Surgical Anatomy (Pelvic Organ Prolapse)
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Anatomy of Pelvic Organ Prolapse.
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Surgical Anatomy (Pelvic Organ Prolapse)
- 1. Female POP (Pelvic Organ Prolapse) For the students of Gulf Medical University, Ajman, MBBS Dr. Seyed Morteza Mahmoudi, MBBS Gulf Medical University, Ajman
- 7. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 11. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 13. • anteverted (angled forward at the junction of the cervix and vagina)
- 14. • anteflexed (angled forward at the junction of the body and cervix)
- 24. v Factors supporting the uterus: a. Position of the uterus. b. Position of the surrounding organs. c. Perineal body. d. Tone of pelvic diaphragm e. Ligaments of uterus: Round lig. of uterus. Transverse cervical lig. (Mackenrodt’s lig.). Utero-sacral lig. Pubo-vesical (cervical) lig.
- 25. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 27. POP (Pelvic Organ Prolapse) Prolapse: protrusion of a viscus through an aperture. Pelvic organ prolapse is descent of followings alone or in combination: Anterior vaginal wall Posterior vaginal wall Uterus The apex of the vagina after hysterectomy,
- 34. Types Cystocele (bladder into vagina) Enterocele (small intestine into vagina) Rectocele (rectum into vagina) Urethrocele (urethra into vagina) Uterine prolapse (uterus into vagina) Vaginal vault prolapse (roof of vagina) - after Hysterectomy
- 35. Risk factors Pregnancy Vaginal childbirth Menopause Aging Hypoestrogenism Chronically increased intraabdominal pressure Chronic obstructive pulmonary disease (COPD) Constipation Obesity Pelvic floor trauma Genetic factors Connective tissue disorders
- 36. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 37. Diagnosis of POP Detailed history and physical examination Pelvic ultrasound Fluoroscopy of rectum & bladder Magnetic resonance imaging (MRI)
- 38. Lower Urinary Tract Symptoms caused by Pelvic Organ Prolapse Stress incontinence Frequency, urgency, urge incontinence Hesitancy, weak stream, incomplete empty Manual reduction of prolapse for voiding
- 39. Bowel Symptoms caused by Pelvic Organ Prolapse Difficulty with defecation Fecal incontinence Fecal staining of underwear Digital manipulation to complete defecation Feeling of incomplete evacuation Rectal protrusion during or after defecation
- 40. Local symptoms caused by Pelvic Organ Prolapse Vaginal pressure or heaviness Vaginal or perineal pain Low back pain Abdominal pressure or pain Observation or palpation of a mass
- 41. Physical examination of Uterine Prolapse
- 43. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 44. Descent of Bladder during Stress
- 45. MRI of Cystocele
- 47. MRI of Rectocele
- 48. MRI of Uetrine Prolapse
- 49. Contents Anatomical relations Support of female pelvic organs Pelvic organ prolapse * Clinical features* Imaging* Treatment *
- 50. Treatment Conservative Measures Pessary Pelvic floor muscle exercises Estrogens Surgical Measures
- 51. Surgery Indications Urinary incontinence Urinary obstruction- hydronephrosis Pressure sores and erosions Difficulty defecation Small bowel obstruction
- 52. Surgeries Obliterative Procedures (Lefort colpocleisis) Reconstructive Procedures Anterior Vaginal Prolapse ANTERIOR VAGINAL COLPORRHAPHY Posterior Vaginal Prolapse Posterior vaginal repair Apical Vaginal Repair SACROSPINOUS LIGAMENT FIXATION UTEROSACRAL LIGAMENT SUSPENSION ABDOMINAL SACROCOLPOPEXY
Editor's Notes
- EXPLANATION: The uterus is stabilized by the cardinal and round ligaments in conjunction with the sacrouterine ligaments. Perinealprocidentia is also known as uterine prolapse and is caused by stretching of the vaginal wall and cardinal and round ligaments of the uterus. Generally, the term perinealprocidentia is synonymous with descent of the uterus fully into the vagina causing its complete eversion. Uterine prolapse is common in multiparous women. There are several stages of uterine prolapse. Stage I (first degree) uterine prolapse is the descent of the cervix and uterus into the vagina to any point above the hymen. Stage II (second degree) uterine prolapse is descent of the cervix to the hymen. Stage III (third degree) uterine prolapse is descent beyond the hymen. The folds/ligaments on the interior surface of the anterior abdominal wall (urachus/median, medial, and lateral umbilical; answers b and c) would not be involved or stretched during uterine prolapse. While the round ligament of the ovary and suspensory ligaments of the ovaries (answers a and d) would be stretched during stage IV prolapse, generally these ligaments stabilize the ovaries within the broad ligament. They generally do not stabilize the uterus.
