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CASE REPORT

Supervised by:
dr. Arie Adrianus Polim, D.MAS, Sp.OG(K)

Presented by:
Sherynne Sulaiman (2013-061-081)
Kent Pradana (2014-061-131)
Emily (2014-061-132)
Marsha Desica (2014-061-136)
Department of Obstetrics and Gynecology
Medical Faculty of Atma Jaya Catholic University

1

2015

2

CHAPTER 1
CASE

1.1.

Patient’s Identity

Name

: Mrs. J

Age

: 57 years old

Nationality

: Indonesian

Address

: Pluit Dalam

Education

: Elementary school

Marital Status

: Married

Occupation

: Housewife

Religion

: Moslem

Date of Admission : November 2nd 2015

1.2.

Anamnesis

Chief Complaint
Feeling a lump in the vagina since 1 month ago
History of Present Illness
Patient came to the hospital because she feels a lump in her vagina since 1 month ago, the
lump size is about 5 cm in diameter. The lump protruding out when the patient is urinating
and resolves spontaneously after that. Patient also feeling a ball in her vagina while she is
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walking and lifting heavy weight, but resolves when resting. Patient denied feeling any pain.
Patient also complained about having an urge to pee everytime she is coughing or lifting a
heavy weight. Patient had an increased frequency of urinating to more than 10 times a day
since 2 months ago. Patient denied feeling unsatisfied after urinating. Patient denied feeling
pelvic and back pain. Patient doesn’t have any sexual activity since 10 years ago.
Patient had a history in difficulty on defecating since a long time ago but she doesn’t
remember since when. Patient was diagnosed with bone tuberculosis for almost 1 year ago
and take medications for tuberculosis since then until now. Patient also had a history of
frequent coughing (more than 10 times a day) since more than 1 year ago. Patient also
diagnosed with hypertension and takes medication (amlodipine 1 x 5 mg) since 2 years ago.

4

3

moderatel
y

7

moderatel
y

1

moderatel
y

History of Past Illness

History of hypertension
History of spondylitis tuberculosis

: since 2 years ago (amlodipine 1 x 5 mg )
: since 11 months ago
(R/H/Z/E)








History of heart disease
History of diabetes mellitus
History of allergy
History of epilepsy
History of hematologic disease
History of urinary tract/ kidney disease
History of trauma
History of surgery

:
:
:
:
:
:
:
:

denied
denied
denied
denied
denied
denied
denied
denied

Family History
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    History of hypertension History of pelvic organ prolapse History of diabetes mellitus History of allergy : : : : denied denied denied denied Contraception History Menstruation History   Menarche : 15 years old  Menstrual cycle First day of last menstrual cycle : Patient didn’t remember : 5 years ago Marital History Married once. Gestational History First day of last menstrual period No . Date Gestational Age 9 months : 5 years ago Breast Labor History Sex Birth weight Vaginal delivery Male 3000 grams yes feeding 1 1980 2 1981 3 1982 9 months Vaginal delivery Male 3000 grams Yes 4 1990 9 months Vaginal delivery Male 3500 grams yes Abortion 6 . for 40 years.

gallop (-).3. General condition : moderately ill appearance Consciousness : compos mentis Blood pressure : 140/80 mmHg Pulse : 96 BPM Respiratory Rate : 20 breaths per minute Temperature : 36.5 1993 Abortion Physical Examination (November 2nd 2015) 1.7o C Weight : 56 kg Height : 144 cm BMI : 27.05 kg/m2 General Examination Eye : Palpebral edema -/Anemic conjunctiva -/Anicteric sclera Oral : Wet oral mucosa Thorax Cor : Auscultation: irregular 1st and 2nd heart sound. murmur (-) Pulmo : 7 .

striae gravidarum (-). linea nigra (-) Palpation : supple in all abdominal region. lesions – Neurologic examination : bulbocavernosus reflex + (weak). 3-4 x/ minute Extremities : Warm Edema -/Physiological reflex ++/++/++/++ Pathological reflex --/-- Gynecology Examination Perineal examination    Inspection : vulvar atrophy -.   Inspection : Symmetric chest expansion in both static and dynamic breathing Percussion : Sonor on both lungs Auscultation : Vesicular breath sound +/+ Wheezing -/Crackles -/- Mammae : Hyperpigmentation of areola +/+ Nipple retraction -/- Abdomen    : Inspection : convex. tenderness (-) Auscultation : bowel sound (+). vaginal atrophy -. anal wink reflex + Speculum examination : o Protrusion come beyond the hymen o Presenting part of the prolaps  anterior o Widen genital hiatus with increased intraabdominal pressure Vaginal examination  POP-Q examination 8 .

 o Genital hiatus o Perineal body o Total vaginal length Speculum examination o Valsava maneuver o Descent of the apex o Anterior vaginal wall urethra o Posterior vaginal wall : 5 cm : 3 cm : : proplapse descends :+ : cystocele +. vaginal sulci -. vaginal rugae -. enterocele – Picture 1. Vaginal & perineal examination 9 . : rectocele -.

Laboratory Examination Hematology    Hemoglobin Hematocrit Leukocyte : : : 12 g/ dL 36% 7.Picture 2.900/ μL 10 . muscle symmetry + • Workup: EKG : ventricular extrasystole 10 times in 1 minute 1.4. Vaginal & perineal examination  Bimanual examination o Pelvic floor musculature : muscle resting tone and strength (grade 3 oxford scale).

000/ μL A/ Rh+ 3 minutes 5 minutes 13.4 mmol/l 1. spondylitis tuberculosis 1.      Thrombocyte Blood group Bleeding time Clotting time PT APTT : : : : : : 239. with second degree uterine prolapse and third degree cystocele.7 seconds : : : : 145 mmol/l 3. 57 years old. uncontrolled hypertension grade 1.Medication from departement of internal medicine: o Hysterectomy transvaginal  postpone until ventricular extrasystole < 6 times in 1 minute 11 .5.6.15 mmol/l 114 mmol/l : : : : : : 27 U/l 24 U/l 21 mg/ dL 0.5 seconds 27.   Therapy Hysterectomy transvaginal Consult to the department of internal medicine for the operation toleration: . SGOT/ AST SGPT/ ALT Ureum Creatinine One time blood glucose HbsAg Admitting Diagnosis P5A2.5 mg/ dL 134 mg/ dL - Electrolyte     Sodium Potassium Calsium Chloride Blood Chemistry       1.

