Advances in Reconstructive Vaginal Surgery
1st Edition

3
Evaluation and Management of Pelvic Organ Prolapse
Carl W. Zimmerman
Pelvic organ prolapse is the downward displacement of any of the central pelvic organs through the urogenital hiatus. Damage to the supportive and suspensory elements of the pelvic floor and endopelvic fascia is required for the development of prolapse (1). The various components of pelvic organ prolapse qualify as hernias. In most cases, childbirth is a necessary but not a sufficient cause for the development of these conditions (2,3,4,5,6,7,8,9,10,11). Prolapse primarily affects the quality of the patient’s life (12,13,14,15,16). Even in large and chronic cases, dangerous complications are infrequently encountered. Management of prolapse should be based on the degree that it interferes with the patient’s daily life. In this chapter, common signs and symptoms, history and physical examination, and management will be discussed.
Signs and Symptoms
Pelvic organ prolapse often develops in an insidious way (12,17). Although some patients describe an index event followed by the rapid development of a protrusion, many individuals will note a gradual and progressive onset of the condition. This progression may occur over a period of several years and only be brought to the clinician’s attention when significant symptoms occur. A complete external prolapse that is asymptomatic may be tolerable to the patient, and even though surgical correction may be offered, the patient may decline this option. Conversely, if a patient has significant urinary incontinence, surgical therapy may be sought in the presence of minimal degrees of prolapse. The patient’s perception of her symptoms and quality of life are key factors in determining the type and timing of intervention.
Anterior vaginal segment prolapse may involve the urethra or the floor of the bladder. Consequently, the most common presenting symptoms are urinary. Disruptions of the support of the urethra are manifested in the form of stress or mixed urinary incontinence (11,18). The exact anatomic mechanism involved with stress incontinence is a matter of debate. Classically, many clinicians have ascribed the development of this symptom to damage of the pubourethral ligaments and consequent rotational descent of the mid to proximal urethra. Anatomically, rotational descent of the urethra is an urethrocele. More recently, disruptions of the lateral paravaginal attachments of the pubocervical septum have assumed increased importance in the etiology of urinary incontinence. The paravaginal disruptions prevent the connective tissue of the pubocervical septum from serving as an occluding base that closes the urethra when pressure is exerted from above (19). Childbirth certainly contributes to the development of stress urinary incontinence; however, the condition may develop in nulligravid patients. For example, the condition is common in female paratroopers. Sudden decelerations at the time of deployment of the parachute and at landing are speculated to be the causative events. Some women report stress incontinence that began in childhood and persists into adulthood. Menopause may also precipitate this condition as a result of tissue atrophy in an environment of estrogen depletion. Although the exact anatomic or clinical cause of stress incontinence cannot be determined in every case, involuntary loss of urine with increased intra-abdominal pressure is one of the leading presenting
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symptoms in patients with anterior vaginal prolapse. Even when the bladder has recently been emptied, coughing, straining, or sudden movements often cause enough leakage of urine to erode significantly the patient’s quality of life (20).
Prolapse of the bladder floor is a cystocele. Historically, attenuation and central distention of the pubocervical septum as a result of childbirth was believed to cause this condition (21,22). Lateral paravaginal detachments and proximal transverse defects in the pubocervical septum are now known to cause anterior vaginal prolapse. Prolapse of the bladder occurs when the midvaginal lateral attachment and the connection between the proximal pubocervical septum and the pericervical ring are disrupted. Cystocele causes little or no pain; however, pressure may be a presenting complaint. Because the floor of the bladder drops below the level of the internal urethral orifice, incomplete emptying of the bladder is the most common presenting complaint. Incomplete voiding leads to frequency of urination and nocturia. Persistence of incomplete emptying leads to the development of urgency symptoms and subsequently to urge incontinence. Urinary tract infections may occur, require treatment, and eventually develop into chronic infections that are difficult to treat. Patients may sense that they have emptied incompletely and resort to the Valsalva maneuver in an effort to complete micturition. Any activity that causes the patient to fix the respiratory diaphragm and to bear down repeatedly to void will eventually enlarge the cystocele and any other type of prolapse that may be present. Heavy lifting, straining, coughing, and straining at defecation are examples of common events that may worsen prolapse.
Prolapse of the superior vaginal segment involves the uterus or hysterectomy scar and the cul-de-sac of Douglas (21,22). Uterine prolapse occurs when the suspensory axis of the uterovaginal complex is damaged. Most frequently due to the forces of labor, disruption of the suspensory axis occurs in the pelvic diameter between the ischial spines (2,8). At this level, the continuity of the uterosacral ligaments, the pericervical ring, and the proximal rectovaginal septum is interrupted. With a loss of uterosacral suspension and posterior displacement, the cervix will eventually descend through the urogenital hiatus. A sense of pressure, exacerbated by lifting, straining, or sexual activity frequently accompanies this condition. Collision dyspareunia may also occur. A feeling of heaviness or cramping may persist for some time after intercourse. Descent of the cervix through the introitus is called procidentia. The hymenal ring at the introitus is the fixed landmark used to divide prolapse into complete and incomplete classifications. When a prolapse becomes complete, it is much more likely to be sufficiently troublesome to cause the patient to seek surgical intervention (12). Posthysterectomy vaginal prolapse is very common. Unless a specific and intentional attempt was made at the time of hysterectomy to reattach the uterosacral ligaments to the vaginal cuff, prolapse is likely to occur at some subsequent point in the patient’s lifetime.
