PELVIC ORGAN PROLAPSE (POP)

Pelvic organ prolapse (POP) is one of the common clinical conditions met in day-to-day gynecological
practice especially among the parous women. The entity includes descent of the vaginal wall and the
uterus. It is infact a form of hernia.

Support of uterus:
The uterus is normally placed in anteverted and anteflexed position. It lies in between the bladder and
rectum. The cervix pierces the anterior vaginal wall almost at right angle to the axis of the vagina. The
external os lies at the level of ischial spines.

The uterus is held in this position and at this level by supports conveniently grouped under three tier
systems. The objective is to maintain the position and to prevent descent of the uterus through the
natural urogenital hiatus in the pelvic floor .

Upper tier

The upper most supports of the uterus primarily maintain the uterus in anteverted position.

The responsible structures are:

• Endopelvic fascia covering the uterus.

• Round ligaments.
• Broad ligaments with intervening pelvic cellular tissues.

The last two are actually acting as a guy rope with a steadying effect on the uterus. They have no action
in preventing descent of the uterus.

Middle tier

This constitutes the strongest support of the uterus.

The responsible structures are:

Pericervical ring —It is a collar

of fibro elastic connective tissue encircling the supravaginal cervix. It is connected with the pubocervical
ligaments and the vesicovaginal septum anteriorly, cardinal ligaments laterally and the uterosacral
ligaments and the rectovaginal septum posteriorly .

Function: It stabilizes the cervix at the level of interspinous diameter along with the other ligaments.

Pelvic cellular tissues—The endopelvic fascia consist of connective tissues and smooth muscles.

The blood vessels and nerves supplying the uterus, bladder, and vagina pass through it from the lateral
pelvic wall. As they pass, the pelvic cellular tissues condense surrounding them and give good direct
support to the viscera.

The endopelvic fascia at places is condensed and reinforced by plain muscles to form ligaments —
Mackenrodt’s, uterosacral, and pubocervical. On the medial side, these are attached to the pericervical
ring covering the cervicovaginal junction on the other end are attached to the lateral, posterior, and
anterior walls of the pelvis .

These are anatomically, morphologically, and functionally the same unit. This hammock-like
arrangement of condensed pelvic cellular tissues is the cardinal support of the uterus.

Inferior tier

This gives the indirect support to the uterus. The support is principally given by the pelvic floor muscles
(levanter ani), endopelvic fascia, levanter plate, perineal body, and the urogenital diaphragm .

Supports of VAGINA

Supports of the Anterior Vaginal Wall Positional support — In the erect posture, the vagina makes an
angle of 45° to the horizontal.

Normal vaginal axis is horizontal in the uppertwo-third and vertical in the lower-third . A well-supported
vagina lies on the rectum and the levater plate and Any raised intra-abdominal pressure is transmitted
exclusively to the anterior vaginal wall which is apposed to the posterior vaginal [Link] cellular
tissue — The vagina is ensheathed by strong condensation of pelvic cellular tissue called endopelvic
fascia.

Traced below, this fascia forms the posterior urethral ligament, which is anchored to the pubic bones
giving strong support to the urethra. Traced laterally, this fascia form the pubocervical fascia or ligament
which is the anterior extension of the Mackenrodt’s ligaments.

Supports of the Posterior Vaginal Wall

Endopelvic fascial sheath covering the vagina and rectum.

Attachment of the uterosacral ligament to the lateral wall of the vault.

The levator ani muscles with its fascial coverings: This muscle is slug like a hammock around the midline
pelvic effluents (urethra, vagina, and the anal canal). This strong, robust, and fatigue-resistant striated
muscle guards the hiatus urogenitalis. It supports the pelvic viscera and counteracts the downward
thrust of increase intra abdominal pressure.

The medial fibers of the pubococcygeus part of levator ani muscles, are attached mainly to the urethra,
vagina and rectum. Few fibrous pass behind the rectum, vagina, and the urethra forming a sling. These
pubovisceral fibers of the levator ani muscles squeeze the rectum, vagina, and urethra and keep them
closed by compressing against the pubic bone.

When the levator ani muscles are damaged, the pelvic floor opens and there is widening of the hiatus
urogenitalis. The vagina is then pushed down by the increased intra-abdominal pressure. Eventually, the
genital organs prolapse.

The levator plate (Figs. 15.5 A to C): Clinically, it is a thick band of connective tissue formed by the
medial fibers of the two levator ani muscles.
Anatomically, it is the anococcygeal raphe that extends between the anorectal junction and the coccyx.
Some of the fibers extend anteriorly encir-cling the anorectal junction and are inserted into the perineal
body.

The levator plate forms a horizontal supportive shelf upon which the rectum, upper vagina, and the
uterus rest . The horizontal posi-tion of this shelf is maintained by the anterior traction

of the fibers of pubococcygeus and the iliococcygeus muscles. Due to its horizontal position, the levator
plate can prevent the prolapse of genital organs. The rectogenitourinary hiatus enlarges and predisposes
to prolapse of the genital organs when the levator plateis damaged and sags .

