Pelvic Organ

Prolapse
SASHA VEREECKEN, MS3
THIENDELLA DIAGNE, MD, MHA
FELLOW OF THE AMERICAN COLLEGE OF OBSTETRICS AND
GYNECOLOGY
Pelvic organ prolapse(POP) – The herniation of
the pelvic organs to or beyond the vaginal walls
  Affects women more than men
Epidemiology  Approximately 45-75% of women may experience
some degree of prolapse in their lifetime
 POP can affect women of all races and ethnicities
 More common with advancing age
 Indeveloped countries the prevalence of POP ranges
up to 50% in women over the age of 80
 In developing countries, the prevalence of pelvic organ
prolapse is even higher, with estimates up to 56% in
some regions
PREVALENCE The exact prevalence of POP is difficult to
measure due to the following
Discrepancy - Variance between the different
classification systems used in diagnosis
Location of Anatomy- many unaware until it
becomes symptomatic
Stigma - many women with POP do not seek
medical attention at all
Characteristics that were significantly
associated with at least 1 pelvic floor
disorder
 Family poverty income ratio
 Body mass index
 Parity
PATIENT WELLBEING
 POP is more than herniation
 impact on activities of daily living, sexual
function, and ability/comfort to exercise
 impact on body image
 associated with shame, fear of judgment,
unable to bring up to health care provider
 Pandemic lead to shift to Telemedicine
 many unable to navigate
 unable to have physical exams
 The Impact of prolapse on the health
INSERT SLIDE ON AGING POPULATION INcare
US system is likely to increase based
upon the growing population of older
adult women

Growing need for

increased training of pelvic
reconstructive surgeons
such as Dr.Diagne
What are activities of daily living?
Essential and routine tasks that most young,
healthy individuals can perform without assistance

The inability to accomplish essential activities of

daily living may lead to unsafe conditions and poor
quality of life
Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently
Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently

Feeding - The ability of a person to feed oneself

Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently

Feeding - The ability of a person to feed oneself

Dressing - The ability to select appropriate clothes and to put the

clothes on
 Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently

Feeding - The ability of a person to feed oneself

Dressing - The ability to select appropriate clothes and to put the

clothes on

Personal hygiene -The ability to bathe and groom oneself and maintain
dental hygiene, nail, and hair care
 Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently

Feeding - The ability of a person to feed oneself

Dressing - The ability to select appropriate clothes and to put the

clothes on

Personal hygiene -The ability to bathe and groom oneself and maintain
dental hygiene, nail, and hair care

Continence -The ability to control bladder and bowel function

 Ambulating - The extent of an individual’s ability to move from one
position to another and walk independently

Feeding - The ability of a person to feed oneself

Dressing - The ability to select appropriate clothes and to put the

clothes on

Personal hygiene -The ability to bathe and groom oneself and maintain
dental hygiene, nail, and hair care

Continence -The ability to control bladder and bowel function

Toileting - The ability to get to and from the toilet, using it

appropriately, and cleaning oneself
  Huge economic burden
 Focus on prevention
 Demand for conservative management
Global & increases in an aging population, especially
Socioeconomic with women giving birth in older age
Significance  The rapid adoption of minimally invasive
techniques and the development of synthetic
and biological grafts have dramatically
transformed options for pelvic organ prolapse
surgery
 Education Access
and Quality

Health Care
Economic
Access and
Instability
Quality

Social
Determinants of
Health

Social and Neighborhood

Community and Built
Context Environment
 History
Leonardo Da Vinci
participated in Pessaries continue to
Papyrus describes extensive cadaveric evolve from lint balls,
recommendations to pelvic dissection balls of brass, cork, wood
correct a displaced or metal, then rubber
womb 1543 1861
380 B.C.