- The levator plate, the shelf on which the pelvic organs rest, is horizontal when the body is in a standing position and supports the rectum and upper two thirds of the vagina above it. Weakness of the levatorani may loosen the sling behind the anorectum and cause the levator plate to sag, opening the urogenital hiatus and allowing pelvic organ prolapse.The urogenital diaphragm closes the levator hiatus, supports and has a sphincter-like effect at the distal vagina, provides structural support for the distal urethra, and contributes to continence in that it is attached to the periurethral striated muscles.There is controversy regarding whether the anterior vaginal wall includes a suburethralfascial layer; regardless, the anterior vaginal wall provides support to the urethra by its lateral attachment to the levators and to the endopelvic fascia from the arcustendineus of the pelvic fascia.
- PreventionPrevention of genital prolapse is the focus of much debate. Antepartum, intrapartum, and postpartum exercises, especially those designed to strengthen the levator and perineal muscle groups (Kegel), often help improve or maintain pelvic support. Obesity, chronic cough, straining, and traumatic deliveries must be corrected or avoided. Estrogen therapy after menopause may help to maintain the tone and vitality of pelvic musculofascial tissues; however, evidence is lacking to support its benefit to prevent or postpone the appearance of anterior vaginal prolapse and other forms of relaxation.Pelvic organ prolapse, except in rare situations, is a condition that impacts only the quality of life. Consequently, the extent and type of treatment should reflect and be commensurate with the degree of impact on the quality of life the patient experiences. Patient perception is also a critical component, and self-image and conceptual discomfort are relevant to any discussion of therapy. Common reasons to intervene are when function is impaired because of the prolapse. Anterior prolapse can contribute to urinary incontinence or, when severe, urinary obstruction. Bulging vaginal epithelium can come into contact with undergarments and clothing and over time develop pressure sores and erosions. A posterior vaginal defect can become so large that fecal evacuation is difficult, or the patient finds it necessary to manually reduce the posterior vaginal wall into the vagina to expedite expulsion of feces. Mobility can be impaired by a large prolapse. All of the preceding complaints are reasons to discuss surgical repair.Chronic decubitus ulceration of the vaginal epithelium may develop in procidentia. Urinary tract infection may occur with prolapse because of anterior vaginal prolapse, and partial ureteral obstruction with hydronephrosis may occur in procidentia. Hemorrhoids result from straining to overcome constipation. Small-bowel obstruction from a deep enterocele is rare.
- Pelvic organ prolapse, except in rare situations, is a condition that impacts only the quality of life. Consequently, the extent and type of treatment should reflect and be commensurate with the degree of impact on the quality of life the patient experiences. Patient perception is also a critical component, and self-image and conceptual discomfort are relevant to any discussion of therapy. Common reasons to intervene are when function is impaired because of the prolapse. Anterior prolapse can contribute to urinary incontinence or, when severe, urinary obstruction. Bulging vaginal epithelium can come into contact with undergarments and clothing and over time develop pressure sores and erosions. A posterior vaginal defect can become so large that fecal evacuation is difficult, or the patient finds it necessary to manually reduce the posterior vaginal wall into the vagina to expedite expulsion of feces. Mobility can be impaired by a large prolapse. All of the preceding complaints are reasons to discuss surgical repair.Chronic decubitus ulceration of the vaginal epithelium may develop in procidentia. Urinary tract infection may occur with prolapse because of anterior vaginal prolapse, and partial ureteral obstruction with hydronephrosis may occur in procidentia. Hemorrhoids result from straining to overcome constipation. Small-bowel obstruction from a deep enterocele is rare.
