PELVIC PROLAPSE (Clinical evaluation (Baden-Walker System ( posterior…
- Gynecologic examination
- Valsalva manouver
- Post voiding residual (ultrasonography, catheterization)
- Assessment of the degree of prolapse
(POP-Q System, Baden-Walker system)
- posterior urethral descent, lowest part other sites
- 0: normal position for each respective site
- 1: descent halfway to the hymen
- 2: descent to the hymen
- 3: descent halfway past the hymen
- 4: maximum possible descent for each site
- The 9 measurements are made: 6 topographical points on the vaginal walls, 2 topographical points on the perineum, and total vaginal length.
- Specific sites are defined separately on the anterior, posterior, and apical vaginal compartments and are measured with respect to a fixed reference point, the hymen.
- Stage 0 denotes no prolapse (the apex can descend as far as 2 cm relative to the total vaginal length).
- Stage 1 - the most distal portion of the prolapse descends to a point less than 1 cm above the hymen.
- Stage 2 - the maximal extent of the prolapse is within 1 cm of the hymen (outside or inside the vagina).
- Stage 3 - the prolapse extends more than 1 cm beyond the hymen but no more than within 2 cm of the total vaginal length.
- Stage 4 - complete eversion, which is defined as extending to within 2 cm of the total vaginal length.
- weight control
- correction of constipation
- administration of estrogen to menopausal women - no evidence supports the use of estrogen to prevent or treat prolapse
- pelvic muscle exercises (especially in younger women immediately following childbirth)
- Routine Kegel exercises can improve pelvic floor muscle tone and stress urinary incontinence, BUT no evidence indicates that improvement of pelvic floor muscle tone leads to regression of POP.
native tissue repairs
- Posterior colporrhaphy
The rectovaginal space is entered and widely dissected to the vaginal apex, beyond the top of the rectocele.
The pararectal fascia is plicated over the rectum with interrupted sutures from the vaginal apex to the introitus.
- Anterior vaginal colporrhaphy
May be associated with vaginal hysterectomy and posterior colpoperineorrhaphy – due to generalized POP
- A hysterectomy is not necessarily a mandatory part of the surgical repair for POP because various types of uterine suspensions can be performed via the abdominal or vaginal route.
- for practical reasons, the uterus is often removed to provide better access to the apical reattachment points, particularly the uterosacral, cardinal, sacrospinous, and anterior sacral ligaments.
- Intraoperative - complications during surgery – 24h
- In the early period - 4-6 weeks after surgery
Damage to the rectum, bladder, urethra during preparation by tuneler
Urinary retention – obstacle under the urethra
- In some patients, after cystocoele surgery a problem of stress urinary incontinence occurs (8-60%)
- Improvement can be achieved with concomitant POP and SUI procedure:
TVT - implantation of tape under middle urethra
Kelly’s procedure - duplication of fascia under urethra
Burch operation (paravaginal fascia to Cooper’s ligaments in patients with open surgery e.g. scrocolpopexy
- Genetic predisposition
- Parity (especially vaginal delivery), giving birth to a large infant, instrumented delivery, prolonged second stage of labor
- Menopause, aging
- Surgical procedures within the pelvis, prior hysterectomy
- Abnormal metabolism of the connective tissue - low amount of type I collagen, an increase in the amount of collagen type III
- Diseases associated with increased intra-abdominal pressure (obesity, chronic constipation, cough)
- Neuropathies, eg. Diabetic
- result from weakness or damage to the normal pelvic support systems.
- Pelvic floor defects are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body.
- this relaxation is linked to multiparity, advanced age, hormonal insufficiency, obesity, neurogenic dysfunction of the pelvic floor, connective tissue abnormalities, or strenuous physical activity.
- Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse.
- no symptoms
- sensation of vaginal fullness or pressure (something is "falling out")
- voiding difficulties, sensation of not complete micturition, longer time of micturition
- Defecatory difficulty
- sacral back pain
- vaginal spotting from ulceration of the protruding cervix or vagina
- lower abdominal discomfort
- coital difficulty
- 14% of the female population between 20 and 70 years of age
- 50% of women over the age of 50, of which 10-20% of the women required surgery
- A lifetime risk of pelvic organ prolapse or urinary incontinence surgery is 11.1%.
- Not a life-threatening condition
- Deteriorates quality of life, sexual function, affects social, physical activity, emotional state.
- is the abnormal descent or herniation of the pelvic organs from their normal position in the pelvis.
- Vaginal cuff prolapse
Developing after hysterectomy. Descent of the vaginal apex.
- Cystocele: Descent of a portion of the anterior bladder into anterior vaginal wall.
- Urethrocele: Descent of the most distal part of the urethra.
- Cystourethrocele: Combination of above mentioned pathologies.
- Rectocele: Herniation of the posterior vaginal wall, with the anterior wall of the rectum
- Enterocele: Any intraperitoneal contents (bowel or mesentery) palpable within the cul-de-sac.