Herniation of cul-de-sac peritoneum containing small bowel is an enterocele (22). An enterocele is present when the abdominal parietal peritoneum is in direct contact with the vaginal epithelium. This condition is due to a disruption of the connection of the proximal rectovaginal septum to the uterosacral ligaments laterally and the pericervical ring centrally. As the enterocele enlarges, traction may develop on the mesenteries of the abdomen. For this reason, enteroceles are the only central pelvic hernias that commonly cause significant discomfort. The pain is perceived as deep in the central and lower abdomen. This discomfort usually is worse after long periods of activity in a standing position. Pain may also be increased when the patient uses Valsalva maneuver to assist in defecation or micturition. The relatively inaccessible location of the anatomic disruption that causes enteroceles is a significant challenge for the pelvic reconstructive surgeon.
Posterior vaginal prolapse involves the anterior rectal wall and the perineum. Pocketing of the anterior rectal wall into the vagina is called a rectocele (22). This prolapse occurs as a result of the same proximal separation of the rectovaginal septum that causes enteroceles. Contrary to traditional teaching and thought, rectoceles and enteroceles descend through the same fascial defect. Perineal descent also results from the proximal disruption of the rectovaginal septum. Rectoceles, enteroceles, and perineal descent occur because the suspensory axis of the vagina is disrupted within the interspinous diameter. Rectoceles have a very specific and recognizable pattern of symptoms. Entrapment occurs as the leading edge of a bowel movement descends from the rectal ampulla into the anus. An intact rectovaginal septum functions to guide effectively the leading edge of a stool toward the anus. Once the bowel movement becomes entrapped within the rectocele pocket, the Valsalva maneuver is used by the patient. As a result, the bowel contents combined with downward pressure cause the rectocele to enlarge and symptoms to worsen over time. This condition is known as obstructed defecation syndrome and frequently results in a patient complaining of constipation. Enlargement of the enterocele and rectocele allows the disrupted rectovaginal septum to retract distally and to worsen the perineal descent.
Proximal disruption of the rectovaginal septum causes both rectocele and enterocele and allows the development of perineal descent. All three of these conditions are a result of disruption of the connection between the rectovaginal septum and uterosacral ligaments. This disruption allows downward displacement of all portions of the suspensory axis that are located distal to the interspinous diameter (see Chapter 17, Fig. 17.1). Perineal descent is an uncomfortable condition because the patient sits on the pressure sensitive soft tissue of the anal verge that has fallen. The anatomic location of the normally suspended perineum is cranial to the plane defined by the ischial tuberosities. These substantial
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bony structures are designed to support the weight of the body without discomfort because no pressure is exerted on the anus.
Disruptions of the perineum usually have an obstetric etiology and frequently are iatrogenic. Most women who have undergone vaginal delivery have some evidence of attenuation or scarring on the perineum. If the damage sufficiently injures the external anal sphincter, fecal incontinence is the result. Although anal incontinence is always troublesome to the patient, a skillful history is often required to elicit the full extent of this type of symptom. Patients are more frequently incontinent of gas than of liquid bowel contents. Incontinence of solid stool may occur with severe disruptions.
Physical examination of the prolapse patient should involve more than an examination of the vaginal canal (18). A careful and complete medical and surgical history will reveal helpful findings in many cases. Any condition or activity that increases the physical load on the pelvic floor will predispose patients to the development of pelvic organ prolapse (4). Examples include obesity, osteoporotic kyphosis, constipation, chronic cough, lifting, and straining (20,23,24). Identification and management of these conditions and factors can potentially prevent the progression of an incipient prolapse if the patient is properly educated and motivated. Postoperative patients also benefit from management of conditions that stress the pelvis. Prevention of stress on the pelvic floor is one of the basic treatments of prolapse and should be continued indefinitely. Control of chronic cough, cessation of smoking, weight loss, prevention of osteoporosis, treatment of constipation, and avoidance of heavy lifting are all valuable interventions in prolapse patients. Strengthening the shoulder girdle, legs, and low back helps to prevent straining and the resultant pressure on the pelvic floor that causes pelvic organ prolapse to develop. Weakened or defective connective tissue predisposes the patient to prolapse (7). Patients with a history of multiple hernias, regardless of location, probably have a hereditary tendency to develop prolapse. Patients receiving chronic steroid therapy are at high risk for progression of prolapse and for failure of operative therapy.
