compact form of vast topic to make it easy to understand and best for the mbbs level students

1. PELVIC ORGAN PROLAPSE
Presenter:
Sabin Bhandari
MBBS Internship,
gynae/obs

2. Case scenario
• A 84 years old multiparous female
complaining of a mass at the introitus which
enlarges on coughing or straining for the last
five years. The mass became irreducible four
months ago.

3. Objectives
To Know;
• Definition
• Support of uterus
• Risk factor of POP
• Types and degree of POP
• Morbid changes
• Diagnosis of POP
• Management

4. • Pelvic organ prolapse is a bulge or
protrusion of pelvic organs and/or their
associated vaginal segment in or through
the vagina.

5. Position of uterus

6. Three tier system
• Upper tier : Broad ligaments, Round ligament and
Endopelvic fascia covering uterus
(keeps uterus in anteverted position)
• Middle tier: Pericervical ring (Ant: pubocervical
ligament and vesicovaginal segment, lat: Cardinal
ligament, Post: uterosacral ligament and
rectovaginal septum), pelvic cellular tissue
• Inferior tier: Pelvic floor muscles, endopelvic fascia,
levator plate, perineal body and urogenital
diaphragm

8. Pelvic diaphragm

10. Components of the Deep Endopelvic
Connective Tissue
• Uterosacral Ligaments
• Cardinal Ligaments
• Pubocervical Ligaments
• Pubocervical Septum or Fascia
• Pericervical Ring
• Rectovaginal Septum

11. Support of vagina
• Anterior vaginal wall: Positional support and
endopelvic fascia
• Posterior vaginal wall: Uterosacral ligamnet
and endopelvic fascia

12. Risk factors
• Vaginal delivery
• Multiparity
• Menopause
• Prior pelvic surgery
• Inborn weakness of
supporting structures
• Connective tissue
disorders
• Increased abdominal
pressure
• Obesity
• Asthenia and
undernutrition
• Anatomical factors:
1. Effect of gravity
2. Anterior inclination of
pelvis directing force
anteriorly
3. Stress of parturition
causing maximum
damage to puborectal
fibers of levator ani
4. Inheritent weakness of
supporting structure

13. Why due to vaginal delivery?
• Excessive stretching of the muscles and pelvic floor
ligaments
• Damage to the nerve : puedendal nerve
• Prolonged bearing down in 2nd stage of labor
• Bearing down efforts before full cervical dilatation
and when bladder is not empty
• Lacerations of perineal body
• Precipitate labor
• Lack of rest in puerperium
• Lack of pelvic floor exercises
• Rapid succession of pregnancies

15. Degree of uterine prolapse
• 1st degree: uterus descends down from its
normal position but external os is still inside the
vagina
• 2nd degree: External os protrudes outside the
introitus but uterine body remains inside vagina
• 3rd degree: uterus, cervix and body lies outside
the introitus.
• Procidentia: Prolapse of uterus with eversion of
entire vagina

17. Baden Walker Halfway classification of
POP

18. POP-Q (Quantification) system
Zero level: Hymen
Negetive : prolapse above the hymen
positive: prolapse below the hymen

20. SYMPTOMS
• Buldge Symptom
Sensation of swelling or fullness in the
vagina , dragging discomfort in the lower
abdomen and pelvis.
• Urinary symptoms:
–Frequency
–Difficulty in emptying the bladder
–Stress incontinence
–Retention of urine

21. Gastrointestinal Symptoms
• Difficulty in emptying rectum, need of digital
evacuation or splinting
Backache
Discharge : Purulent or blood-stained d/t decubitus
ulcer which forms on dependent part. It is due to
compromised venous return when the mass is
compressed at the introitus. This leads to necrosis of
compromised part and ulcer formation occurs.
Sexual problems : Dyspareunia
Poor correlation between severity of
symptom and degree of prolapse

22. Morbid changes

23. Decubitus Ulcer
• It is ulcer always found at dependent part of
prolapsed mass lying outside the introitus.
• CAUSE: friction, congestion and circulatory
changes
• PROCESS: venous stasis infection sloughing
ulcreration
• MANAGEMENT: Manual Reduction, vaginal
packing with roller bandage socked with
antiseptic and glycerin or using estrogen
cream(post menopausal)