This is due to the loss of tone of the levator ani muscles following injury, overstretching (child-birth
process) or attenuation (menopause). Clinically, the levator plate is assessed by palpating the perineum
between two fingers inside the introitus and the thumb outside. It is palpable as 2–2.5 cm band of
muscle on each lateral side of the distal 1/3 of the vagina.

Perineal body and urogenital diaphragm. Perineal body is a solid pyramidal structure at the central point
of the perineum. It receives 9 muscles like the hub of a wheel that grasps the spokes. Damage to
perineal body causes loss of normal vaginal axis.

Etiology of Pelvic Organ Prolapse (POP)

The genital prolapse occurs due to weakness of the structures supporting the organs in position. These
factors may be anatomical or clinical.

The clinical factors are grouped as:

[Link] 2. Aggravating

Predisposing factors:

• Acquired • Congenital

Acquired: Vaginal delivery with consequent injury to the supporting structures is the single most
important acquired predisposing factor in producing prolapse.

The prolapse is unusual in cases delivered by cesarean section.

The injury is caused by:

(1) Overstretching of the Mackenrodt’s and uterosacral ligaments:

(i) Premature bear down efforts prior to full dilatation of the cervix.

(ii)Delivery with forceps or ventouse with forceful traction.

(iii) Prolonged second stage of labor. (iv)Downward pressure on the uterine fundus in an attempt to
deliver the placenta. (v) Precipitate labor.

In all these conditions, the uterus tends to be pushed down into the flabby distended vagina.

(2) Overstretching and breaks in the endopelvic fascial sheath.

(3) Overstretching of the perineum.

(4) Imperfect repair of the perineal injuries. Poor repair of collagen tissue.

(5) Loss of levator function.

(6) Neuromuscular damage of levator ani during childbirth.

(7) Subinvolution of the supporting structures. This is particularly noticeable in: (i) Ill-nourished and
asthenic women.

(ii) Early resumption of activities which greatly increase intra-abdominal pressure before the tissues
regain their tone.

(iii) Repeated childbirths at frequent intervals.

Congenital: Congenital weakness of the supporting structures is responsible for nulliparous prolapse or
prolapse following an easy vaginal delivery. One should be on the look out for an occult spina bifida and
associated neurological abnormalities.

CLINICAL TYPES OF PELVIC ORGAN PROLAPSE

The genital prolapse is broadly grouped into:

• Vaginal prolapse • Uterine prolapse

While vaginal prolapse can occur independently without uterine descent, the uterine prolapse is usually
associated with variable degrees of vaginal descent.

Vaginal Prolapse

Anterior wall

• Cystocele — The cystocele is formed by laxityand descent of the upper two-thirds of the
anterior vaginal wall. As the bladder base is closely related to this area, there is herniation of the
bladder through the lax anterior wall.
• Urethrocele — When there is laxity of the lower-third of the anterior vaginal wall, the urethra
herniates through it. This may appear independently or usually along with cystocele and is called
cystourethrocele.

Posterior wall

• Relaxed perineum—Torn perineal body produces gaping introitus with bulge of the lower part of
the posterior vaginal wall.
• Rectocele — There is laxity of the middle-third of the posterior vaginal wall and the adjacent
recto-vaginal septum. As a result, there is herniation of the rectum through the lax area.
Vault prolapse
Enterocele — Laxity of the upper-third of the posterior vaginal wall results in herniation of the
pouch of Douglas. It may contain omentum or even loop of small bowel and hence, called
enterocele.
Traction enterocele is secondary to uterovaginal prolapse.
 Pulsion enterocele is secondary to
chronically raised intra-abdominal pressure.
Secondary vault prolapse — This may occur following either vaginal or abdominal hyste
rectomy.
Undetected enterocele during initial operation or inadequate primary repair usually results in
secondary vault prolapse .
Uterine prolapse
There are two types:

Uterovaginal prolapse is the prolapse of the uterus, cervix and upper vagina.

This is the commonest type. Cystocele occurs first followed by traction effect on the cervix
causingretroversion of the uterus. Intra-abdominal pressure has got piston like action on the uterus
thereby pushing it down into the vagina.

• Congenital

There is usually no cystocele. The uterus herni-ates down along with inverted upper vagina. This is often
met in nulliparous women and hence called nulliparous prolapse. The cause is congenital weak-ness of
the supporting structures holding the uterus in position.

Degrees of uterine prolapse (clinical)

Three degrees are described:

First degree — The uterus descends down from its normal anatomical position (external os at the level
of ischial spines) but the external os still remains inside the vagina.

Second degree — The external os protrudes outside the vaginal introitus but the uterine body still
remains inside the vagina.

Third degree (Syn: Procidentia, Complete prolapse)— The uterine cervix and body descends to lie
outside the introitus .

Procidentia involves prolapse of the uterus with eversion of the entire vagina.

Complex prolapse is one when prolapse is associated with some other specific defects. Complex
prolapse includes the following: prolapse with urinary or fecal incontinence, nulliparous prolapse,
recurrent prolapse, vaginal and rectal prolapse, or prolapse in a frail woman.