Intact pelvic anatomy is dependent on the pelvic diaphragm, functional pelvic nerves, and normal connective tissue structures and attachments (4,8,9,12,25,26,27,28). During childbirth, intense pressure is exerted on all of these components of the pelvis. Studies have shown that the pudendal nerve is frequently stretched to the point of damage during the process of delivery. The muscles of the pelvic diaphragm are also subjected to enough pressure to create avulsive tears and separations. This damage is known to lead eventually to atrophy of portions of these vital support structures, especially in the presence of pudendal nerve damage (3). Damage of this type to the pelvic diaphragm of parous women has been demonstrated with magnetic resonance imaging studies (26). Lack of the supportive function of the pelvic diaphragm increases the likelihood of prolapse and of failure if surgery is performed. Myopathies and neuropathies are prevalent contributing causes of prolapse, and currently these conditions have no effective treatments. All women, especially those with prolapse, should recognize the value of protection and strengthening of the muscular pelvic floor (29,30,31,32). Pelvic floor voluntary contractions, popularized by Dr. Arnold Kegel, are valuable adjuncts to all other forms of treatment and prevention for pelvic organ prolapse (30). Kegel contractions can be performed at any time during the patient’s day. A particularly valuable way to habituate patients to do these exercises is to combine them with voiding. Upon completion of voiding, the patient is instructed to lean as far forward as feasible. This action elevates the bladder floor and contributes to complete emptying of the bladder. Often this modification in the individual’s position results in a secondary and tertiary void due to the change in the orientation of the bladder floor. A beneficial decrease in the amount of residual urine is the result of this maneuver. After voiding is completed and while still leaning forward, the patient performs a series of isometric Kegel pelvic floor contractions. Frequently, this series of steps will contribute to the resolution of urge symptoms, increase the amount of time between voids, help prevent urinary tract infections, and decrease the number of episodes of nocturia. Teaching the patient the proper way of contracting her pelvic floor muscles, especially during periods of stress on the pelvic floor, empowers the patient to participate actively in the conservative management of her prolapse.
History and Physical Examination
A thorough evaluation of the prolapse patient by history and physical examination greatly assists in the management of the problems associated with these conditions (18). Because prolapse affects urinary, bowel, and sexual function, the caregiver must be sensitive and skillful in persuading the patient to share her symptoms. The role that these symptoms have in the continuum of prolapse should be explained to the patient in a way that she can understand. Frequently, the patient will be asked to discuss matters that she has never discussed with her family or closest friends. In fact, she may believe that no one else has similar problems. Questionnaires may assist in the process of taking a history, especially if they are supplied to the patient before her visit. The answers to quality-of-life questions may be used to guide the discussion and may permit the patient to share details that could be difficult for her to verbalize. Validated quality-of-life forms are available from various sources (33).
Patients must have sufficient cardiopulmonary reserve to tolerate pelvic reconstructive surgery. Evaluation of physical capabilities may be supplemented by communication with appropriate healthcare providers. Histories of significant cardiac disease, myocardial infarction, or pulmonary
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disease are examples of conditions that need to be objectified before consideration of a major surgical procedure. Pulmonary embolism is a major risk factor in all types of pelvic surgery, especially in those cases that require prolonged dorsal lithotomy positioning. Prior to surgery, the surgeon should recognize risk factors for embolism and use proper intervention during and after the surgical procedure.
A morbidly elevated body mass index increases many attendant risks of surgery. The patient should be informed that a significant weight loss may be a useful way for her to demonstrate a commitment to the requirements of recovery and permanent lifestyle restrictions. In a similar way, a diabetic may be asked to stabilize control of her blood sugar before surgery can be offered. For example, a normal major fraction of glycosylated hemoglobin (HbA1c) may be required. Many other chronic health conditions impact the pelvic floor and the ability of the patient to withstand surgery. The clinician should evaluate the patient’s health with the pelvic floor in mind. Changes should be suggested that decrease the likelihood of a complication or an unsuccessful outcome if surgery is required.
Altered urinary function frequently accompanies prolapse. Stress urinary incontinence (SUI) is the involuntary loss of urine when increased pressure is placed on the pelvic floor (34,35). This condition is one of the leading presenting complaints in patients with prolapse. The degree of SUI tolerance is highly individual and often related to lifestyle or personal expectations. If the incontinence is minimal, infrequent, or situational, the patient is likely to resist surgical intervention. If the incontinence is sufficient to require the use of pad or adult diaper protection, surgical intervention is almost certain to be sought. Many patients develop SUI during pregnancy only to have it resolve with the completion of parturition. The symptom may not return until later in life with menopause being the most likely time of recurrence. Patients with SUI associate loss of urine with specific events such as coughing, sneezing, lifting, or straining. Gradual worsening typifies the natural history of the condition. Less frequently, patients associate the onset of SUI with an index event that has placed a significant stress on the pelvic floor. The patient should be educated in the spectrum of management strategies in order to empower her to decide on the course of treatment that best suits her needs.