o Oxygen 2 lpm via nasal canule o Cordarone 150 mg in 50 ml D5 bolus in 15 minutes (diluted to 50 cc via syringe pump)  Cordarone drip 300 mg in 500 ml in 12 hours o Candesartan 1 x 8 mg P.5 ºC • Eye : palpebral edema -/-.00 a.5 mg 1. anemic conjunctiva -/-. headache (-). Follow Up November 3rd 2015 (05.7. palpitation (-)  O: • General condition : Mildly ill appearance • Consciousness : Compos mentis • Blood Pressure : 140/90 mmHg • HR : 88 BPM • RR : 22 breaths/minute • S : 36. icteric sclera -/-. • Oral : Wet oral mucous • Thorax: • Cor • Pulmo : : Auscultation: irregular 1st and 2nd heart sound.O o Tuberculosis regimen: R/H/Z/E 450/400/1000/750 o Alprazolam 2 x 0.m)  S: feeling a lump in her vagina +. Murmur (-) • Inspection : symmetrical in both static and dynamic breathing • Percussion : sonor on both lungs 12 . Gallop (-).

linea nigra -. tenderness – • Percussion: tympanic sound in all abdominal region • Auscultation : bowel sound +.• • • • Auscultation : vesicular breath sound +/+.Hysterectomy transvaginal  postpone until ventricular extrasystole < 6 (stabile) . • Palpation : supple in all abdominal region.O • Tuberculosis regimen: R/H/Z/E 450/400/1000/750 • Alprazolam 2 x 0. striae gravidarum -. with uncontrolled hypertension grade 1. crackles -/- Mammae : hyperpigmentation of areola +/+.O • Candesartan 1 x 8 mg P. 6-7 x/minutes Extremities: Warm • Edema • Physiological reflex : ++/++/++/++ • Pathological reflex : Lower extremities -/- : --/-- Workup: • EKG : ventricular extrasystole 5 times in 1 minute  A : P5A2.Medication from departement of internal medicine: • Oxygen 2 lpm via nasal canule • Monitor vital sign • Cordarone 2 x 200 mg P. nipple retraction -/- Abdomen • Inspection : convex. spondylitis tuberculosis  P: .5 mg 13 . second degree uterine prolapse and third degree cystocele. 57 years old. wheezing -/-.

nipple retraction -/- Abdomen • Inspection : convex. Murmur (-) • Inspection : symmetric in both static and dynamic breathing • Percussion : sonor on both lungs • Auscultation : vesicular breath sound +/+.m)  S: Feeling a lump in her vagina +. • Oral : Wet oral mucous • Thorax: • Cor • Pulmo : • • : Auscultation: irregular 1st and 2nd heart sound. 14 .00 a. icteric sclera -/-. striae gravidarum -. palpitation (-)  O: • General condition : Mildly ill appearance • Consciousness : Compos mentis • Blood Pressure : 138/82 mmHg • HR : 66 BPM • RR : 22 breaths/minutes • S : 37 ºC • Eye : palpebral edema -/-. anemic conjunctiva -/-. wheezing -/-. crackles -/- Mammae : hyperpigmentation of areola +/+.November 4th 2015 (05. Gallop (-). headache (-). linea nigra -.

Medication from departement of internal medicine: • Cordarone 2 x 200 mg P. spondylitis tuberculosis  P: . the operation site was opened by hague and urinary bladder was identified 15 .• • • Palpation : supple in all abdominal region. with uncontrolled hypertension grade 1. 5-6 x/minutes Extremities: Warm • Edema • Physiological reflex : ++/++/++/++ • Pathological reflex : lower extremitites +/+ : --/-- Workup: • EKG: ventricular extrasystole 5 times in 1 minute  A: P3A2.Hysterectomy transvaginal  confirming for operation . 57 years old. tenderness – • Percussion: tympanic in all abdominal region • Auscultation : bowel sound +. second degree uterine prolapse and third degree cystocele.O • Candesartan 1 x 8 mg P. Aseptic and antiseptic procedure in vaginal region and cervix has been done Area other than operation location covered by sterile fabric Major labia dextra and sinistra was put aside then sutured outward to open the operation  site Cervix was fixed with tenaculum and pulled outward.O • Tuberculosis regimen: R/H/Z/E 450/400/1000/750 Operation Report     Patient was in lithotomy position.

Cauterization of  small blood vessels to control the bleeding. uterosacral ligament. spondylitis tuberculosis 16 . and uterine artery Evacuation of the uterus form pelvic cavity Ligation and dissection of latum ligament. Undermining the uterus from peritoneum by cutting the posterior peritoneum fold and    septum Ligation and dissection of cardinal ligament. Incision in a cervical region acording to the vaginal rugae with inverted U shaped incision and circumferential 2 cm proximal portio to identified uterus. Identification of cul de sac and rectovaginal fascia for    posterior colporrhaphy procedure Rectovaginal fascia is sutured in the midline Sutured the posterior vaginal wall sagitally Operation done. with uncontrolled hypertension grade 1. Final Diagnosis P3A2. second degree uterine prolapse and third degree cystocele. Cauterization of small vessels to control the   bleeding Cutting of the fallopian tubes and evacuation of uterus from the vaginal introitus Reconstruction of anterior wall of the vagina by suturing the anterior mucosal wall of the   vagina (anterior colporrhaphy) Reperitonealization to closed the abdominal cavity Suturing of proximal vaginal wall sagitally and transversally to close the hole in the  vagina Incision of posterior vaginal wall. 57 years old.

urinary symptoms prolapse .Bulge symptoms .Gastrointerstinal symptoms . gallop  Gynecolog Examination : 1.buldge symptoms .pelvic and back .CHAPTER II CASE ANALYSIS Compariso Case n Diagnostic Approach Theory (Prolapsus Commentary uteri)  Anamnesis: -Feeling a lump in the vagina -The lump protruding out Evaluation patient with prolapsus uteri : are 2 groups of Symptoms : especially when urinating.7 C  COR : heart sound 1 and 2 irregular .urinary symptoms Patients denied any other symptoms . Perineal . HR : 88 x/min RR:20 x/min Temp : 36. there Gynecolog examination Physical shows that there are examination should uteri and anterior be normal vaginal wall Descent .Protusion come beyond the hymen .Hypertension grade 1 .Irregular heart sound pain examination .can be weight and resolves while asymptomatic resting. pain (-) -Polymiction (+) -Urgency (+) -unsatisfied urinating (+)  Physical examination :  BP : 140/90mmHg.Female sexual Physical examination : dysfunction .Widen genital hiatus with increase intra-abdominal symptoms that we can find from anamnesis : .Anterior wall vagina From this patient. murmur -. walking and lifting heavy .