1500 B.C. 1519 A. C. The first vaginal

Hippocrates Andrea Vesalius 1844
described hysterectomy for
described the
pomegranate POP by Choppin
entire female
pessaries & genital tract and
Succussion used uterine ligaments
to reduce POP
 History

Surgical options for

Grafts began used treatment are
in pelvic achievable via
Manchester laparoscopic or
operation to treat reconstructive
surgery robotic approaches
POP 1895 1971 FUTURE

1888 Mackendrot 1900s Randall and Nichols 2000s To be discussed

described the pelvic reported surgical further
connective tissue outcomes of transvaginal
including cardinal sacrospinous
ligaments fixation for vault
prolapse
 Anatomy

 Pelvic floor support includes:

1. Bony pelvis
2. Broad ligament
3. Round ligament
4. Cardinal and uterosacral ligaments complex
5. Urogenital diaphragm
6. Pelvic diaphragm
7. Perineal body
 Anatomy – Bony Pelvis

 Provides fixed attachment to

pelvic soft tissues
 Consists of the two hip bones
which made up of ilium,
ischium, and pubis
 The pelvis has divided into
 false (or greater) pelvis
 true (or lesser) pelvis
Anatomy
COCCYGEUS MUSCLE
Anatomy
LEVATOR ANI
Anatomy
THE ATLA
Anatomy
UROGENITAL DIAPHRAGM
Anatomy
PERINEAL BODY
Anatomy

 Cardinal and uterosacral

ligaments complex
 INSERT ANATOMY PHOTO
Pathophysiology

The pathophysiology of pelvic organ prolapse (POP) is complex and not fully understood
believed to be from a multitude of factors including
Weak pelvic floor muscles
Damage to the pelvic floor muscles
Increased intra-abdominal pressure
Genetic predisposition
Age
Menopause
Levels of Pelvic Support

 In 1992 DeLancey described a system of three integrated levels of vaginal support

 All levels of vaginal support are connected through a continuous endopelvic fascia support network
Levels of Pelvic
Support – Level 1
 Level 1–Uterosacral / cardinal ligament
complex, which suspends the uterus and
upper vagina to the sacrum and lateral
pelvic side wall
 Loss contributes to the prolapse of the
uterus and/or vaginal apex.
Levels of Pelvic
Support – Level 2
 Level 2– Paravaginal attachments
along the length of the vagina to the
superior fascia of the levator ani
muscle and the arcus tendineus fascia
 Loss of support contributes to anterior
vaginal wall prolapse (cystocele)

.
Levels of Pelvic
Support – Level 3
 Perineal body, perineal membrane,
and superficial and deep perineal
muscles, which support the distal one
third of the vagina
 Anteriorly can result in urethral
hypermobility
 Posteriorly can result in a distal
rectocele or perineal descent
TYPES

Posterior
compartment
prolapse – Hernia of
the posterior vaginal
segment often
associated with
descent of the
rectum (rectocele)
TYPES

Enterocele –
Hernia of the
intestines to
or through the
vaginal wall
TYPES

Anterior
compartment
prolapse – Hernia of
anterior vaginal wall
often associated
with descent of the
bladder (cystocele)
TYPES

Apical compartment
prolapse (uterine
prolapse, vaginal vault
prolapse)– Descent of
the apex of the vagina
into the lower vagina, to
the hymen, or beyond
the vaginal introitus
TYPES

Uterine
procidentia –
Hernia of all three
compartments
through the
vaginal introitus
Break
 Risk Factors

Giarenis, I., & Robinson, D. (2014). Prevention and management of pelvic organ
prolapse. F1000prime reports, 6
Prevention
 Vaginal childbirth is one of the
most important factor in the
aetiology of pelvic organ prolapse
 Caesarean section is not the
answer as there are risks with
the procedure
 Critical thinking to be used –
could be option when
medically appropriate / UR-
CHOICE score can be used
to predict future risk of
pelvic floor dysfunction
 Cleveland Clinic UR CHOIC
E Calculator
Prevention
 Vaginal childbirth is one of the
most important factor in the
aetiology of pelvic organ prolapse
 Caesarean section is not the
answer as there are risks with
the procedure
 Critical thinking to be used –
could be option when
medically appropriate / UR-
CHOICE score can be used
to predict future risk of
pelvic floor dysfunction
 Cleveland Clinic UR CHOIC
E Calculator
Prevention
 Limited data available
 In early stages use of a vaginal pessary has shown lower
stage of prolapse on subsequent exams
 Focus on reducing risk factors
Symptoms

 Symptoms are related to prolapsed structures

 Symptoms severity are related to position – worsened when upright
 Can affect bowel/bladder/sexual function
 Can be completely asymptomatic
 Bulge on physical exam - The anatomic threshold for symptomatic
prolapse is the hymenal ring
Symptoms