Urge incontinence is the involuntary loss of urine associated with a sudden need to void (34,35). This complaint may or may not be associated with prolapse. Frequently, patients have components of both urge and stress incontinence. Skillful interpretation of history and an evaluation using urodynamic techniques help to objectify findings in such patients. Urge symptoms may be situational. Examples of inciting events include exposure to cold air, the sound or sight of water, or arriving at home. The urge to void is sudden in these situations and overpowers the compensatory control efforts of the individual. Loss of urine may be minimal or involve a complete emptying of the bladder. Urge symptoms frequently coexist with prolapse when a significant cystocele is present. As a result, the bladder floor is lower than the urethral orifice and voiding may be incomplete. Residual urine may sufficiently stimulate the bladder to allow development of urge symptoms. Interventions that increase the ability of the bladder to empty help control or eliminate the uncontrollable urge to void. Smokers and patients with interstitial cystitis are particularly prone to this condition. Surgical repair of a cystocele is a useful way to decrease residual urine volumes.
Bowel symptoms are associated with pelvic organ prolapse. The most common presenting symptom is obstructed defecation syndrome. In this condition, the leading edge of a descending bowel movement is entrapped within a rectocele. Anterior pocketing of the rectal wall is always present in a rectocele. The proximal disruption of the rectovaginal septum causes the rectocele and the pocketing. The patient may use the term constipation as a synonym for difficult defecation. In obstructed defecation syndrome, the leading edge of the descending bowel movement becomes entrapped whether constipation is present or not. Many individuals self-discover that support or pressure on the perineum or inside the distal vaginal wall permits more efficient defecation. This process is called splinting and should be encouraged.
Fecal incontinence is common in pelvic organ prolapse patients (35). Various degrees of this problem exist. Patients may be incontinent of gas, liquid, or solid bowel contents. Especially in the parous patient, disruption of the anal sphincter is the most common etiology for this condition. Pudendal and sacral nerve neuropathies need to be considered as potential causes of fecal incontinence. Patients who have diabetes, a history of trauma, back problems, or an inability to voluntarily contract their pelvic floor muscles may have a neurologic component causing fecal incontinence.
Sexual dysfunction may accompany pelvic organ prolapse (16). This topic is complex. Urinary incontinence, fecal incontinence, altered body image, or mechanical difficulties consummating intercourse may all contribute to the problem. A major goal of any treatment for pelvic organ prolapse is compensation or correction of altered anatomy. Elimination or successful management of the problems listed previously may result in a significant sexual lifestyle improvement. Obtaining a sexual history is an art that requires time, trust, and experience. Realistic expectations for sexuality are a critical component for the pelvic reconstructive surgeon. Anorgasmia, for instance, is unlikely to resolve after corrective pelvic surgery. Mechanical difficulties secondary to a large prolapse are more likely to disappear. Dyspareunia from obstetric scarring or from previous anatomically distorting pelvic surgeries may also resolve if properly corrected.
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Pelvic pain is not a common symptom in pelvic organ prolapse. Patients with a significant degree of pain should be carefully evaluated for identifiable causes. Incomplete urinary emptying may cause pain by precipitating bladder spasm. If the bladder empties more completely, this pain may improve after successful pelvic floor rehabilitation or surgery. Similarly, obstructed defecation syndrome may lead to painful bowel spasm or painful pelvic pressure. If corrected, this painful symptom may resolve. In general, prolapse of the central pelvic organs through the urogenital hiatus only causes an annoying pressure sensation. The only exception is the enterocele. If sufficiently large, an enterocele may exert enough traction on the mesenteries of the abdomen to cause periumbilical pain.
Especially in an advanced prolapse, altered axis, depth, and caliber of the vagina are frequent in the postoperative patient (36,37,38). If the practitioner has a detailed understanding of the function, needs, and desires of the prolapse patient, a cooperative understanding of the consequences of treatment may be more accurately outlined. This process allows the patient to make better informed choices regarding treatment.
A complete surgical history is important to the evaluation of the patient with prolapse. A history of hiatal, umbilical, inguinal, or ventral hernia may alert the caregiver to a propensity for weak connective tissue. Hysterectomy is a known risk factor for pelvic organ prolapse. Unless expertly performed to include prophylactic suspension, removal of the uterus leaves a defect in the proximal anterior vaginal wall that is very difficult to completely close. Previous prolapse procedures are highly significant. They raise the risk for future failure and frequently involve significant anatomic distortion or scarring. Previous intra-abdominal procedures, depending on their details, may be accompanied by internal anatomic distortions or adhesions. Procedures on the back carry risks related to neurologic impairment of the pelvis. This list is incomplete; however, it should sufficiently illustrate the type of thought pattern needed in evaluating a surgical history related to prolapse.
Conservative measures may offer significant improvement to the prolapse patient. The routine use of forward leaning Kegel pelvic floor contractions, described previously in this chapter, is an example of an intervention that may be very helpful to the patient. Shoulder, leg, and low back strengthening helps women accomplish more activities without straining or placing repeated stresses on the pelvic floor.