Anterior vaginal wall : . abnormalities wall :rectocele (-).Descent of the apex (+) . Bimanual .Inspection : no cystocele (+) -Posterior vaginal lesion or any 1.POP-Q examination genital hiatus open widely . Perineal examination vaginal atrophy. Vaginal examination . enterocele (-) 3.Neurologic examination  decrease the reflex Examination : oxford grade 3. Vaginal halfway past the hymen Gynecolog Examination POP-Q examination -genital hiatus 5cm -perineal body 3cm Speculum examination .pressure 2.Valsava maneuver : examination : prolapse descent .Speculum examination  prolapse descent while valsava. . -Inspeculo muscle symmetry examination  (+) examine the anatomical 2.

age. connective tissue vaginal delivery.57 years old.Multiparity (P3A2 – vagianl delivery) -Increase abdominal pressure [chronic cough. has already Risk factors for Risk factors for menopause prolapsus uteri are prolapsus uteri multiparity. increase increase abdominal abdominal pressure pressure  Anterior Anterior collporhaphy for manage the  collporrhaphy Hysterectomy transvaginal hysterectomy . Bimanual examination  examine the pelvic floor musculature Risk factors . vaginal identified in this case delivery. race.examine the vaginal wall 3. multiparity. are age. and disorder. constipation. overweight] Management Hysterectomy transvaginal cystocele and transvaginal for manage the uterine prolapse .

3 3. a woman has an estimated lifetime risk of 11 percent to undergo surgery for prolapse or incontinence. Definition Pelvic organ prolapse (POP) is a global health problem.1. pelvic pressure. and splinting or digitation. affecting adult women of all ages. it is the third most common indication for hysterectomy. It decreases their quality of life considerably. an estimated 30% of women require re-operation. The failure rate is relatively high. whereas digitation aids stool evacuation.1 percent prevalence of pelvic organ prolapse at a standard physical assessment in postmenopausal women older than 60 years who had not had a hysterectomy. Signs include descent of one or more of the following: the anterior vaginal wall. The prevalence of POP varies widely across studies. POP is one of the most common reasons for gynaecological surgery in women after the fertile period.2.4 In the Women's Health Initiative study. Splinting is manual bolstering of the prolapse to improve symptoms. 4 In the United States. depending on the population studied and entry criteria. or the perineum Symptoms include vaginal bulging. posterior vaginal wall. although it is more common in older women. the apex of the vagina after hysterectomy. investigators found a 41. 3 .Epidemiology Pelvic organ prolapse (POP) is a health concern affecting millions of women worldwide.CHAPTER III LITERATURE REVIEW Pelvic Organ Prolapse 3.1 Pelvic organ prolapse is a condition of specific signs and symptoms that lead to impairment of normal function and diminished quality of life. uterus and cervix. Women of all ages may be affected. 3. Moreover.

3. It lies in between the bladder and rectum.3. They have no action in preventing descent of the uterus. The responsible structure are  Pericervical ring It is a collar of fibroelastic connective tissue encircling the supravaginal cervix. The objective is to maintain the position and to prevent descent of the uterus through the natural urogenital hiatus in the pelvic floor 1. Middle tier This constitutes the strongest support of the uterus. The last two are actually acting as a guy rope with a steadying effect on the uterus. It is . 2.Support Of Uterus The uterus is normally placed in anteverted and anteflexed position. broad ligaments with intervening pelvic cellular tissues. Upper tier The responsible structure are endopelvic fascia covering the uterus and round ligament. The cervix pierces the anterior vaginal wall almost at right angle to the axis of the vagina. The uterus is held in this position and at this level by supports conveniently grouped under three tier systems.

morphologically. and pubocervical. the pelvic cellular tissues condense surrounding them and give good direct support to the viscera. posterior. bladder. This hammock-like arrangement of condensed pelvic cellular tissues is the cardinal support of the uterus. As they pass. and vagina pass through it from the lateral pelvic wall.connected with the pubocervical ligaments and the vesicovaginal septum anteriorly. uterosacral. and anterior walls of the pelvis. Inferior tier This gives the indirect support to the uterus. On the medial side. The blood vessels and nerves supplying the uterus. levator plate. these are attached to the pericervical ring covering the cervicovaginal junction and on the other end are attached to the lateral.Support of Vagina . The support is principally given by the pelvic floor muscles (levator ani). and functionally the same unit. endopelvic fascia. cardinal ligaments laterally and the uterosacral ligaments and the rectovaginal septum posteriorly. perineal body. Function: It stabilizes the cervix at the level of interspinous diameter along with the other ligaments. The endopelvic fascia at places is condensed and reinforced by plain muscles to form ligaments : Mackenrodt’s.4. and the urogenital diaphragm 6 3. 3.  Pelvic cellular tissues The endopelvic fascia consist of connective tissues and smooth muscles. These are anatomically.

It supports the pelvic viscera and counteracts the downward thrust of increased intra-abdominal pressure. this fascia forms the posterior urethral ligament. Support of the Posterior Vaginal Wall These parts are include Endopelvic fascial sheath covering the vagina and rectum and attachment of the uterosacral ligament to the lateral wall of the vault. robust. Few fibrous pass behind the rectum. and urethra and keep them closed by compressing against the pubic bone. The vagina is then pushed down by the increased intra-abdominal pressure. 5 3. This muscle is slug like a hammock around the midline pelvic effluents (urethra. vagina. Support of the Anterior Vaginal Wall  Positional support.  Pelvic cellular tissue The vagina is ensheated by strong condensation of pelvic cellular tissue called endopelvic fascia.1. which is anchored to the pubic bones giving strong support to the urethra. Traced laterally. the vagina makes an angle of 45° to the horizontal. Normal vaginal axis is horizontal in the upper two-third and vertical in the lower-third . Eventually. Traced below. Any raised intra-abdominal pressure is transmitted exclusively to the anterior vaginal wall which is apposed to the posterior vaginal wall. the pelvic floor opens and there is widening of the hiatus urogenitalis. the genital organs prolapse. The medial fibers of the pubococcygeus part of levator ani muscles. and fatigue-resistant striated muscle guards the hiatus urogenitalis. are attached mainly to the urethra. 2. 6 When the levator ani muscles are damaged.5. and the urethra forming a sling. vagina and rectum.Risk Factors . vagina. These pubovisceral fibers of the levator ani muscles squeeze the rectum. and the anal canal). This strong. vagina. A wellsupported vagina lies on the rectum and the levator plate . this fascia form the pubocervical fascia or ligament which is the anterior extension of the Mackenrodt’s ligaments. In the erect posture. The levator ani muscles with its fascial coverings.

