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Pelvic organ prolapse

3. Perineal body, membrane and superficial/deep
POP is the herniation of pelvic organs to or beyond
the vaginal walls.
Supports distal 1/3 of vagina
Cystocoele = anterior compartment prolapse Loss contributes to rectocoele
often associated with descent of the bladder

Rectocoele = posterior compartment prolapse S2 S4 (pudendal nerve)

associated with the rectum o External anal sphincter
S2 S4 direct innervation
Enterocoele = herniation of the small bowel o Levator ani
into the vagina o Coccygeus
o Urogenital diaphragm
Apical compartment prolapse (uterine or vaginal
vault prolapse) = descent of the apex of the vagina to Signs & symptoms
the hymen or beyond the vaginal introitus. Apex can
be uterus + cervix, cervix or vaginal vault. Pressure
o Sense of fullness in the vagina
Uterine prolapse = descent of the uterus o Sensation of something falling out of
toward/beyond the introitus the vagina
Vaginal prolapse = descent of the vaginal o Stress incontinence
vault/cuff after hysterectomy o Obstruction 2 to urethral kinking by
prolapsed organ
Occurs in 41% of women aged 50 79 o Constipation
Cystocoele is most common (34%) followed o Incomplete emptying
by rectocoele & uterine prolapse o Faecal urgency
Only 10 20% of women will seek help o Faecal incontinence
Risk factors/Aetiology o If 3rd degree, maybe dried, thickened
Vaginal child birth (due to damage to vaginal mucosa
pudendal n., connective tissue & muscle o Ulcerations may resemble vaginal
structures) cancer (pain + bleed)
age Criteria
Prior pelvic surgery e.g. hysterectomy Grading based on the level of protrusion of prolapsed
intra-abdominal pressure e.g. obesity, pelvic organ
chronic constipation 1st degree to the upper vagina
Pathophysiology 2nd degree to the introitus
3rd degree external to the introitus
Levels of pelvic organ support
Uterine prolapse
1. Uterosacral/cardinal ligament complex
Suspends the uterus & upper vagina to the 1st degree to the upper vagina
sacrum & lateral pelvic wall 2nd degree to the introitus
Vertical fibres of the paracolpium 3rd degree cervix is outside the introitus
4th degree (uterine procidentia) herniation
2. Paravaginal attachments to the superior fascia of of all 3 compartments (uterus and cervix)
the levator ani & arcus tendinous fascia outside the introitus
Loss contributes to cystocoele
Diagnosis From BMJ

Mainly clinical: 1. Asymptomatic observation +/- pelvic floor

muscle exercises
2. Symptomatic
o Single-bladed speculum against
1st line: pessary
posterior vaginal wall
2nd line: reconstructive surgery
o Asking patients to strain makes the
+ anterior/posterior vaginal repair
prolapse visible/palpable
+ Burch urethropexy or mid-urethral sling
o Retracting anterior vaginal wall
o Asking patients to strain makes the
prolapse visible/palpable
Assessment of post-void residual urine
volume (PVR) if >100mL = urine retention is



Pessaries inserted into the vagina to

maintain reduction of the prolapsed
Pelvic floor exercises (Kegel)
Surgical repair of supporting structures
(anterior & posterior colporrhaphy +/-
o Avoid heavy lifting for 3 months after

Uterine prolapse

Asymptomatic 1st or 2nd degree

o No treatment required

Symptomatic 1st or 2nd degree

o Pessary
o Surgery (2nd line)
Hysterectomy with colporrhaphy +
suspension of the top of the vagina
Vaginal sacrospinous ligament
Abdominal sacrocolpopexy

3rd and 4th degrees

o Via abdominal lap surgery

Surgical shortening & tightening of the perineum
Cystocoele Urethrocoele Rectocoele Enterocoele Uterine Vaginal
What is the Bladder Urethra Rectum Small bowel/pouch of Uterus Apex of vagina
prolapsing Douglas
Where does it Upper 2/3 of anterior Lower 1/3 of the Lower posterior vaginal Upper posterior vaginal 1st degree to the upper 2nd degree to the
extend to? vaginal wall anterior vaginal wall wall wall vagina introitus
2nd degree to the
introitus 3rd degree
3rd degree cervix is external to the
outside the introitus introitus
4th degree (uterine
procidentia) herniation
of all 3 compartments
(uterus and cervix)
outside the introitus
Risk factors Vaginal childbirth Concomitant Vaginal childbirth Childbirth Pregnancy (especially 2 to hysterectomy
Chronic constipation presence of a Use of forceps during Ageing multiple births) (All the other stuff)
Violent coughing cystocoele delivery Vaginal childbirth
Heavy lifting Childbirth Prolonged labour Urinary incontinence
Congenital pelvic Congenital pelvic Previous vaginal tear (obstruction overflow)
floor weakness floor weakness (esp. if 3rd degree) Obesity
Chronic intra-abdominal
constipation/straining pressure (e.g. coughing,
Signs & Sense of fullness in Recurrent UTI Sensation of rectal Pulling sensation in 1st degree: If 3rd degree, maybe
symptoms the vagina Thin, reddish fullness the pelvis Minimal dried, thickened
Urinary membrane Incomplete emptying Feeling of pelvic 2nd degree: vaginal mucosa
incontinence protruding from one Constipation fullness/pain Pulling sensation in Ulcerations may
Incomplete portion of the Lower abdo pain Palpable bulge in the pelvis resemble vaginal
emptying urethral opening Lower back pain the vagina Feeling of pelvic cancer (pain +
Recurrent UTI Urinary Faecal incontinence Dyspareunia fullness/pain bleed)
frequency/urgency Palpable bulge in the Signs of
Dysuria vagina thrush/infection
Dyspareunia Dyspareunia Presence of
3rd degree cystocoele/
Bulge or protrusion of rectocoele
the cervix or vaginal
cuff +/- spontaneous
+/- ulcerations
Diagnosis Pelvic examination Pelvic examination Pelvic examination Pelvic examination Pelvic examination Pelvic examination
Single-bladed Single-bladed
speculum against Voiding speculum against
posterior vaginal cystourethrograms anterior vaginal wall
wall (VCUG) Asking patients to
Asking patients to strain makes the
strain makes the IV pyelogram prolapse
prolapse visible/palpable
visible/palpable Urodynamic testing
Urine post-void residual defaecagram
volume (PVR)
>100mL = urine
Management 1. Vaginal pessary + 1. Lifestyle (weight 1. Lifestyle (high fibre 1. Observation 1. Asymptomatic 1st or 2nd degree
pelvic floor physio loss, exercise) + diet, fibre No treatment required
pelvic floor physio supplements, stay 2. Pessary + pelvic floor Kegel exercises
2. Surgical repair of hydrated) physio
supporting 2. Symptomatic 1st or 2nd degree
structures (anterior 2. Conservative (stool 3. Surgery Pessary
& posterior softeners) Surgery (2nd line)
colporrhaphy +/- i. Hysterectomy with colporrhaphy +
perineorrhaphy2) 3. Pelvic floor exercises suspension of the top of the vagina
ii. Vaginal sacrospinous ligament
4. Insertion of pessary suspension/
iii. colpopexy
iv. Abdominal sacrocolpopexy

3. If cannot tolerate prolonged surgery

Vaginal obliteration
o Pros: short duration, low
perioperative risk, low risk of
prolapse recurrence
o Cons: no longer able to have vaginal

Surgical shortening & tightening of the perineum