Pelvic Organ Prolapse: When to operate, What to do

Pelvic Organ Prolapse – When to operate, What to do

2015 UP-PGH Department of Obstetrics and Gynecology Annual Postgraduate Course June 20-22, 2015. SMX, MOA

Pelvic Organ Prolapse - When to operate, What to do

Joanne Karen S. Aguinaldo, MD, FPOGS, FPSURPSSection of Urogynecology and Pelvic Reconstructive Surgery




Image credit: joanne_aguinaldo_md



Definition

PELVIC ORGAN PROLAPSE ““Buwa”Buwa”

● A female condition● Descent of the pelvic organs

through the vaginal opening – i.e. uterus and the vagina, the urethra and the

bladder, and/or the rectum and the large intestines



Etiology● Complex● Multifactorial

– Risk factors predispose, incite, promote and decompensate



Pathophysiology● Failure of the suspensory and

supportive structures of the pelvic organs – usually, the pelvic muscles and

connective tissues



Normal anatomy

Image credit: www.iuga.org

Pelvic floor musclePelvic floor muscle

Uterosacral-cardinal Uterosacral-cardinal ligament complexligament complex

Endopelvic fasciaEndopelvic fascia

http://www.iuga.org/



Pathophysiology● Weakened pelvic floor muscle● Endopelvic fascial defects



Image credit: joanne_aguinaldo_mdImage credit: joanne_aguinaldo_md

PathophysiologyStrain on uterosacral-cardinal Strain on uterosacral-cardinal ligament complexligament complex

Weakened pelvic floor muscle

Endopelvic fascial defect(s)Endopelvic fascial defect(s)

joanne_aguinaldo_md_2015




Pelvic organ prolapse

Anterior compartment

Middle compartment

Posterior compartment





For women with Pelvic organ prolapse:

When do we operate? What can we do?




Outline

1. When to operate(a) Symptom(b) Severity

2. What to do- according to site



Symptoms


Uterus & Vagina Bladder & Urethra

Vaginal Bulge Incontinence Incontinence

Heaviness Frequency Urgency

Urgency

Dyspareunia

Lack of sensation

Rectum & Intestines

Sensation of something falling out

Splinting or digitation to start/complete

defecationFeeling of incomplete emptying

Manual reduction to start/complete voiding

Change postion to start/complete voiding



Symptoms


● Weak correlation between symptoms and clinical stage of prolapse

● Cochrane: – Pelvic organ prolapse surgery is usually

effective in controlling the principle symptom of prolapse (vaginal bulge).

– Surgery may impact on specific bowel, bladder and sexual functions, BUT can also make symptoms worse or result in new symptoms



Severity


● Physical examination– POP-Q system– Pelvic floor muscle grading

● Modified Oxford Scale– 0 : no contraction– 1 : flicker– 2 : weak squeeze, no lift– 3 : fair squeeze, definite lift– 4 : good squeeze, with lift– 5 : strong squeeze with good lift



Severity


● Work-up– Urinary symptoms

● Irritative symptoms: – Screen for infection, bladder stones, other

pathologies– Imaging – KUB, pelvic

● Incontinence/ Voiding difficulties: – Urodynamics

– Bowel symptoms● Incontinence

– Sphincter injury: Endoanal ultrasound




Severity● Work-up

– Urinary symptoms ● Irritative symptoms:

– Screen for infection, bladder stones, other pathologies

– Imaging – KUB, pelvic● Incontinence/ Voiding difficulties:

– Urodynamics– Bowel symptoms

● Incontinence– Sphincter injury: Endoanal ultrasound




SeverityCompartment POP Q point Definition

Anterior Point Aa

Point Ba

Midline Point C Cervix or vaginal cuff

Point D Posterior fornix (USL attachment)

Posterior Point Ap

Point Bp

Located midline, 3 cms from the urethral meatus; fixed point (-3 to +3)

