Craig DysonSioned GriffithsOctober 2013

Normal Anatomy Causes of prolapse Types of Prolapse Investigation Management

• “To fall out”• Protrusion of an organ or structure

beyond its normal confines and with an epithelial surface

• Genitourinary prolapse – Descent of one or more of pelvic organs.

• 41% of 50-79 year old’s but uncertain• Uterocoele, Cystocoele, Rectocoele,

Enterocoele

Levator Ani/Endopelvic Fascia important Damage to these structures can occur

through: Trauma Neuropathic Injury Disruption/Stretching

Multifactorial – Orientation of bones may be a factor.

Increasing Age (Double risk with every decade)

Vaginal Delivery Increasing parity Obesity Spina Bifida

Pregnancy Variables Macrosomia Prolonged 2nd stage Episiotomy Use of

forceps/oxytocin FH of prolapse Constipation Connective Tissue

Disorder Occupation

• Anterior• Urethrocoele

– Urinary Stress Incontinence

– Rare• Cystocoele

– Increased frequency– UTI– Sensation of mass– No Symptoms

• Both– Most Common

• Middle• Uterine Prolapse• Vaginal Vault Prolapse

– Post Hysterectomy– Assoc with

cystocoele, rectocoele and enterocoele.

– Retention• Enterocoele

– Pouch of Douglas– Cough Impulse

Posterior Rectocoele

• Pelvic Organ Prolapse Quantification System

• Valsalva - ? Left Lateral• Stage 0• Stage 1 – 1cm above hymen• Stage 2 - Within 1 cm of hymen• Stage 3 - >1cm below plane of hymen

but <2cm of total length of vagina• Stage 4 – Complete eversion of vagina

• General– Fullness– Sensation of bulge– Backache

• Urinary– Incontinence– Frequency

• Coital– Dypareunia– Flatus

• Bowel– Constipation/Incontinence– Need to apply digital pressure

History and Examination

Urinalysis Post-Voidal Urine

volume testing Urodynamics US Urea/Creatinine

Conservative Watchful Waiting Lifestyle

Modification Pelvic Floor

Exercises Evidence?

Vaginal Oestrogen Creams

Pessary

Inserted into vagina to reduce prolapse

Made of silicon or plastic or Soaked in wine…

Good short term option

Surgical Effective Re-operation

required in 29% of cases

Fitness of patient Sexually Active Surgeons Advice

• Anterior Colporrhaphy– Involves plication of anterior vaginal wall to

reinforce.• Hysterectomy• Sacrospinous Fixation

– Unilateral or bilateral fixation of uterus to sacrospinous ligament

• Sacocolpoplexy– Mesh used to attach top of vagina to sacrum.

Prolapse is increasingly common with age.

Can be classified according to compartment or level of prolapse

Can be clear on examination Good conservative and surgical options

available Good prognosis

Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Lamers BH, Broekman BM, Milani AL - Int Urogynecol J (2011)

Rev Urol. 2004; 6(Suppl 5): S2–S10. PMCID: PMC1472875. Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Sender Herschorn

Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092–1139. Rectocele | Vaginal Surgery & Urogynecology

Institute .vaginalsurgeryandurogynecologyinstitute.com Int J Med Sci 2012; 9(10):894-900. doi:10.7150/ijms.4829. Three-dimensional Ultrasound

Appearance of Pelvic Floor in Nulliparous Women and Pelvic Organ Prolapse Women. Tao Ying Corresponding address, Qin Li, Lian Xu, Feifei Liu, Bing Hu

http://www.patient.co.uk/health/Genitourinary-GU-Prolapse.htm www.pelvicfloor.com/knowledge/imagelibrary/1/img/1.jpg www.bristolsurgery.com/images/Preop%20Rectocele.jpg