epidural analgesia. The pelvic organ support study found age to be a risk factor for pelvic organ prolapse risk doubled with each decade of life. Of the 17 000 women in the Oxford family planning study. 2 Figure 1. if all women . Rortveit and colleagues (2007) found that the risk of prolapse increased significantly in woman with one vaginal delivery.The aetiology of pelvic organ prolapse is multifactorial. those with a history of two vaginal deliveries were 8. Risk Factors2 Obstetric Related Risks 1. Although there is some evidence that pregnancy itself predisposes to pelvic organ prolapse. and oxytocin stimulation of labor. episiotomy. Increasing parity was also associated with increasing severity of prolapse. Elective Cesarean Delivery Controversy has arisen over the topic of elective cesarean delivery to prevent pelvic floor disorders such as pelvic organ prolapse and urinary incontinence.4 times more likely to have surgery for prolapse than those with no such history. forceps use. anal sphincter laceration. 3 2. Theoretically. Multiparity Vaginal childbirth is the most frequently cited risk factor. In the Reproductive Risks for Incontinence Study at Kaiser (RRISK) study. prolonged second-stage labor. Other obstetric related risks are macrosomia.

a layer of smooth muscle referred to as the muscularis and an adventitia. mainly fibroblasts are found. But most women do not develop pelvic floor disorders. aging is a complex process. The ECM contains fibrillar components (collagen and elastin) embedded in a nonfibrillar ground substance. a subepithelial dense connective tissue layer.1 Women with connective tissue disorders may be more likely to develop POP. Estrogen and progesterone receptors have been identified in the nuclei of connective tissue and smooth muscle cells of both the levator ani stroma and uterosacral ligaments. maturation and degradation. In addition.underwent cesarean delivery. recommendations regarding elective cesarean delivery to prevent pelvic floor disorders must be individualized. The connective tissue underlying the vagina contains relatively few cells. producing components of the extracellular matrix (ECM). Connective Tissue Disorder The vaginal wall is composed of four layers: a superficial layer of stratified squamous epithelium. At this point in time. As with other risks for POP. composed primarily of collagen and elastin. The increased incidence may result from physiologic aging and degenerative processes as well as hypoestrogenism. This . Age In women aged 20 to 59 years. The fibrillar component is thought to contribute the most to the biomechanical behaviour of these tissues. providing longitudinal and central support. with the exception of the arcus tendineus fasciae pelvis. Beside fat cells and mast cells. elective cesarean delivery would subject many women to a potentially dangerous intervention who would otherwise not develop the problem. This ground substance consists of non-collagenous glycoproteins. the incidence of POP roughly doubled with each decade. The quantity and quality of collagen and elastin are regulated through a precise equilibrium between synthesis. Clinical and basic investigations clearly demonstrate an important role for reproductive hormones in the maintenance of connective tissues and the extracellular matrix necessary for pelvic organ support. these tissues contain a significant amount of smooth muscle cells . there would be fewer women with pelvic floor disorders. proteoglycans and hyaluronan. 3 3. 3 4. The vaginal subepithelium and muscularis together form a fibromuscular layer beneath the vaginal epithelium. This process results in a dynamic process of constant remodelling. which is composed of loose connective tissue.

cystourethrocele. uterus (cervix). uterine procidentia. racial differences in the bony pelvis may also play a role. 3 6. chronic constipation. or the perineum.6.relative decrease in well organized dense collagen is believed to contribute to weakening of vaginal wall tensile strength and an increased susceptibility to vaginal wall prolapse. Higher body mass index (BMI) has been associated with POP. For instance. and enterocele have traditionally been used to describe the structures behind the vaginal wall thought to be prolapsed 3 . This condition is present with obesity. Increased Abdominal Pressure Chronically elevated intraabdominal pressure is believed to play a role in POP pathogenesis. rectocele. and repetitive heavy lifting. the apex of the vagina after hysterectomy. Although differences in collagen content have been demonstrated between races. The terms cystocele.2 3.3 Women who are overweight (body mass index 25-30) or obese (>30) are at high risk of developing prolapse. uterine prolapse. posterior vaginal wall. These shapes are protective against POP compared with the gynecoid pelvis typical of most white women. whereas Hispanic and white women appear to have the highest risk. alone or in combination. Black and Asian women show the lowest risk. 3 5. Description and Classification Visual Descriptors Pelvic organ prolapse is descent of the anterior vaginal wall. black women more commonly have a narrow pubic arch and an android or anthropoid pelvis. Race Racial differences in POP prevalence have been demonstrated in several studies. chronic coughing.

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Six points are located with reference to the plane of the hymen: two on the anterior vaginal wall (points Aa and Ba). perineal body (Pb). the International Continence Society defined a system of Pelvic Organ Prolapse Quantification (POP-Q). All POP-Q points. which is a anatomic landmark that can be identified consistently. and two on the posterior vaginal wall (points Ap and Bp) The genital hiatus (Gh). 3 . This system contains a series of site specific measurements of a woman’s pelvic organ support. and total vaginal length (TVL) are also measured.Pelvic Organ Prolapse – Quantification (POP-Q) In 1996. two in the apical vagina (points C and D). are measured during patient Valsalva and should reflect maximum protrusion. except TVL. Prolapse in each segment is measured relative to the hymen.

e. its quantitation value is <-1 cm) Stage II The most distal portion of the prolapse is ≤1 cm proximal to or distal to the plane of the hymen (i. Stage I The criteria for stage 0 are not met...The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support Stage 0 No prolapse is demonstrated.e.e.(TVL-2) cm (i. the quantitation value for point C or D is ≤-[TVL-2] cm).e. Ba and Bp are all at -3 cm. and either point C or D is between -TVL (total vaginal length) cm and . Ap. Points Aa. but the most distal portion of the prolapse is >1cm above the level of the hymen (i. Stage IV Essentially. the leading edge of . The distal portion of the prolapse proturdes to at least (TVL-2) cm (i. complete eversion of the total length of the lower genital tract is demonstrated...e.. its quantitation value is ≥+[TVL-2] cm). In most instances. its quantitation value is >+1 cm but < + [TVL-2] cm). its quantitation value is ≥-1 cm but ≤+1 cm) Stage III The most distal portion of the prolapse is >1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters (i.

