ligaments and attach the vaginal vault. You take the two apexes that are going to get attached back down to the uterosacral ligaments. You want to take the stitch as close to the ischial spine as possible to maintain a nice length of vagina.
The ileococcygeus suspension can be used also, has great success and is very easily done. We do use this procedure, usually in conjunction with the sacrospinous suspension, where we do a right sacrospinous suspension and then a left iliococcygeal suspension, so we are not really splaying out the vagina, taking both sides all the way back to the sacrospinous. You can certainly use this as your sole procedure for vault suspension and it works well also. The support structures are not as strong as the sacrospinous ligaments, so the long-term results may be questionable.
It is very, very important when you are treating prolapse – if you have a prolapse, third degree or beyond – eighty percent of those patients will have incontinence when supported. You need to test for that and it can be done in the office with a pessary or a packing or even procto swabs that will hold up in place, fill the patient's bladder up to their maximum cystometric capacity, but not so much that they have an urge, which would trigger bladder contractions which would cause incontinence also, and then have them cough and bear down in the standing position. You want to find the incontinence in the most provocative position, which would be standing, well supported, bearing down, coughing and see if they have incontinence. You need to do an anti-incontinence procedure if you find it.
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