UV prolapse

Dr Liyana Alya & Dr Afifah

Supervised by Dr Kamaliah
 Anatomy
Definition
• Protrusion of
one/more female
pelvic organs
• Outside the
pelvis through
the vagina

https://www.rcog.org.uk/globalassets/documents/patients/patient-information-
leaflets/gynaecology/pi-pelvic-organ-prolapse.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6336571/
 Causes/Risk Factors
• Vaginal delivery (multiple)
• Advancing age (> in menopausal women)
• Obesity
• Delivery of big baby
• Prolonged second stage of labour
• Constipation
• Heavy lifting
 Clinical manifestations
• Bearing down sensation
• Heaviness during urination/defecation
• Discomfort in the lower abdomen
• Stress incontinence
• Voiding dysfunction, UTI
• Constipation/tenesmus
• Affect coital function
 Types

Anterior Cystocele

Rectocele/
Posterior
Enterocele

Apical UV prolapse
Cystocele
Rectocele
 Diagnosis
• Pelvic examination • Grading prolapse
– Grade the prolapse & – Valsalva maneuver:
ascertain status of pelvic
straining will help display
strength
the greatest degree of
prolapse

• POP-Q system – Lubricated speculum:

after reduction, PE to
• Pelvic floor strength: Oxford inspect for lesions/other
measurement of Kegel abnormalities
exercise
https://journals.lww.com/jaapa/fulltext/2014/03000/pelvic_organ_prolapse__an_overview.5.aspx
 https://onlinelibrary.wiley.com/doi/full/10.1002/nau.23740

Points and landmarks for POP–Q system examination. Aa,

point A anterior, Ap, point A posterior, Ba, point B anterior; Bp,
point B posterior; C, cervix or vaginal cuff; D, posterior fornix
(if cervix is present); gh, genital hiatus; pb, perineal body; tvl,
total vaginal length
• Bimanual examination
– To rule out obvious adnexal mass/tenderness

• Rectal examination
– To check for obvious weakness of the anterior
rectal wall
 Staging
• Stage 0
– No prolapse
• Stage I
– Most distal prolapse >1cm above
hymenal ring
• Stage II
– Most distal point is <1cm above
hymenal ring
• Stage III
– Most distal point is >1cm below the
hymenal ring but not farther than
2cm than the total vaginal length
• Stage IV
– Complete vaginal eversion
 Degree of prolapse
• 1o :cervix is visible when
the perineum is depressed
• 2o :uterine cervix has
prolapse through the
vaginal with the fundus
remining within the pelvis
proper
• 3o :complete uterine
prolapse = the entire
uterus is outside the
vagina
 Complication
• Ulceration of prolapse tissue
• Hypertrophy of cervix
• Recurrent UTI
• Incarceration of prolapse
• Urinary Tract Obstruction →hydronephrosis
(results from cystouteric reflux in urine →
renal failure
 Investigation
• Biochemical
– Urianalysis and C&S to rule out infection
– RP
• Cervical cystology
– Pap smear
• Imaging
– USG of abdomen- to look out for any cause of increase intra-abdominal pressure
• Urodynamic assessment (filling and voiding cystometry)
– To rule out stress incontinence and pelvic organ prolapse
– Plan a bladder diary
– Even after treatment (anterior colporrhaphy), patient can have urinary
obstruction and urinary incontinence. So patients who has cystocele need to be
evaluated for any evidence of stress incontinence.
 Management

Expectant Conservative
Management Management Surgical
 Expectant management
• Indicated in asymptomatic patient
• Only advice on the prophylactic measures
– Treatment of chronic respiratory and obesity
– Correction of constipation
– Weight control, nutrition and smoking cessation
counselling
– Regular pelvic muscle exercise – kiegell exercise
 Conservative Management
• Depends on:
– Age
– Sexual activity
– Desire for future childbearing
– Type of prolapse, stage and degree
– Patient wish
– Concomitant gynaecological condition –
carcinoma of cervix
 Supportive pessary therapy
• Indications:
– Primary therapy for prolapse
– For patients who are not fit for surgery
– Pregnant mother
– Urinary incontinence
– Temporary measure while waiting for surgery e.g. for decubitus
ulcer to heal before surgery
• Factors need to consider before selecting pessaries
– Grade of pelvic organ prolapse
– Integrity of vaginal mucosa
– Stenosis or vaginal interoitus
• Type of pessary:
– Ring-type pessary (first or
second degree prolapse)
– Gellhorn pessary
(advanced prolapse)
 Supportive pessary therapy
• Successful pessary fitting defined as:
– Pessary not expelled with Valsalva or cough
– Patient comfortable and not aware of pessary in
vagina
Need to change every 4-6 months
 Hormone Replacement Therapy
• Oestrogen replacement therapy strengthened
the support and alleviate trivial symptoms
 Surgical Intervention
• Depends on
– Degree and types of prolapse
– General health status
– Preservation of menstrual, coital and reproductive
function
 Anterior Wall Middle Compartment Defect Posterior
Defects Compartment
Defect
Descend Bladder, Bowel Vaginal, uterus, vault Anus, Rectum
of
Terms Cystocele, Vault prolapse, uterovaginal prolapse Rectocele,
Urethrocele Enterocele
Repair Anterior Vault Prolapse: Rectocele:
colporrhaphy – 1. Colpectomy and Colpocleisis – remove 1. Posterior
reapproximates vagina and closing of the space colpoperine
the pubocervical 2. Colpopexy – resuspend the vagina apex orrhaphy
fascia in the 3. Sacrocolpopexy and uterosacral plication
midline under the Uterovaginal prolapse: Enterocele:
bladder neck 4. Vaginal hysterectomy 1. Mc Call
5. Manchester repair – this method culdoplasty
preserve the uterus, so appropriate for
those who has desire for future
childbirth
6. Shirodkar modification of Manchester
repair – does not amputate the cervix
7. Utero-cervicopexy and Sling operation –
fortifies the supporting ligamentary
structures
8. Lefort Repair – reserved for very erderly
postmenopausal women
 Reference
• RCOG
• Various Approaches and Treatments for Pelvic Organ
Prolapse in Women (
www.ncbi.nlm.nih.gov/pmc/articles/PMC6336571/)
• Manual for Practical Obstetric and Gynaecology By Dr
Sachchithbabtham, Dr Somsubrha De