Baden Walker Halfway System This descriptive tool is also used to classify prolapse during phys. it is adequate for clinical use . Although not as informative as the POP-Q.stage IV prolapse will be the cervix or vaginal cuff sac.ical examination and is in widespread clinical use.

and vaginal wall. These include genetic predisposition. loss of pelvic floor striated muscle support. bladder. 3 Table 24-3. These work in concert to provide support and also maintain normal physiologic function of the vagina. vaginal wall weakness. Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse During Physical Examination Grade Normal position for each respective site Grade 1 Descent halfway to the hymen Grade 2 Descent to the hymen Grade 3 Descent halfway past the hymen Grade 4 Maximum possible descent for each site 3. Although multiple mechanisms have been hypothesized as contributors to the development of prolapse. none fully explain the origin and natural history of this process. and rectum. pelvic floor connective tissue. and posterior) is evaluated. urethra. 1. Grade 0 Pathophysiology Pelvic organ support is maintained by complex interactions among the pelvic floor muscles.if each compartment (anterior. Several factors are believed to be involved in pelvic organ support failure. and loss of connective attachments between the vaginal wall and the pelvic floor muscles and pelvic viscera. apical. Change to the levator ani muscle It is widely believed that the levator ani muscles sustain either direct muscle or denervation injury during childbirth and that these injuries are involved in the pathogenesis of pelvic organ .7.

and upper vagina.prolapse. It is hypothesized that during second-stage labor. cervix. they stretch and may eventually fail. Thus. vaginal apex. resulting in prolapse. Loss of skeletal muscle volume and function occurs in virtually all striated muscles during aging. Role of connective tissue Connective tissues and ligaments surrounds the pelvic organs and attaches them to the levator ani muscle and bony pelvis. The arcus tendineus fascia pelvis is a condensation of the parietal fascia covering the medial aspects of the obturator internus and levator ani muscles. Estrogen deficiency can affect the . Loss of connective tissue support at the vaginal apex leading to stretching or tearing of the arcus tendineus fascia pelvis. 2. Abnormalities in uterosacral ligament support of the pelvic organs contribute to the development of prolapse. and microfibers. and proximal urethra. The connective tissue that invests the pelvic viscera provides substantial pelvic organ support. which are anchored in an extracellular matrix of polysaccharides. elastin. Results obtained from young and older women with pelvic organ prolapse indicate that the levator ani muscle undergoes substantial morphologic and biochemical changes during aging. Denervated muscle loses tone and the genital hiatus opens. As connective tissues bear these loads for long periods. The arcus tendineus fascia pelvis is therefore poised to withstand descent of the anterior vaginal wall. possibly those with pre. loss of levator tone with age may contribute to pelvic organ support failure in older women. The result is apical and anterior vaginal wall prolapse. The uterosacral ligaments contribute to apical support by suspending and stabilizing the uterus. thereby leading to pelvic viscera prolapse. nerve injury from stretch or compression or both leads to partial denervation of the levator ani.existing defects in connective tissue support. As striated muscles lose tone. It provides the lateral and apical anchor sites for the anterior and posterior vagina. smooth muscle. ligamentous and connective tissue support of the pelvic organs must sustain more forces conferred by abdominal pressure. The ligament is comprised of approximately 20 percent smooth muscle. The fascia and connective tissues of the pelvic floor may also lose strength consequent to aging and loss of neuroendocrine signaling in pelvic tissues. The connective tissue of the pelvis is comprised of collagen.

and quantity of collagen. abundant elastic fibers.biomedical composition. and neurovascular bundles. a fibroelastic muscularis layer. Exogenous estrogen supplementation has been found to increase the skin collagen content in postmenopausal women who are estrogen deficient 3 Figure 2. which was previously referred to as endopelvic fascia. Role of vaginal wall The vaginal wall is comprised of mucosa (epithelium and lamina propria). Connective Tissues and Ligaments2 3. The muscularis and adventitial layers together form the fibro muscular layer. The fibromuscular layer coalesces laterally and attaches to the arcus tendineus fascia pelvis and superior fascia of . Estrogen influences collagen content by increasing synthesis or decreasing degradation. and an adventitial layer that is composed of loose areolar tissue. quality.

women may comment on feeling a ball in the vagina. urinary symptom. female sexual dysfunction. the vaginal wall is attached directly to the perineal membrane and the perineal body. Evaluation of the Patient with Pelvic Organ Prolapse Symptoms Associated with pelvic Organ Prolapse There are some symptoms that appear in women with organs prolapse such as bulge symptoms. Level III support results from fusion of the distal vagina to adjacent structures. Abnormalities in the anatomy. vaginal prolapse is associated with loss of smooth muscle. in fibromuscular tissue taken at the vaginal apex from both the anterior and posterior vaginal walls. 3 3. An attenuation of the vaginal wall without loss of fascial attachments called distension cystocele or rectocele.8.type prolapse. and posterior. Both defect types could result from the stretching or tearing of support tissues during second-stage labor. The association of POP with vaginal delivery is consistent with this theory. 5. sitting . due to attenuation. With distension. With displacement-type prolapse.the levator ani muscle. In contrast. and increased protease activity. physiology. and cellular biology of vaginal wall smooth muscle may contribute to POP. Defects in each level of support result in identifiable vaginal wall prolapse: apical. Level of Vaginal support Level I support suspends the upper or proximal vagina. Level II support attaches the midvagina along its length to the arcus tendineus fascia pelvis. prevents the vagina and uterus from descent when the genital hiatus is open. In the lower third of the vagina. 4. or even asymptomatic. vaginal rugae are visible. anterior. the vaginal wall appears smooth and without rugae. abnormal smooth muscle phenotype. This suspensory system. In bulge symptoms. pelvic and back pain. Specifically. The defect theory of pelvic organ prolapse This theory states that tears in different sites of the endopelvic fascia surrounding the vaginal wall allow herniation of the pelvic organs. together with the uterosacral ligaments. anterior and posterior wall defects due to loss of the connective tissue attachment of the lateral vaginal wall to the pelvic side wall are described as displacement (para. myofibroblast activation.vaginal) cystocele or rectocele.

and male sexual dysfunction. urinary retention. These may include stress urinary incontinence (SUI). problems with arousal. Female sexual dysfunction is present in women with dyspareunia. aging. frequency.on a weight. or voiding dysfunction. These symptoms worsen with prolapse progression. Patients with POP often have concurrent urinary symptoms. urgency. Sexual dysfunction was worse in women with symptomatic prolapse versus those with asymptomatic prolapse. Two commonly used questionnaires are the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ) . recurrent urinary tract infection. and inability to achieve orgasm. low libido. or noting a bulge rubbing against their clothes. several tools may be useful in assessing severity. The etiology is frequently multifactorial and includes psychosocial factors. urogenital atrophy. urge urinary incontinence. During symptom inventory.