Most dependent point (lowest) of anterior vagina – fr point Aa to the anterior fornix

Located midline, 3 cms from the hymen; fixed point (-3 to +3)

Most dependent point (lowest) of anterior vagina – fr point Ap to the posterior fornix



Severity


CCDD

AaAa

ApAp


Notes:

Anterior Point Aa

Midline Point C Cervix or vaginal cuff

Point D

Posterior Point Ap

POP Q point

Fixed point Range: -3 to +3“urethrovesical

crease”

Posterior fornix (USL attachment)

Fixed point Range: -3 to +3



Severity


AaAa

ApAp

BaBa

BpBp


Notes

Anterior Point Ba

Posterior Point Bp

POP-Q point

Arbitrary point Lowest point of upper anterior vagina (fr Aa to fornix)

Arbitrary point Lowest point of upper posterior vagina (fr Ap to fornix)





IIIIII

IIIIII

IVIV

Definition

0 No descentI Leading point lie >1 cm above the hymenII Leading point lie 1 cm above to 1 cm below hymenIII Leading point lie >1 cm below the hymen to a point <(TVL-2) cmsIV Leading point lie to a point >(TVL-2) cms below the hymen

POP-Q Stage

Severity



Severity

joanne_aguinaldo_md_2015● Most important landmark : HYMEN

– If leading point is above, usually asymptomatic

– If leading point falls below, symptoms and degree of bother increase



Outline


1. When to operate(a) Symptom

Local or vaginal, Significant bother(b) Severity

Prolapse reaches the hymen




Outline1. When to operate

(a) Symptom(b) Severity

2. What to do- Symptoms and severity- Patient’s general health- Surgeon preference/capabilities



Surgery

joanne_aguinaldo_md_2015● Aims:

– Restoration of normal vaginal anatomy; – Restoration or maintenance of normal

bladder, bowel and sexual function.

– Reconstructive over obliterative– Uterine-preserving



Surgery

joanne_aguinaldo_md_2015● Consider:

– Native repair– Autologous grafts– Artificial grafts or mesh



Surgery

joanne_aguinaldo_md_2015● IUGA Recommendation

– Benefit of mesh use clearly outweighs risk only for sacral suspension of the apex

– Mesh is not for primary repair of cystocele, cystourethroceles, and rectoceles



Surgery


Vaginal AbdominalAnterior

PosteriorRectocele Posterior colporrhaphy Sacrocolpopexy

Midline

Cystocele/ Cystourethrocele

Anterior colporrhaphy, Paravaginal repair

Burch colposuspension, Paravaginal repair,

Sacrocolpopexy

Uterine prolapse/ Vault prolapse/

Enterocele

Sacrospinous fixation, Prespinous fixation

(iliococcygeal), Uterosacral

fixation/plication, McCall's culdoplasty, Colpocleisis

Sacrohysteropexy, Sacrolpopexy, Uterosacral

fixation/plication, Culdoplasty (Moschowitz/

Halban)





joanne_aguinaldo_md_2015● Anterior

colporrhaphy– Plication of the

pubocervical fascia

– Repair of the midline fascial defects






Image credit:www.glowm.com/section_view/heading/Abdominal%20Operations%20for%20Urinary%20Stress%20Incontinence/item/61

● Paravaginal repair– Dissection

space of Retzius

– Reattachment of the pubocervical fascia to the white line

http://www.glowm.com/section_view/heading/Abdominal%20Operations%20for%20Urinary%20Stress%20Incontinence/item/61