- SACROSPINOUS LIGAMENT FIXATIONA popular method of vaginal vault suspension is that of unilateral or bilateral fixation to the sacrospinous ligament. In this technique, the vaginal epithelium is separated from the rectovaginal tissues. Perforation through the rectal pillar is accomplished by directing blunt dissection toward the ischial spine through the loose areolar tissue. After an appropriate location on the sacrospinous ligament is identified (usually 2–3 cm medial to the ischial spine), one of several techniques may be used to safely pass 2 or more permanent (or delayed absorbable) ligatures through the ligament to the submucosal apex of the vagina. Tying the sutures brings the vaginal apex to that sacrospinous ligament, and a posterior colporrhaphy is then performed (as noted previously). Closing the dead space by intermittently suturing the vaginal mucosa to the underlying reconstituted rectovaginal septum may be useful.Vaginal vault suspension to 1 or both sacrospinous ligaments has the potential of injury to the pudendal nerve or pudendal vessels and is often technically difficult. Because gluteal and posterior leg pain is a potential complication of this procedure, particularly if the branches of the sacral plexus are disturbed by suturing deep to the ligament, the procedure requires a skilled vaginal surgeon and should be undertaken only by those familiar with the technique.ILIOCOCCYGEAL VAGINAL SUSPENSIONFirst described in 1962, this procedure uses the fascia overlying the iliococcygeal muscle. Although not nearly as commonly used as other procedures, this point of attachment allows reliable apical fixation without the need to gain peritoneal access. It is generally a safe procedure requiring a posterior vaginal incision in the midline with wide dissection of the overlying epithelium. Bilateral placement of permanent or delayed absorbable suture can be used.BILATERAL UTEROSACRAL LIGAMENT SUSPENSIONThe use of the uterosacral ligaments to attach the vaginal cuff has become a re-appreciated technique in apical repairs. Several modifications of the procedure have been described since its introduction in 1938. This technique, as with the other vaginal procedures, can be done at the time of vaginal hysterectomy or to correct posthysterectomy apical cuff prolapse. After entrance into the peritoneum is complete, traction on the ipsilateral posterior vaginal wall with rectal digital examination will facilitate transperitoneal identification of the uterosacral ligament. Placement of a pair of permanent sutures in a lateral-to-medial fashion, 1 at the level of the ischial spine and another placed more cephalad, can be performed bilaterally. These sutures are then brought to the ipsilateral vaginal apices. Fixation of the cuff at this level reproduces cuff placement to the normal position of the cervicovaginal junction. Anterior vaginal repair should be performed before tying down the vaginal cuff.A risk of this procedure is medial displacement and kinking of the ureters, which has been reported to occur in up to 11% of patients undergoing this procedure. Cystoscopic assessment of ureteral function without and with tension on the fixation sutures, before tying down the vaginal apices, is critical to identify any potential compromise intraoperatively. If ureteral flow reduction is identified, then removal of the sutures on the affected side will often restore normal function.ABDOMINAL SACROCOLPOPEXYVaginal vault suspension can also be performed abdominally by attaching the vaginal cuff to the sacral promontory. Abdominal sacrocolpopexy is an excellent primary procedure for apical vaginal prolapse and enterocele and is the procedure of choice for those who are already having an abdominal approach for hysterectomy or for another indication. In this procedure, a laparotomy is performed, and the cul-de-sac and peritoneum overlying the sacrum are visualized. A window in the peritoneum over the sacral promontory is created, and 2 permanent sutures are placed through the anterior longitudinal ligament, approximately at the level of S1. The vaginal cuff is then exposed by dissecting off the overlying peritoneum. Fixation of a graft over the anterior and posterior vagina is then performed fashioning a Y-shape or 2 individual strips of graft. This Y graft is then brought posteriorly along the hollow of the sacrum and affixed to the anterior longitudinal ligament sutures overriding the sacral promontory. Avoidance of undue tension is critical to prevent postoperative dyspareunia.Dissection and suture placement over the sacrum may introduce risk of operative hemorrhage. During placement of the sacral sutures, the nearby fragile sacral veins may be lacerated. Bleeding from these veins is difficult to control if the veins retract into the bone. Use of sterile thumbtacks to occlude these veins has been an operative technique used to stem potentially life-threatening hemorrhage.Many different graft types have been described, as well as different methods of attaching these grafts to the vagina. Biologic grafts, however, have high failure rates when placed at the apex. Synthetic grafts are effective; however, they have erosion complication rates between 5% and 10%. As graft technologies continue to evolve, identification of the optimal graft material that maximizes durability and compatibility may materialize.Numerous studies demonstrate this colpopexy to be highly curative of apical/uterine prolapse. Most surgeons consider the sacrocolpopexy to be the gold standard for apical repair. In the largest prospective evaluation of sacrocolpopexy outcome, the success rates are more than 95%. The procedure can also be performed laparoscopically. A prospective study evaluating outcomes of this approach in more than 100 women describe no apical recurrences and no mesh complication. Another retrospective study of 188 cases resulted in a 10% erosion rate; however, 13 of the 19 erosions occurred with concomitant hysterectomy.