 Vaginal bulge symptoms for predicting prolapse beyond the hymen

 Specificity of is high (99 percent to 100 percent)
 Sensitivity is low (16 percent to 35 percent)
 A cross-sectional study of women older than 40 years using POP-Q examinations
assess symptoms determined that the anatomic threshold of 0.5 cm distal to the
hymen
 Sensitivity (69 percent) and specificity (97 percent) for protrusion/bulge symptoms
 Some women are able to see a protrusion of the prolapse beyond the introitus
 Protrusion of the vagina may result in chronic discharge and/or bleeding from
ulceration
Symptoms

 Anterior – “Urinary symptoms”

 Stress urinary incontinence (SUI) often coexist with stage I or II prolapse
 As prolapse advances, women may experience improvement in SUI, but increased difficulty
voiding.
 Elevation of prolapse during pelvic examination may unmask "occult" SUI – which
occurs due to the kinking - leaks only when the prolapse is reduced this is called occult
stress urinary incontinence
 Women with POP have a up to a 5x risk of overactive bladder symptoms
 In addition, some women with POP experience enuresis or incontinence with sexual
intercourse
Symptoms

 Posterior – “Defecatory symptoms”

 Constipation
 Incomplete emptying
 Fecal urgency
 Fecal incontinence (accidental bowel leakage),
 Obstructive symptoms [eg, straining, or the need to apply digital pressure to the
vagina or perineum (splint) to completely evacuate
Symptoms

 Effect on sexual function

 Mild prolapse does not appear to be associated with decreased sexual
desire or with dyspareunia
 Reports vary according to whether POP is associated with adverse effects
on orgasm or sexual satisfaction
 Some women may avoid sexual due to fear of discomfort or
embarrassment associated with POP, particularly those with urinary or
fecal incontinence during sexual activity
 Fecal/Urinary incontinence can occur during intercourse
Diagnostic Tests
 Diagnosis primarily done on pelvic exam
 Visual inspection
 Bimanual Exam - in which the healthcare provider inserts two fingers into the
vagina and one finger into the rectum to assess the strength of the pelvic floor
muscles and the position of the pelvic organs
 If POP additional tests may be ordered such as
• Pelvic ultrasound
• Dynamic MRI
• Cystoscopy
• Urodynamics
 POPQ Score

 Introduced in 1996 by America Urogynecologic Society

 POP is diagnosed using pelvic examination
 A medical history is important to elicit prolapse-associated symptoms since treatment
is generally indicated only for symptomatic prolapse
 Ensure patient has empty bladder prior to scoring
 Patientis then positioned where the utmost magnitude of the prolapse is shown and
can be confirmed by the patient
 POP-Q Interactive Website
 POPQ Score

 Depending on the measurements, prolapse of each of the compartments is staged based on its
relationship to the hymen
 Stage 0: No prolapse is demonstrated (points Aa, Ba, C, D Ap, and Bp are all </ = −3 cm).
 Stage I: The most distal portion of the prolapse is more than 1 cm above the level of the hymen (points Aa, Ba,
C, D, Ap, and Bp are all <−1 cm).
 Stage II (Figure 3): The most distal portion of the prolapse is situated between 1 cm above the hymen and 1 cm
below the hymen (any of the points Aa, Ba, C, D, Ap, and Bp has a value between −1 cm and +1 cm).
 Stage III: The most distal portion of the prolapse is more than 1 cm beyond the plane of the hymen, but not
completely everted meaning no value is >/ = TVL −2 cm (any of the points Aa, Ba, C,D,Ap, Bp is >/ = +2 and
</ = tvl −3 cm)
 Stage IV (Figure 4): Complete eversion or eversion to within 2 cm of the total vaginal length of the lower
genital tract is demonstrated (any of the Points Ba, C, D, or Bp is >/ = to TVL −2 cm)
Management
 Treatment is indicated for women with symptoms of prolapse or
associated conditions
 Obstructed urination or defecation or hydronephrosis from chronic
ureteral kinking are all indications for treatment, regardless of degree of
prolapse
 Treatment is generally not indicated for women with asymptomatic
prolapse
 Establishing patient goals —
 Treatment is individualized according to each patient's symptoms and their impact on
her quality of life
 Establishing realistic patient expectations is also important because medical
comorbidities impact the patient's experience of symptoms
Management
 Limited
data comparing surgical vs nonsurgical
approaches exist
 Thechoice of therapy depends upon the patient's
preferences
 In a study of 152 women
 older patients and those with increased preoperative pelvic
pain scores were more likely to choose pessary over
surgery
 the likelihood of choosing surgery was increased in women
with more severe prolapse or a prior POP repair
Management