Image credit: http://emedicine.medscape.com/article/1848220-overview#a2



● Burch colposuspension– Attachment of the

paravaginal fascia to the Cooper's ligament

– Primarily for stress urinary incontinence

http://emedicine.medscape.com/article/1848220-overview#a2




Posterior compartment

joanne_aguinaldo_md_2015● Posterior

colporrhaphy– Plication of the

rectovaginal fascia– Repair of midline

fascial defects





Middle compartment

joanne_aguinaldo_md_2015● Sacrocolpopexy/

Sacrohysteropexy– Suspension of the vagina

(or uterus) to the sacral promontory

– Recreation of the normal anatomic support of the uterosacral ligaments





Middle compartment

joanne_aguinaldo_md_2015● Sacrospinous ligament

fixation– Suspension of the vagina

(or cervix) to a sacrospinous ligament

– Unilateral





Middle compartment

joanne_aguinaldo_md_2015● Ileococcygeus suspension– Suspension of the vagina (or

cervix) to the ileococcygeus fascia

– Bilateral




Midline comparmentBefore colpocleisis


After colpocleisis

joanne_aguinaldo_md_2015● Removal of the vaginal

epithelium● Apposition of the anterior to

the posterior vagina with imbricating stitches

● Obliterative




Midline comparmentBefore colpocleisis


After colpocleisis

joanne_aguinaldo_md_2015● Colpocleisis

– Removal of the vaginal epithelium

– Apposition of the anterior to the posterior vagina with imbricating stitches

– Obliterative




Apical/ Middle compartment

Image credit: http://emedicine.medscape.com/article/2047195-technique#c 2

● Colpocleisis


http://emedicine.medscape.com/article/2047195-technique#c



Apical/ Middle compartment

Image credit: https://wholewoman.com/blog/?p=728https://wholewoman.com/blog/?p=728

● Colpocleisis


https://wholewoman.com/blog/?p=728https://wholewoman.com/blog/?p=728



Surgery

joanne_aguinaldo_md_20151. When to operate2. What to do

● Restore normal anatomy and function● CORRECT ALL SITES

● Risk of re-operation ~30%



References1) Gill EJ(1), Hurt WG. Pathophysiology of pelvic organ prolapse. Obstet Gynecol Clin North Am. 1998 Dec;25(4):757-69.

2) Doshani A, Teo REC, Mayne CJ, Tincello DG. Uterine prolapse. BMJ. 2007 Oct 20;335(7624): 819–823.

3) Swift SE, Tate SB, Nicholas J. Correlation of symptoms with degree of pelvic organ support in a general population of women: what is pelvic organ prolapse? Am J Obstet Gynecol2003;189:372-7.

4) Bump, RC. The POP-Q system: two decades of progress and debate. Intl Urogynecol J. 2014 April; 24(4); 441-443.

5) Bump RC, Mattiasson A, Bø K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL,Smith AR. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996 Jul;175(1):10-7.

6) Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW; San Diego Pelvic Floor Consortium. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct. 2005 May-Jun;16(3):203-9; discussion 209.

7) Barber MD, Brubaker L, Nygaard I, Wheeler TL 2nd, Schaffer J, Chen Z, Spino C;Pelvic Floor Disorders Network. Defining success after surgery for pelvic organ prolapse. Obstet Gynecol. 2009 Sep;114(3):600-9.

8) Lee U, Raz S. Emerging Concepts for Pelvic Organ Prolapse Surgery: What is Cure? Current Urology Reports. 2011;12(1):62-67.

9) Siddiqui NY, Edenfield AL. Clinical challenges in the management of vaginal prolapse. Int J Womens Health. 2014 Jan 16;6:83-94.

10) Davila GW, Baessler K, Cosson M, and Cardozo L. IUGA Grafts Roundtable 2010 Selection of patients in whom vaginal graft use may be appropriate. Consensus of the 2nd IUGA Grafts Roundtable: Optimizing Safety and Appropriateness of Graft Use in Transvaginal Pelvic Reconstructive Surgery. Intl Urogynecol J 2012.

Date post:	02-Aug-2015
Category:	Health & Medicine
Upload:	joanne-karen-aguinaldo
View:	154 times
Download:	3 times

Pelvic Organ Prolapse: When to operate, What to do

Health & Medicine