Physical examination of the prolapse patient should be complete. Of course, the full scope of physical examination and diagnosis cannot be described in this textbook. Generally, any condition that has the potential to exert increased pressure on the pelvic floor, disrupt the muscle strength of the body, disrupt the neurologic integrity of the pelvis, or weaken the connective tissue of the pelvis has the potential to be an etiology of pelvic organ prolapse. Every woman has a urogenital hiatus. This opening, located in the most dependent portion of the trunk of the body, is large enough to allow the passage of a term-sized infant. Because of its location, this hiatus bears the weight of all the abdominal contents (Fig. 3.1). The potential for disruptions of normal pelvic anatomy is increased when the respiratory diaphragm is fixed and significant pressure is exerted downward on the pelvic floor. The seasoned examiner will automatically recognize conditions that predispose to prolapse and understand their role in successful management and treatment.
Figure 3.1 Vectors of force are exerted directly on the pelvic floor and urogenital hiatus. (From, frontpiece,
Zacharin RF. Pelvic Floor Anatomy and the Surgery of Pulsion Enterocele. Wein New York, Springer-Verlag: 1985
, with permission.)
A normal cranial nerve examination helps to rule out central nervous system conditions that could contribute to pelvic floor neuropathy. Observing the patient’s gait helps to evaluate mobility, flexibility, strength, and the integrity of key sacral nerve roots. Sacral nerve roots 2, 3, and 4 are necessary for dorsiflexion and spread of the toes.
The abdomen should be inspected for evidence of intra-abdominal disease or masses. A large abdominal mass or ascites may increase the load on the pelvic floor and convert an incipient prolapse into a clinically evident condition. Obviously such pathology may be significantly more threatening than the presenting condition. Previous surgical scars may give valuable evidence of a propensity to herniation or the condition of the peritoneal cavity. Examination of the groin for inguinal herniation is recommended.
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Femoral pulses should be documented. Poor vascular supply to the legs may preclude prolonged placement in the dorsal lithotomy position. Flexibility and the ability to externally rotate at the hip are necessary for positioning during surgery.
The pelvic examination for prolapse includes the basic elements of a normal gynecologic evaluation. The presence of other disease processes may delay or alter the treatment of prolapse. For example, a large pelvic mass or significant degree of pelvic pain may require entry into the abdomen and preclude a primary vaginal approach. During the examination, the patient should be made as comfortable as possible. Correct positioning, comfortable room and instrument temperature, and proper covering of the body contribute to the physical comfort of the patient. Continuous verbal contact with the patient maximizes her mental comfort. If possible, the examiner should assure the patient that he/she recognizes the problem that the patient has described. When a patient’s description of her prolapse does not match the findings on examination, the patient should be encouraged to perform any maneuver needed to demonstrate the full extent of the problem. Repeated Valsalva maneuvers, change to a standing position, or a trip to the restroom may be required (39). When desired or appropriate, a mirror may be used to further involve the patient in the interactive examination.
Knowledge of normal pelvic anatomy allows for more complete assessment of the distortions caused by pelvic organ prolapse. A complete and systematic evaluation is necessary to recognize all components of prolapse. The vaginal canal may be divided into anterior, superior, and posterior segments. In most cases of symptomatic prolapse, one vaginal segment may be considered dominant. The dominant segment will occupy the most dependent position within the urogenital hiatus. When the dominant segment is reduced, other codominant, secondary, or incipient segments of prolapse will likely be apparent. If a dominant prolapse is repaired in isolation, other segments are likely to descend at some subsequent time. This concept illustrates the interconnected and interdependent nature of normal pelvic support and suspension anatomy. Recognition of all damaged segments allows for more complete and successful treatment.
A characteristic pattern of fine transverse creases, rugae, is present in the normal vaginal wall. Rugae signify the presence of deep endopelvic connective tissue septa beneath the vaginal epithelium of the anterior and posterior walls. In the presence of prolapse, the septa are disrupted and sheared away from normal proximal and lateral attachment points. Displacement of the detached septa allows the enlargement of the prolapse. A careful search for the presence and absence of rugae reveals much information about the location of displaced normal deep endopelvic connective tissue. As a general rule, connective tissue does not atrophy. Even in cases of advanced prolapse, a careful search for and sculpting of the displaced fascial septa reveals sufficient connective tissue to allow repair of prolapse using native tissue. Use of a pelvic organ prolapse map to record the presumed location of displaced fasciae can assist the clinician in surgical planning (Figs. 3.2 and 3.3).
Figure 3.2 Pelvic organ prolapse map. Key elements of pelvic support anatomy. Three dimensions are reduced to two by dividing the vagina at the 3 o’clock and 9 o’clock positions. Baden-Walker vaginal support profile sites: 1, urethral; 2, vesical; 3, uterine; 4, cul-de-sac; 5, rectal; 6, perineal. PT, pubic tubercle; ATFP, arcus tendineus fasciae pelvis; ATFRV, arcus tendineus fasciae rectovaginalis; IS, ischial spines; U, urethra; CX, cervix; A, anus. (From,
Zimmerman CW. Pelvic organ prolapse. In: Rock JA, Jones HW, eds. Te Linde’s Operative Gynecology. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003:943
, with permission.)