First. Patients who are unable to adequately complete a Valsalva maneuver are asked to cough. posterior. structures are artificially lifted.Physical Examination Initial pelvic examination is performed with a woman in lithotomy position. lesions. With speculum examination. A neurologic examination of sacral reflexes is performed using a cotton swab. Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina. or apical)? (3) Does the geni. this assessment helps answer three questions: (1) Does the protrusion come beyond the hymen? (2) What is the presenting part of the prolapse (anterior. evaluation of anal sphincter innervation is completed by stroking lateral to the anus and observing a reflexive contraction of the anus. Intact reflexes suggest normal sacral pathways. Secondly.tal hiatus significantly widen with increased intraabdominal pressure? . or displaced. the bulbocavernosus reflex is elicited by tapping or stroking lateral to the clitoris and observing contraction of the bulbocavernosus muscle bilaterally. supported. or other abnormalities. The vulva and perineum are examined for signs of vulvar or vaginal atrophy. Importantly. known as the anal wink reflex.

The speculum is slowly withdrawn to assess descent of the apex. Sagging lateral vaginal sulci with vaginal rugae still present suggest a paravaginal defect. the genital hiatus (Gh) and perineal body (Pb) are measured during Valsalva maneuver The total vaginal length (TVL) is then measured by placing a marked ring forceps.tocele or enterocele is present. confirming enterocele. desire for future sexual function and/or fertility. a patient with prolapse of the vaginal apex beyond the hymen.For vaginal examination. a . and points C and D are then measured with Valsalva. a lateral loss of support. A split speculum is then used to displace the posterior vaginal wall and allow for visualization of the anterior wall and measurement of points Aa and Ba. It displaces the anterior and posterior vaginal walls. bulges at the apical segment of the posterior vaginal wall should implicate enteroceles. An evidence-based appraisal of each option’s success rate should be included. whereas bulges in the distal posterior wall are presumed to be rectoceles. 3 3. A bivalve speculum is then inserted to the vaginal apex. A central bulge and loss of vaginal rugae is called a midline or central defect. at the vaginal apex and noting the distance to the hymen. Points Ap and Bp are measured.Approach to Treatment Treatment for woman who have POP depends on the type and severity of symptoms. In general. Attempts are made to characterize the nature of the anterior vaginal wall defect.9. whose only symptom is bulge or pelvic pressure. age and medical comorbidities. If the posterior vaginal wall descends. attempts are made to determine if rec. In the simplest case. If loss of support appears to arise from detachment of the anterior vaginal wall’s apical segment from the apex. could be offered pessary or surgical treatment. Enterocele can only definitively be diagnosed by observing small bowel peristalsis behind the vaginal wall. it is termed a transverse or anterior apical defect The split speculum is then rotated 180 degrees to displace the anterior wall and allow examination of the posterior wall. and risk factors for recurrence. A clinician’s index finger is placed in the rectum and thumb on the posterior vaginal wall. In a more complicated case. if the POP-Q examination is performed. that is. or a ruler. Further distinction may be found during standing rectovaginal examination. Often a combination of nonsurgical and surgical approaches may be selected. Small bowel may be palpated between the rectum and vagina.

and they are safe and simple to manage.woman with prolapse beyond the hymenal ring may note a bulge. Also. space-filling pessaries maintain their position by creating suction between the pessary and vaginal walls (cube). Incontinence ring. Non Surgical Treatment  Pessary Pessaries are the standard nonsurgical treatment for POP. These are effective in women with first and second degree prolapse. Support pessaries. Ring pessaries may be constructed as a simple circular ring or as a ring with support that looks like a large contraceptive diaphragm. which is supported by the symphysis pubis. the support ring’s diaphragm is especially useful in women with accompanying anterior vaginal wall prolapse. Risser. The types of pessaries are divided into two broad categories: support and spacefilling pessaries. such as the ring pessary. It contains a concave disc that fits against the cervix or vaginal cuff and has a . One multicenter randomized crossover trial compared two pessary types for relief of prolapse symptoms and urinary complaints. use a spring mechanism that rests in the posterior fornix and against the posterior aspect of the symphysis pubis. and pelvic pain. or by both mechanisms (Gellhorn). 2000. pessaries have been reserved for women either unfit or unwilling to undergo surgery. the device should lie behind the pubic symphysis anteriorly and behind the cervix posteriorly. Women who have undergone at least one previous attempt at surgical management without relief may often choose a pessary over additional surgery. Vaginal support results from elevation of the superior vagina by the spring.9. When properly fitted. Pessaries may also be used diagnostically. and Gehrung.1. Liang. and Mar-land. 3. urge urinary incontinence. constipation. Pessaries are usually made of silicone or inert plastic. Hodge. The Gellhorn is often used for moderate to severe prolapse and for complete procidentia. Traditionally. The most common indications for use pessaries is pelvic organ prolapse. A pessary may also be placed diagnostically to identify which women are at risk for urinary incontinence after prolapse-correcting surgery (Chaikin. by creating a diameter larger than the genital hiatus (donut). In contrast.the lever pessaries include the Smith. 2004). Pessaries may also help some women with prolapse and associated incontinence.

a patient is fitted with a pessary while in the lithotomy position after she has emptied both her bladder and rectum. A digital examination is performed to assess vaginal length and width. alternate sizes may be required. If a pessary is ideally fitted. A patient must be an active participant in the treatment decision to use a pessary. prior hysterectomy. Its success will depend upon her ability to care for the pessary—either alone or with the assistance of a caretaker—and her willingness and availability to come for subsequent evaluations. and the stem is useful for device removal.stem that is positioned just cephalad to the introitus. a woman should be fitted with the largest size that can be comfortably worn. . Vaginal atrophy should be treated before or concomitantly with pessary initiation. and an initial estimation of pessary size is made. The concave disc supports the vaginal apex by creating suction. Of all pessaries. sexual activity. a patient is not aware of its presence. After a pessary is selected. Generally. As a woman ages and gains or loses weight. and stage and site of POP. The type of device selected may be affected by patient factors such as hormonal status. the two most commonly used and studied devices are the ring and Gellhorn pessaries.