 Conservative management — Conservative therapy is the

first line option for all women with POP, since surgical
treatment incurs the risk of complications and recurrence
 Vaginal pessary — The mainstay of nonsurgical treatment for
POP is the vaginal pessary
 Pessaries are silicone devices in a variety of shapes and sizes, which
support the pelvic organs. Approximately half of the women who use
a pessary continue to do so in the intermediate term of one to two
years. Pessaries must be removed and cleaned on a regular basis.
Approach to Management
 Pelvic floor muscle exercises — Pelvic floor muscle
training (PFMT) appears to result in improvements in
POP stage and POP-associated symptoms.
 PFMT associated with greater improvement in prolapse
symptom scores and objective POP stage
 Less improvement seen when prolapse extends
beyond the hymen
Surgical Management
 Surgical candidates include women with symptomatic prolapse who have failed or declined conservative
management
 Surgery dependent on symptoms, location, severity, and patient/physician preference
 Here is a list of some of the most common surgical interventions for POP as
 Obliterative surgery
 Uterosacral ligament suspension and sacrospinous fixation
 Colporrhaphy
 Sacrohysteropexy
 Hysterectomy
 Urethral sling
 Bladder neck suspension
 Rectopexy
“Will I have a life after surgery?”
Complications
• Fistula
• Recurrent prolapse
• Renal Complications
• Urinary tract infections
• Kidney stones
• Hydronephrosis
• Chronic kidney disease
• End-stage renal disease (ESRD)
Differentials
• Urinary tract infection (UTI)
• Vaginal cysts
• Cervical polyps
• Elongation of the cervix
• Tumors of the urethra or bladder
• Large urethral diverticulum
• Skene gland cysts
• Uterine fibroids
• Endometriosis
• Pelvic inflammatory disease (PID)
2019 FDA POP MESH BAN
 2005: Chevron Phillips discontinues providing materials to Boston Scientific over concerns that it was
unsuitable for implantation in the human body
 2011: SUFU/AUG Joint Statement – Physician must recognize complications and be able to manage
postoperative complications and adverse events
 2018: Boston Scientific found to be using counterfeit Marlex from China to continue production
 Mesh reported to only lasting a few months
 2019: FDA bans use of Transvaginal mesh strictly for POP for transvaginal repair as risks of use outweighed
the benefits
 The most common complications- - Pain, Bleeding, Infection, Erosion of the mesh through the vaginal wall, Organ
perforation, Scarring, Sexual dysfunction
 Current: Other Mesh products available, suitable for other indications such as Stress Urinary Incontinence and
Abdominal Hernia repairs, importance of educating patient on topic prior to placement
Future
Future
Future
Future
 Future

 Research geared to preventative measures, POP options,

 Improved access to care earlier on – “Primary Prevention”
 Decreased stigma/shame regarding POP
 Improved techniques for surgical options – bladeless/bloodless procedures using lasers
 Advocacy to go away from “Vaginal Rejuvenation” procedures from unlicensed – shift
to proper treatment from certified urogynecologists
USMLE Step 2
CK Level
Questions
A 72-year-old woman comes to the office due to intermittent lower abdominal
discomfort for the past several months.  The patient also reports frequent urges for
bowel movements every day producing small-volume stools or just mucus and are often
followed by a sensation of incomplete evacuation.  Physical examination shows a
nondistended and nontender abdomen.  Digital rectal examination reveals normal rectal
tone and an empty rectal vault.  When the patient is instructed to bear down, an
erythematous mass with concentric rings protrudes through the anus and spontaneously
retracts.  Which of the following is the strongest risk factor for this patient's current
condition?

A. Colonic polyps
B. Crohn disease
C. HPV
D. Multiple childbirths
E. Portal hypertension
A 72-year-old woman comes to the office due to intermittent lower abdominal
discomfort for the past several months.  The patient also reports frequent urges for
bowel movements every day producing small-volume stools or just mucus and are often
followed by a sensation of incomplete evacuation.  Physical examination shows a
nondistended and nontender abdomen.  Digital rectal examination reveals normal rectal
tone and an empty rectal vault.  When the patient is instructed to bear down, an
erythematous mass with concentric rings protrudes through the anus and spontaneously
retracts.  Which of the following is the strongest risk factor for this patient's current
condition?

