1.

Pelvic organ prolapse

Pelvic organ prolapse (POP) is a protrusion of pelvic organ and their
associated vaginal segments into or through the vagina. It is common in older women.
It has been predicted that the demand for treatment of pelvic organ prolapse will
increase in the population of women older than 50 years old.
1.1 Risk factors
A significant risk factor in pelvic organ prolapse is vaginal delivery. Women with
at least one vaginal delivery were twice as likely as nulliparous women to have pelvic
organ prolapse. Another study revealed that the incidence of pelvic organ prolapse
doubled between the ages of 20 and 59 years. Other associated risk factors include
history of hysterectomy, obesity, and history of previous prolapse operations.
1.2 Pathophysiology
Pelvic organ prolapse results from attenuation of supportive structure, whether by
actual breaks of by neuromuscular dysfunction or both. Support of the vaginal canal is
provided by the endopelvic connective tissue that is the first line of support buttressed
intimately with the pelvic diaphragm, composed of the levator ani and coccygeus
muscles. These muscles provide a supportive diaphragm through which urethra,
vagina, and rectum egress. The muscular support can be contracted as in the setting of
increased abdominal pressure, the rectum, vagina, and urethra are pulled anteriorly
toward the pubis.
A rectocele is a protrusion of the rectum into vaginal lumen resulting from weakness
in the muscular wall of the rectum and the paravaginal musculoconnective tissue ,
which hold the rectum in place posteriorly.
An enterocele is a rupture of the peritoneum and small bowel. Most enteroceles occur
downward between the uterosacral ligaments and the rectovaginal space.
A cystocele is a rupture of the urinary bladder through the anterior vaginal wall.
Usually occur when the pubocervical musculoconnective tissue detaches from its
lateral/superior connecting points.
A uterine prolapse is the result of poor cardinal or uterosacral ligament apical
support, which leads to downward protrusion of the cervix and uterus toward the
introitus.

2. Uterine prolapse
Uterine prolapse is the herniation of the uterus into or beyond the vagina. It
often coexists with prolapse of the vaginal walls, involving bladder or rectum.
2.1 Epidemiology
In the United States, uterine prolapse was found in 14% of the 27 342 women
enrolled in the study. The oxford Family Planning Association found uterine prolapse
in more than 17 000 women aged 25 – 39 years old. The annual incidence of hospital
admission with prolapse was 20.4/10 000, and the annual incidence of surgery was
16.2/10 000.
2.2 Risk factors
Increasing parity was also associated with increasing severity of prolapse. Of
the 17 000 women in the Oxford Family Planning Study, those with a history of two
vaginal deliveries were 8.4 times more likely to have surgery for prolapse than those
with no such history.
Although vaginal delivery is also clearly associated with the uterine prolapse,
other obstetric risk factors remain controversial, such as macrosomia, prolonged
second stage of labour, episiotomy, and epidural analgesia usage. Women who are
overweight (BMI 25 – 30) or obese (>30) are at high risk of developing prolapse too.
2.3 Symptoms
Many symptoms have been attributed to uterine prolapse, although none of the
symptoms are specific, except for seeing or feeling a vaginal bulge.

2.3 Pathophysiology
Delancey’s three levels of support:
Level 1: The cardinal-uterosacral ligament complex that provides apical attachment
of the uterus and vaginal vault to the bony sacrum. Uterine prolapse occurs when the
cardinal-uterosacral ligament complex breaks or is attenuated.
Level 2: The arcus tendineous fascia pelvis and the fascia overlying the levator ani
muscles provide support to the middle part of vagina
Level 3: The urogenital diaphragm and the perineal body provide support to the lower
part of the vagina
2.4 Staging

2.5 Examination
 A pelvic examination using a Sim’s single bladed speculum can be done to
define the extent of the prolapse and establish the compartments of the vagina
affected (anterior, posterior, or apical).
The patient should be at rest and straining during a valsava manoevre. The
estrogens status of the tissues (signs of vaginal atrophy) and the size and mobility of
the uterus and adnexae should be assessed. Other test that may be needed include
urinalysis and urodynamic investigation.