The clinician’s finger should barely slide between the lateral edges of the ring pessary and the vaginal sidewall. a woman is prompted to perform a Valsalva maneuver. it may be grasped by the thumb and index finger and removed. return visits may be semiannual. a return visit may follow in 1 to 2 weeks. cough. Women are sent home from their initial fitting session with instructions describing the management of commonly encountered problems (Table 24-7). the pessary is inserted by pushing in an inferior. For patients comfortable with their pessary management. an index finger is inserted into the vagina to hook the ring’s leading edge. Ideally. and replaced the next morning. For those unable or unwilling to remove and replace a device themselves. She should be able to stand. an index finger is directed into the posterior vaginal fornix to ensure that the cervix is resting above the pessary. the device is held in the clinician’s dominant hand in a folded position. Here. Following pessary placement. Next. and urinate without difficulty or discomfort. which might dislodge an improperly fitted pessary. Lubricant is placed on either the vaginal introitus or the pessary’s leading edge. For removal of a ring pessary. a pessary is removed nightly to weekly.For ring pessary placement. While holding the labia apart. After initial placement. Delaying visits longer than this may lead to problematic discharge and odor. Too much pressure may increase the risk for pain. . Traction is applied along the vaginal axis to bring the ring toward the introitus. Instruction on removal and placement should then follow. washed in soap and water. cephalad direction against the posterior vaginal wall. walk. The pessary should fit snuggly but not tightly against the symphysis pubis and the posterior and lateral vaginal walls. a pessary may be removed and the patient’s vagina inspected at the provider’s office every 2 or 3 months.

water-based lubricants applied to the pessary may help prevent these complications. or granulation tissue (Fig. Prolapse ulcers have the same appearance as pessary ulcers. All pessaries tend to trap vaginal secretions and obstruct normal drainage to some degree. washing. and the vagina is inspected for erosions. . however. the former result from the prolapsed bulge rubbing against patient clothing. ulcerations. Vaginal bleeding is usually an early sign and should not be ignored. and reinsertion the next day. Pessary ulcers or abrasions are treated by changing the pessary type or size to alleviate pressure points or by removing the pessary completely until healing occurs. At each return visit. The resultant odor may be managed by encouraging more frequent night time device removal.Serious complications such as erosion into adjacent organs are rare with proper use and usually result only after years of neglect. the pessary is removed. abrasions. 24-20). Alternatively.

Surgical Treatment For pelvic organ prolapse. The two approaches to prolapse surgery are obliterative and reconstructive.2. Pelvic Floor Muscle Exercise These exercises have been suggested as a therapy that might limit progression and alleviate prolapse symptoms. it may be offered to asymptomatic or mildly symptomatic women who are interested in prevention of progression and who decline other treatments. However. pelvic floor exercise has minimal risk and low cost. . women learn to consciously contract muscles before and during increases in abdominal pressure. 3. This prevents organ descent. Alternatively. also known as Kegel exercises. 2004). regular muscle strength training builds permanent muscle volume and structural support. There are two hypotheses that describe the benefits of pelvic floor muscle exercise for prolapse prevention and treatment (Bø.9. From these exercises. there are two choices of surgeries. For this reason.

Latent stress urinary incontinence can be unmasked with colpocleisis due to downward traction on the urethra. suturing anterior and posterior vaginal walls together. hysterectomy will more readily allow the vaginal apex to be resuspended with the previously described apical suspension procedures. uterosacral ligament vaginal vault suspension. Obliterative Procedures Obliterative approaches include Lefort colpocleisis and complete. and rectocele repair. Procedures include sacrocolpopexy. and selection is individualized. Maher. However. such as young women with severe prolapse. these procedures must be modified or specific uterine suspension procedures performed. obliterating the vaginal vault. If hysterectomy is not performed in the context of apical prolapse. The decision to proceed with a vaginal. paravaginal repair. surgeons with advanced laparoscopic skills who can perform the same operation laparoscopically should have equivalent results. abdominal. These procedures involve removing vaginal epithelium. or those believed to be at higher risk for recurrence. Vaginal. and offer superior success rates compared with reconstructive procedures. and robotic approaches may be used. require less operative time. abdominal. In contrast. Laparoscopic and robotic approaches to prolapse repair are becoming more common. laparoscopic. Obliterative procedures are technically easier. or minimally invasive approach depends on multiple factors including the patient’s unique characteristics and surgeon’s expertise. Obliterative procedures are only appropriate for elderly or medically compromised patients who have no future desire for coital activity. . 2004a. If apical or uterine prolapse is present. These include women with prior failure of a vaginal approach. those with a shortened vagina. a vaginal approach typically offers shorter operative time and a quicker return to daily activities.b). and effectively closing the vagina.  Reconstructive Procedures These surgeries attempt to restore normal pelvic anatomy and are more commonly performed for POP than obliterative procedures. 1996. An abdominal approach appears to have advantages in certain instances (Benson.

Weber and associates (2001b) found a low rate of anatomic success. and dyspareunia. a. if a lateral defect is suspected. . pain. Despite these limitations. yet long-term anatomic success rates are poor. Vaginal Apex There is a growing appreciation that support of the vaginal apex provides the cornerstone for a successful prolapse repair. there are significant risks. 2005a). In a randomized trial of three anterior colporrhaphy techniques (traditional midline plication. anterior vaginal wall prolapse results from fibromuscular defects at the anterior apical segment or transverse detachment of the anterior apical segment from the vaginal apex. Some experts believe that isolated surgical repair of the anterior and posterior walls is doomed for failure if the apex is not adequately supported (Brubaker. and traditional plication plus lateral reinforcement with synthetic mesh). anterior colporrhaphy has been the most common operation. Mesh is used to reinforce the vaginal wall and is sutured in place laterally. anterior colporrhaphy may be performed. In many cases. In these situations.Alternatively. ultralateral repair. or uterosacral ligament vaginal vault suspension. Alternatively. Recent studies show improved anatomic success when mesh is used for anterior wall repair. hysterectomy need not be incorporated into prolapse repair. continuity is also reestablished between the anterior and posterior vaginal fibromuscular layers to prevent enterocele formation. The vaginal apex can be resuspended with a number of procedures including abdominal sacrocolpopexy. Paravaginal repair is performed by reattaching the fibromuscular layer of the vaginal wall to the arcus tendineus fascia pelvis. if a central or midline defect is suspected. The poor rates of anatomic success with traditional anterior colporrhaphy have prompted reevaluation of repair concepts and development of other procedures. With these procedures. if apical or cervical prolapse is not present. These include mesh erosion. sacrospinous ligament fixation. abdominal. paravaginal repair can be performed through a vaginal. Mesh or biomaterial may also be used in conjunction with anterior colporrhaphy or by itself. or laparoscopic route. an apical suspension procedure such as an abdominal sacrocolpopexy or uterosacral ligament vaginal vault suspension will resuspend the anterior vaginal wall to the apex and reduce anterior wall prolapse. Anterior Compartment Historically. b.