- Anterior vaginal colporrhaphy is the most common surgical treatment for anterior vaginal prolapse (Fig. 42–17). Traditional anterior colporrhaphy (anterior repair) is a vaginal approach that involves dissecting the vaginal epithelium from the underlying fibromuscular connective tissue and bladder, and then plicating the vaginal muscularis across the midline. Excess vaginal epithelium may be excised and the wound closed. Recurrence of anterior prolapse as high as 52% has been reported and has always been a limitation of all reparative procedures. Modifications involving permanent suture material and graft materials have been introduced in the hope of increasing durability.
- Anterior Vaginal ProlapseANTERIOR VAGINAL COLPORRHAPHYAnterior vaginal colporrhaphy is the most common surgical treatment for anterior vaginal prolapse (Fig. 42–17). Traditional anterior colporrhaphy (anterior repair) is a vaginal approach that involves dissecting the vaginal epithelium from the underlying fibromuscular connective tissue and bladder, and then plicating the vaginal muscularis across the midline. Excess vaginal epithelium may be excised and the wound closed. Recurrence of anterior prolapse as high as 52% has been reported and has always been a limitation of all reparative procedures. Modifications involving permanent suture material and graft materials have been introduced in the hope of increasing durability.PARAVAGINAL REPAIRThe etiology of the anterior vaginal prolapse has been much debated, beginning with White in 1912. The repair of defects in the anterior vaginal segment has traditionally been done by midline plication. An alternative method based on the anatomic observations by Richardson and colleagues advocates identification of the specific defect in the pubocervical fascia underlying the anterior vaginal epithelium and repairing the discrete breaks (Fig. 42–9). This relationship and a lack of correction of apical defects may help explain why no single operative repair should be universally applied to patients with anterior vaginal wall defects and why traditional repair has resulted in high recurrence rates.Paravaginal repair is performed for anterior vaginal prolapse that is confirmed to be a result of detachment of the pubocervical fascia from its lateral attachment at the arcustendineus fascia pelvis (white line). This defect can be unilateral or bilateral. It can be confirmed preoperatively by noting loss of the lateral sulci and lack of rugation over the epithelium along the base of the bladder and elongation to the anterior vaginal wall. Clinically, vaginal examination using a speculum reveals a preponderance of the prolapse lateralized to 1 side as the speculum is withdrawn. In addition, a ring forceps can be used by gently exerting anterior traction along the vaginal sulci. If the defect is reduced, then the defect is consistent with a paravaginal defect and can be approached with a paravaginal repair technique.The surgery can be performed either abdominally or vaginally. Both require identification of the white line and placement of serial sutures from the medial portion of the pubocervical fascia to the lateral side-wall at the level of the white line as it runs from the ischial spine over the obturatorinternus muscle to the posterior and inferior aspect of the pubic bone on the ipsilateral side. Reapproximation of the detached pubocervical fascia should reduce the anterior vaginal prolapse. This procedure can be done with other reconstructive procedures in the vagina as well as surgery to alleviate incontinence. Short-term surgical studies have shown good results, but no long-term or comparative data exist for this repair.A transabdominal approach to the paravaginal repair may be elected to correct the anterior vaginal prolapse when an abdominal approach is necessary for other pelvic conditions such as abdominal hysterectomy, adnexal surgery, or, most commonly, with sacral colpopexy for apical prolapse repair.Posterior Vaginal ProlapseThe traditional repair (Fig. 42–18) involves posterior midline incision, often high, to the level of the posterior fornix. The vaginal epithelium is separated off the underlying fibromuscular layer and endopelvic fascia. This fibromuscular layer is then serially plicated across the midline. Some describe adding levator muscle plication as well. No attempt at identifying specific fascial defects is made.An alternate method of posterior vaginal defect (rectocele) repair relies on the identification of discrete defects in the rectovaginal fascia (Fig. 42–19). The surgeon inserts a finger of the nondominant hand into the rectum to inspect the rectovaginal fascia for defects. The rectal wall is brought forward to distinguish the uncovered muscularis (fascial defect) from the muscularis that was covered by the smooth semitransparent rectal vaginal septum. The defects are then repaired with interrupted sutures to plicate over the rectal wall. In this manner, the isolated defects are repaired, and the functional anatomy is optimally restored. Notably absent is any effort to plicate the levatorani musculature, as this often results in a bandlike stricture over the posterior wall—a likely cause of dyspareunia. Randomized trials do not support improved outcomes using this technique.