Pelvic Organ Prolapse : Overview of Causes and Surgical Options

1. Pelvic Organ Prolapse :Overview of Causes and Surgical Options Vincent Tse MB BS ( Hons ) MS ( Syd ) FRACS Male and Female Incontinence Urodynamics Neuro-urology Pelvic Floor Reconstructive Surgery Department of Urology, Concord Hospital, Sydney, NSW

2. “Pelvic Floor Reconstructive Surgery” • Recent time becoming a cross-disciplinary field • Gynaecologist • Urologist the PELVIC FLOOR SURGEON • Colorectal surgeon • Common interest and training in pelvic floor dysfunction • Various national and international societies collaborating research in this growing area

3. What is POP ? Herniation of adjacent structures into vagina

4. What is Pelvic Organ Prolapse ? (POP) • Herniation of various pelvic structures adjacent to the vagina • Can be in the form of : • anterior compartment – cystocele • vault – enterocele/uterine prolapse • posterior compartment – rectocele • perineum – perineal descent

6. POP Prevalence • 20-30% in multiparous • 2% in nulliparous • 20% in post-gynaecological surgery • 10% in requiring POP surgery in lifetime

7. Pathophysiology of POP • Central is genetic predispositon • Age • Childbirth ( pudendal nerve injury denerevateslevators) • One birth doubles POP risk • 10-15% increase every subsequent birth • Nerves • Collagen • Abdo pressure • BMI > 30 increases risk by 40-75% • Surgery • Burch • Hysterectomy

8. Pathophysiology of POP ... Leading to herniation of various pelvic structures adjacent to the vagina from DETACHMENT or DISRUPTION

9. Types of Defects • Detachment • vagina is broken away from the pelvis and needs to be reattached • Disruption • vaginal structure is torn and needs to be patched or repaired

10. Normal Pelvic Support • Muscle • Levator ani ( ‘pelvic floor muscle’) • Obturator muscles • Ligaments • Endopelvic fascia • Pubourethral, urethropelvic, vesicopelvic, cardinal, uterosacral, rectovaginal septum … • Nerves • Blood Supply

11. Level 1 support – vault/uterine prolapse Level 2 Support – cystocele, enterocele,rectocele Level 3 Support –Perineal descent,low rectocele

12. LEVEL 2 and LEVEL 3 SUPPORTS

13. Level 2 Support Defects - Anterior Compartment :The Cystocele • 2 types : • CENTRAL DEFECT • Defect in fascia between vagina and bladder • Loss of central rugae • Looks like a round bulge on Valsalva • LATERAL DEFECT • Defect in fascia supporting lateral bladder to pelvic side wall • Central rugae intact • Flat sagging anterior vagina • >80% are mixed

16. Anterior Compartment Prolapse :Cystocele • Patient may present with : • Asymptomatic • ‘bulge’ or pressure in vagina • Often worse at end of day • Back ache • Irritation from contact with underwear • Voiding difficulty and Recurrent UTIs • Obstructive uropathy • Cystocele are often accompanied by : • Prolapse of other compartments prolapse ( eg. vault or rectocele ) • STRESS incontinence

18. Grading of Pelvic Organ Prolapse ( POP ) • Baden-Walker ( older, more clinically useful ) • Grade 1: minimal displacement with straining • Grade 2: towards introitus with straining • Grade 3: to and beyond level of introitus with straining • Grade 4 : outside introitus at rest • POP-Q ( newer … ) • Cumbersome and questionable clinical utility other than for research ( standardisation ) purposes

19. Management • Conservative • Simply observe • Vaginal ring pessary • Topical estrogen cream if indicated • Surgical • Most pts need pre-operative urodynamics to exclude occult stress incontinence • Anterior colporraphy ( central defect ) • Paravaginal repair ( lateral defect ) • +/- TVT or fascial pubovaginal sling

20. Type of Surgery Depends on … • Detachment • vagina is broken away from the pelvis and needs to be reattached • Disruption • vaginal structure is torn and needs to be patched or repaired

22. Anterior Compartment • To Replace • Add mesh/biologic (graft augmentation)

23. Mesh Use in PRIMARY Cystocele Repair

24. Level 2 Support Defects - Posterior Compartment:The Rectocele • May present with : • Asymptomatic • Defecatory difficulty/constipation • Digital manipulation of posterior vaginal wall • Deep pelvic pain • Back pain • Urinary difficulty

25. Entero-Rectocele

26. Management • Conservative • Bowel softeners • Exclude other possible low rectal conditions (eg. cancer) • Ring Pessary • Surgical • Pre-operative defecatory rectoproctography • Posterior colporraphy • Transanal Delorme repair • Perineorraphy if perineal descent present

27. Level 1 Support Defects :Vault / Uterine Prolapse • Presentation often similar to cystocele • Often co-exist with cystocele/rectocele • Beware of the little old lady with unexplained back pain, recurrent UTIs, or renal failure – exclude PROLAPSE

28. Procidentia

29. Management • Conservative • Observe • Ring pessary • Topical Estrogen if required • Surgical • In general, • YOUNGER and SEXUALLY ACTIVE • Suspend to the sacrum • OLDER and NON-SEXUALLY ACTIVE • Suspend to the sacrospinous ligament

30. Surgical Management : Level 1 FUNCTIONAL • To sacrum • Sacrocolpopexy/hysteropexy • Open, laparoscopic, robotic • Uterosacral ligament • To other level 1 sites • Sacrospinous ligament • Iliococcygeal fascia, etc NON-FUNCTIONAL • colpocleisis

32. Open Sacrocolpopexy sigmoid Sacral promontory rectum vault bladder

33. Transvaginal Sacrospinous Ligament Fixation

34. Open vs Transvaginal Sacrocolpopexy • Open • Level 1 evidence – most durable and effective • Preserves vaginal axis hence less dyspareunia • Lower complication profile • Rx of choice for recurrence • Longer stay and return to activity • Transvaginal • Equally effective but … • Alters vaginal axis, hence higher dyspareunia rate ( 15%) • May be more appropriate for the older, less sexually active • Shorter stay and less invasive

35. CONCLUSION

36. Conclusion • Causes of POP • Level 1 and 2 support defects • Overview of conservative and operative management of cystocele, rectocele and vault prolapse

37. Take Home Messages • Aetiology is multifactorial • CAVEAT : pelvic examination in the elderly female with confusion, recurrent UTIs, unexplained renal impairment ! • Conservative management with pessary • Pelvic floor exercises may retard the progression of POP, but will not reverse any existing POP • Management of pelvic prolapse are now managed by pelvic floor reconstructive surgeons who have had special training and may be a gynaecologist, urologist or colorectal surgeon !

38. Thank You for your Patience !