A. Colonic polyps
B. Crohn disease
C. HPV
D. Multiple childbirths
E. Portal hypertension
 Rectal prolapse

•Women age >40 with history of vaginal deliveries/multiparity

•Prior pelvic surgery
Risk factors •Chronic constipation, diarrhea, or straining
•Stroke, dementia
•Pelvic floor dysfunction or anatomic defects

•Abdominal discomfort
•Straining or incomplete bowel evacuation, fecal incontinence
Clinical •Digital maneuvers possibly required for defecation
presentation •Erythematous mass extending through anus with concentric rings
(full-thickness prolapse) or radial invaginations (non–full-thickness
prolapse)

•Medical
• Considered for non–full-thickness prolapse
• Adequate fiber & fluid intake, pelvic floor muscle
Management exercises
• Possible biofeedback therapy for fecal incontinence
•Surgical
• Preferred for full-thickness or debilitating symptoms
(eg, fecal incontinence, constipation, sensation of mass)
A 70-year-old woman comes to the office for worsening constipation.  The patient has chronic
constipation for which she takes over-the-counter fiber supplements and stool softeners; however, for the
past 3 months, the patient has had to push 2 fingers into her vagina to defecate.  She has had increased
bloating but no nausea, diarrhea, or abdominal pain.  The patient has 1 son.  Medical history includes
hypothyroidism and type 2 diabetes mellitus for which she takes levothyroxine and metformin.  A
colonoscopy last year was normal.  BMI is 32 kg/m2.  Vital signs are normal.  The abdomen is soft and
nontender with normoactive bowel sounds.  On rectal examination, the resting sphincter tone is normal
and there are no palpable masses.  With Valsalva maneuver, the posterior vaginal wall extends outside the
hymenal ring.  There is no fecal incontinence with Valsalva maneuver.  Anocutaneous reflex is intact
bilaterally.  TSH is 3.9 mU/L and serum hemoglobin A1c is 7.5%.  Fecal occult blood testing is negative. 
Which of the following is the most likely underlying cause of this patient's presentation?

A. Autonomic dysfunction due to neuropathy

B. External anal sphincter disfunction
C. Levator Ani muscle complex injury
D. Overuse of fibre supplementation
E. Subtherapeutic levothyroxine dosing
A 70-year-old woman comes to the office for worsening constipation.  The patient has chronic
constipation for which she takes over-the-counter fiber supplements and stool softeners; however, for the
past 3 months, the patient has had to push 2 fingers into her vagina to defecate.  She has had increased
bloating but no nausea, diarrhea, or abdominal pain.  The patient has 1 son.  Medical history includes
hypothyroidism and type 2 diabetes mellitus for which she takes levothyroxine and metformin.  A
colonoscopy last year was normal.  BMI is 32 kg/m2.  Vital signs are normal.  The abdomen is soft and
nontender with normoactive bowel sounds.  On rectal examination, the resting sphincter tone is normal
and there are no palpable masses.  With Valsalva maneuver, the posterior vaginal wall extends outside the
hymenal ring.  There is no fecal incontinence with Valsalva maneuver.  Anocutaneous reflex is intact
bilaterally.  TSH is 3.9 mU/L and serum hemoglobin A1c is 7.5%.  Fecal occult blood testing is negative. 
Which of the following is the most likely underlying cause of this patient's presentation?

A. Autonomic dysfunction due to neuropathy

B. External anal sphincter disfunction
C. Levator Ani muscle complex injury
D. Overuse of fibre supplementation
E. Subtherapeutic levothyroxine dosing
 Pelvic organ prolapse

•Anterior prolapse: Bladder (eg, cystocele)

•Posterior prolapse: Rectum (eg, rectocele)
Definitions •Enterocele: Small intestine
•Apical prolapse: Uterus, vaginal vault
•Procidentia: Complete herniation

•Obesity
•Multiparity
Risk factors
•Hysterectomy
•Menopause
•Pelvic pressure
•Obstructed voiding
•Urinary retention
Clinical
•Urinary urgency/incontinence
presentation
•Constipation
•Fecal urgency/incontinence
•Sexual dysfunction
•Weight loss
•Pelvic floor muscle training
Management
•Pessary
•Surgical repair
References

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