PELVIC ORGAN PROLAPSE

Prof.Junizaf,MD
Division of Urogynecology Reconstructive Deptment of Obstetrics and Gynecology Faculty of Medicine University of Indonesia Jakarta

DEFINITION

Pelvic organs prolapse is protrusion of

pelvic organs into the vaginal canal or outside vaginal introitus

PREVALENCE
50% women had previous vaginal delivery
20% gynecological cases who will be operated come from pelvic organs prolapse At RSCM-FKUI 2000 2005, 240 cases uterine prolaps treatment by operation, the age of patients years old 60 70 and parity three or more

ETIOLOGY

Damage or the weakness the pelvic floor support

PELVIC FLOOR ANATOMY

De Lancey

Endopelvic fascia Levator ani muscles (pelvic diaphragm) Urogenital diaphragm

ENDOPELVIC FASCIA

Cardinal ligaments Uterosacral ligaments

Rectovaginal fascia
Pubocervical fascia Paracolpium fascia

Upper vagina Cervix Uterus

Cardinal ligaments Uterosacral ligaments

Lateral vaginal wall Sacrum

Mid vagina Pubocervical Fascia Rectovaginal Fascia

Fascia paracolpium

Arcus Tendineus Fascia Pelvic

LEVATOR ANI MUSCLES

LEVATOR ANI MUSCLES (PELVIC DIAPHRAGM)

Pubococcygeus Puborectalis

Iliococcygeus

LEVATOR ANI MUSCLES/ PUBOCOCCYGEUS

Arcus tendineus fasia pelvis
FA FA
Uretra

Vagina

Rectum
Pubococcygeus muscle

NORMAL GENITAL POSITION

Levator ani muscles functions to pull the

rectum, vagina, urethra, anteriorly towards the pubic bones, compressing their lumens closed.

Primary support for the pelvic organs come from the levator ani muscles.

UROGENITAL DIAPHRAGM

Function: Attach to the ischiopubic rami: the lateral walls of vagina perineal body

PERINEAL BODY

Mass of dense connective tissue: Fibers from:

Bulbocavernosus Superficial perinei transverse External anal sphincter Perineal membrane

Perineum

Type pelvic organs prolapse

Risk Factor

Child birth Parity Chronic Intra abdominal pressure Age Congenital Genetic Race Obesity Smoking

Classification
Baden Walker
Stadium I When the prolapse still on vaginal canal Stadium II When the prolapse at introitus vaginal Stadium III When the prolapse outside from introitus vaginal

prolapsus uteri

POPQ

Anatomic landmark used during pelvic organ prolapsed quantification

Aa

The point in the midline of the anterior vaginal wall 3cm proximal to the urethral meatus, corresponding to the urethrovesical junction. Range: 3 to +3 On the anterior vaginal wall, the most dependent position between point Aa and the vaginal cuff or anterior vaginal fornix Cervix or vaginal cuff (posthysterectomy) Posterior fornix corresponding to the pouch of Douglas (in the absence of cervix) The point in the midline of posterior vaginal wall 3 cm proximal to the hymenal ring. Range -3 to +3 On the posterior vaginal wall, the most dependent position between point Ap and the vaginal cuff or posterior fornix

Ba C D Ap Bp Gh Pb

Genital hiatus - midportion of the urethral meatus to the posterior margin of the genital hiatus
Perineal body - between posterior margin of the genital hiatus and the midportion of the anus

TVL Total vaginal length - greatest depth of the vagina

Staging of pelvic organ prolapsed

Stage 0 : No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm and either point C or point D is within 2 cm of TVL The most distal portion of the prolapse is l cm above the level of the hymen (above -1) The most distal portion of the prolapse is l cm or less proximal to or distal to the hymen.

Stage I :

Stage II :

Stage III :

The most distal portion of the prolapse is 1 cm below the hymen but protrudes no further than 2 cm less than the TVL.
Complete eversion of the total length of the lower genital tract. Distal protrusion quantify >+ [TVL-2] cm. leading edge of the prolapse: cervix or vaginal cuff scar.

Stage IV :

SYMPTOMS

Sensation bulging at introitus vaginal

Sensation of vaginal of pelvic fullness Back pain and disminish when lying Vaginal discharge or bleeding Urinary incontinence

Constipation
Sexual complaints

Diagnosis

Anamnesis Physical examination

Gynecology examination

TREATMENT

Prevent Limitations vaginal delivery Prevent second stage more than two hours Prevent vaginal delivery by instrument Prevent placental delivery by crede metode Repair laseration pelvic floor after vaginal delivery Kegel exercise Prevent or treatment condition can cause intra abdominal pressure increase Treatment Conservative Operative

Conservative Treatment

Pessary Estrogen hormon, special for oldest women

OPERATIVE TREATMENT

Anterior colporrhaphy
Posterior colporrhaphy Ventrofixation

Vaginal hysterectomy
Colpoperineorhaphy Colpocleisis

Uterosacropexy
Sacrospinosus fixation