The interspinous diameter is critically important in evaluation of prolapse. As the narrowest diameter in the female human pelvis, this plane is the location of the highest pressures generated during the process of childbirth. In addition, all named pelvic suspension components of the deep endopelvic connective tissue intersect in the interspinous diameter. This combination of facts leads to a general pattern of disruption within the interspinous diameter and displacement of connective tissue structures toward the vaginal opening. Rugae will be preserved in the areas of the vagina that are closer to the vaginal opening. Smooth areas of distended vaginal epithelium are located adjacent to the interspinous diameter. Paravaginal paravesical defects cause the pubocervical fascia to retract to the opposite of the patient’s body. Bilateral paravaginal defects may also occur. A patient right, full-length paravaginal defect is the most common anterior vaginal prolapse pattern encountered clinically. Posteriorly, a transverse full-width detachment of the rectovaginal septum with displacement
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toward the perineum is the most common pattern seen (Fig. 3.4).
A rectal examination is necessary to rule out palpable abnormalities of the rectal wall. Anterior displacement of the examining digit frequently allows the examiner to palpate the detached edge of the rectovaginal septum and to evaluate the presence of rectocele, enterocele, and perineal descent.
Figure 3.3 Posthysterectomy pelvic organ prolapse map. Key elements of posthysterectomy pelvic support anatomy. Three dimensions are reduced to two by dividing the vagina at the 3 o’clock and 9 o’clock positions. Baden-Walker vaginal support profile sites: 1, urethral; 2, vesical; 3, hysterectomy scar; 4, cul-de-sac; 5, rectal; 6, perineal. PT, pubic tubercle; ATFP, arcus tendineus fasciae pelvis; ATFRV, arcus tendineus fasciae rectovaginalis; IS, ischial spines; U, urethra; CX, cervix; A, anus. (From,
Zimmerman CW. Pelvic organ prolapse. In: Rock JA, Jones HW, eds. Te Linde’s Operative Gynecology. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003:943
, with permission.)
Gently swiping a finger across the skin adjacent to the anus normally elicits an anal wink. The presence of this reflex demonstrates an intact autonomic innervation of the rectum. The muscles of the pelvic floor form the pelvic diaphragm, are normally under voluntary control, and may be contracted by the patient. This voluntary exercise is termed a Kegel contraction. The puborectalis muscle is the strongest of these muscles. When contracted, the levator ani muscles partially occlude the urogenital hiatus and form the primary supportive mechanism of the uterovaginal complex. Assessing the strength of these muscles provides important information in the presence of prolapse. A subjective ordinal scale can be used to assign strength of 0 to 4/4. Partial or complete weakening of the ability to contract the puborectalis indicates a loss of muscle mass or a pudendal neuropathy. A weak or neuropathic pelvic floor increases the risk of failure in the surgical and nonsurgical treatment of pelvic organ prolapse.
Figure 3.4 Pelvic organ prolapse map: Typical pattern of fascial damage. The most frequently encountered pattern of fascial damage in pelvic organ prolapse: (i) full-length right paravaginal paravesical defect; (ii) transverse apical detachment of the pubocervical septum; and (iii) transverse apical detachment of the rectovaginal septum. This pattern of damage is consistent with the mechanics of a left occipitoanterior delivery. Baden-Walker vaginal support profile sites: 1, urethral; 2, vesical; 3, uterine; 4, cul-de-sac; 5, rectal; 6, perineal. PT, pubic tubercle; ATFP, arcus tendineus fasciae pelvis; ATFRV, arcus tendineus fasciae rectovaginalis; IS, ischial spines; U, urethra; CX, cervix; A, anus. (From,
Zimmerman CW. Pelvic organ prolapse. In: Rock JA, Jones HW, eds. Te Linde’s Operative Gynecology. 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2003:944
, with permission.)
Various methods exist that allow for more objective recording of the presence and severity of pelvic organ prolapse. Traditionally, a subjective classification of mild, moderate, and severe was used for specific sites. Poor interobserver reproducibility led to the development of the two systems in use today. The Baden-Walker Halfway System is useful primarily in clinical circumstances (21). The assignment of a score to each of six specific midline sites encodes a large amount of information in a small amount of time and space. When descriptive notes and a pelvic organ prolapse map are added, a more complete description of the prolapse can be created. Although descriptive, some shortcomings exist in the Baden-Walker system. For instance, a strategically placed 1-cm increase in prolapse results in an increase in the assigned stage. In addition, interobserver agreement is not perfect with the Baden-Walker system (see text box on following page).
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The extent of prolapse is recorded using a number (0 to 4) at each of six sites in the vagina. Two sites are located on the anterior, superior, and posterior walls of the vagina, respectively. Table 3.1 lists the anatomic sites and the associated symptoms. The six numbers are recorded as a measure of descent. For all sites except the perineum, the hymen is used as a fixed anatomic reference point. Zero indicates normal anatomic position for a site, whereas 4 represents maximum prolapse. Between these extremes, the intervening numbers grade descent using a halfway system as illustrated in Figure 3.5. The examination is performed with the patient straining so that maximum descent is attained. The patient may wish to stand to demonstrate maximum descent.
