PELVIC ORGAN PROLAPSE

PELVIC ORGAN PROLAPSE
Presentation lecture by:Neena Agarwala,M.D.
Laparoscopic Surgery & Urogynecology

Elements comprising the Pelvis
* Bones
o Ilium, ischium and pubis fusion
* Ligaments
* Muscles
o Obturator internis muscle
o Arcus tendineus levator ani or white line
o Levator ani muscles
o Urethral and anal sphincter muscles
* Endopelvic fascia
o Meshwork of collagen, elastin and smooth muscle
o Extends from the level of uterine artery to the fusion of the vagina and levator ani
o Attached to uterus is parametrium – cardinal-uterosacral ligament complex
o Attached to vagina is paracolpium – pubocervical and rectovaginal fasciae

Normal Vaginal Support Anatomy
* Bladder, upper two-third vagina and rectum lie in a horizontal axis
* Urethra, distal one-third vagina and anal canal are vertical in orientation
* Pelvic floor is horizontal and like a hammock – levator plate
* Levator ani muscles and perineal body support the vertical orientation

The axes of pelvic support
* Three support axes
* Upper vertical axis (cardinal-uterosacral ligament complex)
* Horizontal axis leads to lateral and paravaginal supports
o Two platforms pubocervical fascia and rectovaginal septum
* Lower vertical axis supports the lower third of the vagina, urethra and anal canal

DeLancey’s three levels of vaginal support
* Apical suspension
o Upper paracolpium suspends apex to pelvic walls and sacrum
o Damage results in prolapse of vaginal apex
* Midvaginal lateral attachment
o Vaginal attachment to arcus tendineus fascia and levator ani muscle fascia
o Pubocervical and rectovaginal fasciae support bladder and anterior rectum
o Avulsion results in cystocele or rectocele
* Distal perineal fusion
o Fusion of vagina to perineal membrane, body and levators
o Damage results in deficient perineal body or urethrocele

Fascial and Muscular layers of the Pelvic Floor
Attachments of cardinal/uterosacral ligaments
Perineum
External genital muscles and the Urogenital diaphragm
Pelvic Relaxation
* Cystocele
* Stress urinary incontinence
* Rectocele
* Enterocele
* Uterine and vaginal prolapse

Boat in dock analogy
* Boat- pelvic organs
* Water- levator muscles
* Moorings- Endopelvic fascial ligaments
* Problem is with the water or moorings or both
* Result is sinking of the boat
* Really the boat itself is fine

PROLAPSE

* Mutifactorial involving both neuromuscular and endopelvic fascial damage
* Relaxation of the tissues supporting the pelvic organs may cause downward displacement of one or more of these organs into the vagina, which may result in their protrusion through the vaginal introitus.

Factors promoting prolapse
* Erect posture causes increased stress on muscles, nerves and connective tissue
* Acute and chronic trauma of vaginal delivery
* Aging
* Estrogen deprivation
* Intrinsic collagen abnormalities
* Chronic increase in intraabdominal pressure

Clinical Evaluation
* Hormonal and neurologic evaluation
o Level of estrogenization
o Sensory and sacral reflex activity
* Quantitative site-specific assessment of pelvic floor components
o in lithotomy position, patient sitting
o at rest and with valsalva
o ability to contract levator and anal sphincter muscles

Patient position for evaluating pelvic floor defects
Anterior compartment defects
* Urethral hypermobility
* Cystocele
Evaluation of a cystourethrocele
Posterior compartment defects
Rectocele
Evaluation of a rectocele
Apical defects
Uterine prolapse
Complete Uterovaginal procidentia
Complete genital procidentia
Enterocele
Principles of reconstructive pelvic surgery
Conservative treatments

PELVIC ORGAN PROLAPSE.ppt