24. Diagnosis of POP
• History
• Clinical examination :
General examination: BMI, Signs of myopathy
and neuropathy, features of chronic airway
disease or any abdominal mass

25.  Pelvic examination:
• Inspection :
i)vulva, perineum for lacerations
ii) stress incontinence by asking the patient to strain
iii)Presence of decubitus ulcer
iv) Cystocele: presence of cough impulse
v) Relaxed perineum: gaping introitus
• Palpation: palpation of perineal body and levator
muscle to determine the muscle tone.
• To diagnose procidentia : If a thumb placed anteriorly
and the finger posteriorly above the mass outside
the introitus are apposed

26. • Per speculum examination: to detect degree
of prolapse, vaginal prolapse and condition of
vagina and cervix
• Per rectal examination : to differentiate
rectocele and enterocele

27. Differential diagnosis
Uterine prolapse: Congenital elongation of
cervix, Chronic inversion and fibroid polyp
Cystocele: Gartner’s cyst ( rugosities absent,
vaginal mucosa is tense and shiny, margin well
defined, not reducible, no impulse on
coughing)

28. Management

30. CONSERVATIVE METHOD OF
TREATMENT
• Treating underlying conditions
• Life style modification
• Pelvic floor exercises
• Estrogen replacement therapy
• Vaginal pessary
• Periodic follow-up and examination of prolapse.
Indication of conservative management
1. Asymptomatic women
2. Mild degree Prolapse
3. POP in early pregnancy

31. Indications of pessaries
• 1st trimester of pregnancy (upto 18 weeks)
• Puerperium
• Patient unfit for surgery
• Patient unwilling for surgery
• Patient waiting for surgery
• To relieve urinary symptoms

32. Types of pessaries
• Ring pessary
• Donut pessary
• Gellhorn pessary
• Cube pessary
• Shaatz pessary
• Gehrung pessary
• Lever pessary
• Incontinence pessary

33. Method of introducing ring pessary
• Folding pessary in half,
• Inserting it with curved side up
• Once in vagina rings open up
• Lower rim of pessary should be placed behind
the pubic symphysis

35. Surgical management
• Indications for Surgery
a) Failed conservative treatment
b)Severe degree of Prolapse
c) Patient who has completed her family size
and doesn't desire to preserve fertility

36. Surgical treatment
A. Uterovaginal prolapse:
1.Vaginal hysterectomy with pelvic floor repair
Indications:
o UV prolapse in Post menopausal women
o UV prolapse in perimenopausal age group a/w
DUB, unhealthy cervix, small submucous fibroid
o As alternative to Manchester operation when
family is completed

37. 2. Fothergill/Manchester operation
Indications:
• Preservation of reproductive function
• When symptoms are due to vaginal prolapse
associated with elongation of supravaginal
cervix
Principle Steps:
• Preliminary D and C
• Amputation of cervix
• Plication of Cardinal ligament
• Anterior colporrhaphy
• Colpoperineorrhaphy
(low amputation if future reproduction required)

38. Vaginal wall prolapse:
Combined
anterior and
posterior
Cystocele and
Rectocele
Pelvic Floor Repair

39. Vault prolapse following hysterectomy
Transvaginal approach:
• Repair of vaginal vault along with PFR
• LE fort operation
• Colpoclesis
• Sacrospinous colpopexy
Abdominal approach:
• Vault suspension (Sacral colpopexy)

40. Nulliparous (congenital) prolapse:
• Cervicopexy/Sling operation

41. Complications of surgery:
• Intraoperative:
Reactionary hemorrhage
Trauma to bladder, rectum
• Post operative
Primary and secondary hemorrhage
Sepsis
Urinary retention
Thromboembolism

42. • Late complications:
Dyspareunia
Recurrence of prolapse
Vesicovaginal fistula
Rectovaginal fistula
Vault prolapse

43. References
• DC DUTTA’S TEXT BOOK OF OBSTETRICS,
HIRALAL KONAR, 7th edition
• www.wikipedia.com
• https://www.youtube.com/watch?v=rnMz2XT
ogbE
• Medscape

44. • Thank you!!!