The perineum is graded using the familiar perineal laceration system used in obstetrics (Fig. 3.5). The patient is asked to hold or Kegel to evaluate the amount of muscular and fascial compensatory support. Comments may include site of dominant prolapse, location of scars, palpable plications, and the type of efforts necessary to demonstrate maximum prolapse. Strength of the levator contraction may be recorded as 0 to 4.
Example: Baden-Walker pelvic support profile 12/44/32. A dominant complete proximal prolapse is noted with enterocele, significant cystocele, and rectocele, and perineal attenuation to the level of the external anal sphincter. 2/4 levator strength is present.
Although this type of notation encodes much information in a small space, no specific location of fascial defects is indicated (21).
Table 3.1 Primary and Secondary Symptoms at Each Site
  Symptom(s)
Anatomic Site Primary Secondary
1 Urethral Urinary incontinence Falling out
2 Vesical Voiding difficulties Falling out
3 Uterine Falling out Heaviness, and so forth
4 Cul-de-sac Pelvic pressure (standing) Falling out
5 Rectal True bowel pocket Falling out
6 Perineal Anal incontinence (gas/feces) Too loose
Baden-Walker Halfway System: Primary and Secondary Symptoms at Each Site (From, Baden WF, Walker T. Surgical Repair of Vaginal Defects. Philadelphia: Lippincott, 1992:12, with permission.)
In an effort to create an encoding tool useful to both the clinician and researcher, the Standardization Subcommittee of the International Continence Society created the Pelvic Organ Prolapse Quantification System or POP-Q system in 2002 (34,35,40,41). This system relies on specific measurements of defined points in the midline of the vaginal wall. The fixed reference point used for measurement is the hymenal ring. In this system, small increases in prolapse are recorded as small increases in measurement. Because specific measurements at nine sites are recorded in a tic-tac-toe grid, interobserver agreement is improved. Researchers favor the use of the POP-Q system for this reason. Unfortunately, the detail involved in making and recording nine measurements has been an impediment to more widespread clinical adoption of this system. The routine use of the POP-Q system decreases significantly the amount of time needed to collect the desired data (see text box below).
This system was developed as an effort to introduce more objectivity into the quantification of pelvic organ prolapse. For example, measurements in centimeters are used instead of grades. Nine specific measurements are recorded as indicated in Figure 3.6. Point Aa is defined as being 3 cm proximal to the external urethral meatus on the anterior vaginal wall. Point Ap is defined as being 3 cm proximal to the hymen on the posterior vaginal wall. Points Ba and Bp are defined as points of maximum prolapse excursion on the anterior and posterior vaginal walls, respectively. Measurements are recorded as negative numbers when proximal to the hymen and positive numbers when distal to the hymen. POP-Q sites C and D are identical in location to Baden-Walker sites three and four in the proximal vagina. In addition, measurements of the total vaginal length, genital hiatus, and perineal body are taken. All measurements are recorded on a tic-tac-toe style grid (Fig. 3.7). When combined with sagittal line drawings, a fairly complete picture of prolapse is attained (Fig. 3.8). Ordinal stages of pelvic organ prolapse are then assigned from stage 0 (no prolapse) to stage V (complete prolapse) so that the outcomes of cases of like magnitude may be compared. This system is a physical examination tool and does not assign the specific location of fascial defects (35).
Both the POP-Q and Baden-Walker systems may be supplemented by the use of a pelvic organ prolapse map. When combined with a brief notation of the dominant prolapse, location of scar contractions, strength of the levator ani contraction, and other anatomic findings, this map can significantly supplement the amount of detail that can be rapidly recorded. An effort should be made to assess each of the important sites of pelvic organ prolapse and accurately record the findings, regardless of the system used.
A complete history and physical examination with emphasis on details that specifically impact the pelvic floor is necessary for proper planning in the management of pelvic organ prolapse.
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Figure 3.5 Baden-Walker Halfway System. Guidelines on how to assign ordinal grades in the Baden-Walker Halfway System. (From,
Baden WF, Walker T. Surgical Repair of Vaginal Defects. Philadelphia: Lippincott, 1992:236
, with permission.)
Figure 3.6 Pelvic organ prolapse quantification (POP-Q) system. The nine specific sites of measurement used in the POP-Q system are indicated by the letters in this figure. gh, genital hiatus; pb, perineal body; tvl, total vaginal length (see Fig. 3.7). (From,
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:12
, with permission.)
Management
Pelvic organ prolapse is generally a quality-of-life issue. Serious medical consequences are uncommon in this condition. No patient should be persuaded or encouraged to undergo an operation for prolapse. The patient’s perception of how the prolapse impacts her day-to-day life is the key element in the management of her individual prolapse. As in other quality-of-life medical conditions, conservative measures should be used primarily. A given patient may tolerate a significant degree of prolapse and not complain. When conservative measures are ineffective then surgery may be considered.