Although infrequent. Performed vaginally or abdominally. which deflects the vagina posteriorly (Barber. c. Abdominal Sacrocolpopexy. Maher. 2004b.b). usually at the vaginal apex. Enterocele is defined as herniation of the small bowel through the vaginal fibromuscular layer. This results from a lack of exposure of the mesh to vaginal bacteria that occurs when the vagina is  opened with total abdominal hysterectomy. Shull. or robotic procedure. This surgery suspends the vaginal vault to the sacrum using synthetic mesh. Posterior vaginal wall prolapse may be due to enterocele or rectocele. Sacrospinous Ligament Fixation. With the cervix left in situ. Accordingly. The vaginal apex is suspended to the sacrospinous ligament unilaterally or bilaterally using a vaginal extraperitoneal approach. enterocele repairs have as their goal reattachment of these . 1997a. Posterior Compartment  Enterocele Repair. Discontinuity of the anterior and posterior vaginal wall fibromuscular layers allows for this herniation. 2000).2000. Sacrocolpopexy may be performed as an abdominal. Advantages include the procedure’s durability over time and conservation of normal vaginal anatomy. After sacrospinous ligament fixation (SSLF). the uterosacral ligament vaginal vault suspension is believed to replace the vaginal apex to a more anatomic position than SSLF. recurrent apical prolapse is uncommon. consideration should be given to performing a supracervical rather than a total abdominal hysterectomy. Complications associated with SSLF include buttock pain from nerve involvement with supporting ligatures in 3 percent of patients and vascular injury in 1 percent (Sze. laparoscopic. With this procedure. significant and life-threatening hemorrhage can follow injury to blood  vessels located behind the sacrospinous ligament Uterosacral Ligament Vaginal Vault Suspension. This is one of the most popular procedures for apical suspension. the risk of postoperative mesh erosion at the vaginal apex is believed to be diminished. When hysterectomy is performed in conjunction with sacrocolpopexy. the vaginal apex is attached to remnants of the uterosacral ligament at the level of the ischial spines or higher. This procedure may be used primarily or as a second surgery for women with recurrences after failure of other prolapse repairs.

Thus. Posterior vaginal wall prolapse due to rectocele is repaired with one of several techniques. the graft is attached to the perineal body. Sullivan. Traditional posterior colporrhaphy aims to rebuild the fibromuscular layer between the rectum and vagina by performing a midline fibromuscular plication. graft augmentation with allograft. 1997. some surgeons plicate the levator ani muscles concurrently with posterior repair. repair of this  defect should reduce the posterior wall prolapse. 1997. 2001). it is best avoided in  women who are sexually active. Thus. This repair is based on the assumption that specific tears exist in the fibromuscular layer. Rectocele Repair. or superior (Fig. which can be identified and repaired in a discrete fashion. or synthetic mesh has been used in conjunction with posterior colporrhaphy and site-specific repair. This modification of sacrocolpopexy may be selected for correction of posterior vaginal wall descent when an abdominal approach is employed for other prolapse procedures or if treatment of perineal descent is necessary (Cundiff . in situations in which the fibromuscular layer cannot be identified to perform a midline plication or sitespecific repair. To narrow the genital hiatus and prevent recurrence. Sacrocolpoperineopexy. xenograft. In an effort to reduce prolapse recurrence. If technically possible. Defects may be midline. Mesh Reinforcement. in which the fascial tear is identified and repaired. If posterior wall prolapse is due to enterocele. Mesh is sutured in place laterally with a minimum number of sutures. its theoretical advantage lies in its restoration of normal  anatomy rather than plication of tissue in the midline. distal. This approach is conceptually analogous to a fascial hernia. graft augmentation may be the only surgical option. With this procedure. Site-Specific Posterior Repair. Generally. However. the graft is attached to the vaginal apex and the uterosacral ligament.  Distally. the graft is placed after colporrhaphy or site-specific repair is completed. Moreover.fibromuscular layers. Visco. this practice may contribute to dyspareunia. the posterior sacrocolpopexy mesh is extended down the posterior vaginal wall to the . lateral. 24-21). 2001. Lyons.

In several case series. and lead to entry dyspareunia. A disrupted perineal body will allow descent of the distal vagina and rectum and will contribute to a widened levator hiatus. d. Therefore. overly aggressive plication can narrow the introitus. high perineorrhaphy with intentional introital narrowing is believed to decrease the risk of posterior wall prolapse recurrence. During surgery. Importantly. The Use of Mesh and Materials in Reconstructive Pelvic Surgery Synthetic mesh for sacrocolpopexy and midurethral slings has been widely studied and is safe and eff ective. Perineorrhaphy is often done in conjunction with posterior colporrhaphy to recreate normal anatomy. the perineum is rebuilt through midline plication of the perineal muscles and connective tissue. synthetic mesh is recommended for sacrocolpopexy and midurethral slings.perineal body. e. in a woman who is not sexually active. anatomic cure rates were greater than 75 percent. Perineum The perineum provides distal support to the posterior vaginal wall and anterior rectal wall and anchors these structures to the pelvic floor. However. Mesh erosion occurs in a small percentage of cases but can be managed with local estrogen therapy and limited vaginal wall mesh excision. create a posterior vaginal wall ridge. .

based on pore size (Table 24-8) (Amid. flexibility. whereas granulocytes and macrophages are typically larger than 10 µm. high risk for recurrence (obesity. Allografts come from a human source other than the patient and include cadaveric fascia or cadaveric dermis. connective tissue disease 4. Xenografts are biologic tissue obtained from a source or species foreign to the patient such as porcine dermis. or bovine pericardium. type I monofilament is the best choice for reconstructive pelvic surgery. Morbidity is low. Biologic materials have varying biomechanical properties and as noted earlier. From these findings. and strength. and some use it only for limited indications. Multifilament mesh has small intrafiber pores that can harbor bacteria. Pore sizes of 50 to 200 μm allow for superior tissue ingrowth and collagen infiltration. therefore. chronically increased intraabdominal pressure. are associated with high rates of prolapse recurrence. Pore size is the most important property of synthetic mesh. hematoma. weak or absent connective tissue 3. consensus suggests that if synthetic mesh is used. and young age) 5. allograft.Some surgeons routinely use graft or mesh augmentation. Selective use may include: 1. type I mesh has the lowest rate of infection compared with types II and III. 1997). Autologous grafts are harvested from another part of the patient’s body such as rectus abdominis fascia or thigh fascia lata. the need to bridge a space 2. Synthetic mesh is classified as types I through IV. but may include increased operative time. Bacteria generally measure less than 1 μm. or xenograft. or weakened fascia at the harvest site. monofilament mesh is recommended. Mesh or graft augmentation will undoubtedly persist due to the current poor cure rates with traditional transvaginal repairs. porcine small intestinal submucosa. others never use it. Meshes are either monofilament or multifilament. a mesh with pore size < 10 µm may allow bacterial but not macrophage infiltration and thereby predispose to infection. . angiogenesis. Accordingly. Thus. Pore size is also the basis of tissue ingrowth. pain. shortened vagina Biologic grafts may be autologous.

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