Figure 3.7 Pelvic organ prolapse quantification (POP-Q) system. The tic-tac-toe grid used to record measurements in the POP-Q system. (From,
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:13
, with permission.)
Certain things should be suggested to everyone with prolapse or at risk for developing prolapse. Specific measures can help strengthen specific muscle groups, protect the pelvic floor, and increase efficient emptying of the bladder and bowel (11). These same techniques are useful in both prevention and postoperative management of the prolapse patient.
Shoulder, upper extremity, and low back strengthening will help an individual to accomplish daily tasks without
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placing undue strain on the pelvic floor. Low resistance exercise to increase muscle tone is encouraged for all patients, especially those who either have or have had prolapse. Exercise weights in the 1 to 5 pound range will help accomplish this goal. Greater upper body strength allows a greater work load to be performed without resorting to the compensatory use of the Valsalva maneuver.
Figure 3.8 Pelvic organ prolapse quantification (POP-Q) system. Two examples that use the POP-Q system. Measurements in the left grid correspond to a complete external prolapse. Measurements in the right grid correspond to normal anatomic position without any prolapse. (From,
Bump RC, Mattiasson A, Bo K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175:4
, with permission.)
Lower body strength is helpful to lifting. Proper technique of lifting primarily strengthens the quadriceps of the lower extremity and, to a lesser extent, the erector spinae muscles. Walking on an incline and range of motion low back exercises are helpful for all patients with prolapse.
A comprehensive, well-organized, and well-taught program of physiotherapy is a necessary and universally recommended component of the care of a patient with prolapse (29,30,32,42). Pelvic floor strengthening and specific voiding and defecating techniques were described earlier in this chapter. Consultation with a physiotherapist or other individual who has the time and knowledge to successfully teach the patient all of these concepts can help improve the chances for a good surgical or conservative management strategy. Patients should understand that all of these techniques are lifelong recommendations. Postpartum patients are frequently told to perform Kegel exercises for a short time immediately after delivery. Perhaps a more comprehensive instruction at that time would be helpful. No one knows if good physiotherapy would help prevent the development of prolapse if initiated postpartum and continued through life. Common sense would certainly suggest that none of these activities would be harmful.
Postmenopausal hypoestrogenemia is believed to be a major risk factor for the development of pelvic organ prolapse (13). Administration of hormone replacement therapy is controversial because of the complex risk and benefit analysis associated with postmenopausal estrogen (43).
Pessary management is only slightly more invasive than physiotherapy (13,15,42,44,45). Because no surgical intervention is required, this option should be presented to most prolapse patients. Pessaries act as bolsters that hold the apical portion of the prolapse above the pelvic diaphragm. If properly fitted and maintained, they may significantly improve a patient’s quality of life. A large variety of pessaries exist. Each has a specific set of strengths and limitations. A full discussion of the application of these devices is beyond the space and scope of this text. Traditionally, pessaries have been most useful to elderly, debilitated patients and those patients with multirecurrent failure. Younger and more active patients may also benefit from pessaries. A patient who engages in specific activities, such as work, jogging, or tennis, may wish to wear a device at those times and not routinely.
Surgery is the only known way to reverse the structural damage that has allowed prolapse to develop (13,21,36,37,46,47,48,49,50). Once prolapse is present, spontaneous regression will not occur. If sufficient deterioration of lifestyle is present, surgery should be included in the potential management strategies offered to the patient.
During the last half of the twentieth century, significant advances were developed in the way that prolapse was approached. A shift from anatomically distorting plication procedures to anatomically restoring site-specific techniques occurred. Biomechanical principles of suspension, lateral attachment, fusion, and bolstering have been included in these new techniques. Now prolapse surgery uses principles of hernia repair. For that reason, permanent suture has replaced absorbable suture for connective tissue reattachment and bolster placement. Inherent conceptual problems will forever exist with prolapse surgery. The urogenital hiatus is large enough to accommodate the birth of a full-term infant. This hiatus is not closed in anatomically
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restoring site-specific repairs. Restoration of the suspensory axis simply places the prolapse above the pelvic diaphragm and posterior to the urogenital hiatus over the levator plate. For these complex anatomic reasons, the propensity for failure will always be present in prolapse; however, it may be successfully and permanently repaired. Surgical procedures that account for all of the biomechanical principles listed previously and that restore normal anatomic relationships will have the greatest success and longevity.
Patients who experience recurrent or very large prolapse may require obstruction of the urogenital hiatus. Occlusion of the vagina by colpocleisis is an intentionally anatomically distorting surgery of last resort (Chapter 21).
A complete and current review of specific surgical techniques, described by experts in the field of pelvic reconstructive surgery, is included in the following chapters of this text. Comprehensive care of the prolapse patient is not limited to surgery. Metabolic control, weight control, physiotherapy, lifestyle management, and surgery are all integral and necessary requirements for complete management of these complex problems
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