Morbid Changes

Vaginal mucosa: The mucosa becomes stretched and if exposed to air, becomes thickened and dry with
surface keratinization. There may be pigmentation.

Decubitus ulcer : It is a trophic ulcer, always found at the dependent part of the prolapsed mass lying
outside the introitus. There is initial surface

keratinization → cracks → infection → sloughing→ ulceration. There is complete denudation of the

surface epithelium. The diminished circulation is due to constriction of the prolapsed mass by the
vaginal opening and narrowing of the uterine vessels by the stretching effect.
Management:

(a) Cervical cytology to exclude malignancy. (b) Manual reduction of prolapse.

(c) Vaginal pack with roller bandage socked with antiseptic lotion glycerin and acriflavin or using
estrogen cream (postmenopausal women).

Cervix

Vaginal part — There is chronic congestion which may lead to hyperplasia and hypertrophy of the
fibromusculoglandular components. These lead to vaginal part becoming bulky and congested.

Addition of infection leads to purulent or at times blood-stained discharge from ulceration.

Supravaginal part — The supravaginal part becomes elongated due to the strain imposed by the pull of
the cardinal ligaments to keep the cervix in position, whereas the weight of the uterus makes it fall
through the vaginal axis. Chronic interference of venous and lymphatic drainage favors elongation.

Urinary System

Bladder— There is incomplete emptying of the bladder due to sharp angulation of the urethra against
the pubourethral ligament during straining. As a result, there is hypertrophy of the bladder wall and
trabeculation.

Incomplete evacuation also favors cystitis.

Ureters — The ureters are carried downwards along with elongated Mackenrodt’s ligaments and thus,
mechanically obstructed by the hiatus of the pelvic floor. They may be compressed even by the uterine
arteries at their crossing. As a result, hydroureteric changes may occur.

Infection of the bladder may thus ascend up to produce pyelitis or pyelonephritis. On rare occasions,
uremia may occur, especially in long-standing cases of procidentia.

Incarceration: At times, infection of the para-vaginal and cervical tissues makes the entire prolapsed
mass edematous and congested. As a result, the mass may be irreducible.

Peritonitis: Rarely, the peritoneal infection (pelvic peritonitis) may occur through the posterior vaginal
wall.

Carcinoma: Carcinoma rarely develops on decubitus ulcer.

Symptoms

The symptoms are variable. Even with minor degree, the symptoms may be pronounced, paradoxically
there may not be any appreciable symptom even in severe degree. However, the following symptoms
are usually associated:

(a) Feeling of something coming down per vaginum, especially while she is moving about. There may be
variable discomfort on walking when the mass comes outside the introitus.

(b) Backache or dragging pain in the [Link] above two symptoms are usually relieved on lying down.

(c) Dyspareunia.
(d) Urinary symptoms (in presence of cystocele).

• Difficulty in passing urine, more the strenuous effort, the less effective is the evacuation. The
patient has to elevate the anterior vaginal wall for evacuation of the bladder.
• Incomplete evacuation may lead to frequent desire to pass urine.
• Urgency and frequency of micturition may also be due to cystitis.
• Painful micturition is due to infection.
• Stress incontinence is usually due to associated urethrocele.
• Retention of urine may rarely occur.

(e) Bowel symptom (in presence of rectocele).

• Difficulty in passing stool. The patient has to push back the posterior vaginal wall in position to
complete the evacuation of feces. Fecal incontinence may be associated.

(f) Excessive white or blood-stained discharge per vaginum is due to associated vaginitis or decubitus
ulcer.

Clinical Examination and Diagnosis of POP

• A composite examination — inspection and palpation: Vaginal, rectal, rectovaginal or even

under anesthesia may be required to arrive at a correct diagnosis
• General examination — details, including BMI, signs of myopathy or neuropathy, features of
chronic airway disease or any abdominal mass should be done.
• Pelvic Organ Prolapse (POP) is evaluated by pelvic examination in both dorsal and standing
positions. The patient is asked to strain as to perform a Valsalva maneuver during examination.
This often helps to demonstrate a prolapse which may not be seen at rest.
• A negative finding on inspection in dorsal position should be reconfirmed by asking the patient
to strain on squatting position.
• Prolapse of one organ (uterus) is usually associated with prolapse of the adjacent organs
(bladder, rectum).
• Etiological aspect of prolapse should be evaluated.
MANAGEMENT OF PROLAPSE
[Link] [Link] [Link]
PREVENTIVE
The following guidelines may be prescribed to prevent or minimize genital prolapse.
Adequate antenatal and intranatal care
• To avoid injury to the supporting structures during the time of vaginal delivery either
spontaneous or instrumental.
• Adequate postnatal care
To encourage early ambulance.
To encourage pelvic floor exercises by squeezing the pelvic floor muscles in the puerperium.
• General measures
To avoid strenuous activities, chronic cough, constipation and heavy weight lifting.
To avoid future pregnancy too soon and too many by contraceptive practice.
CONSERVATIVE
 Indications of conservative management are:
• Asymptomatic women.
• Mild degree prolapse.
• POP in early pregnancy.
Meanwhile, following measures may be taken:
• Improvement of general measures
• estrogen replacement therapy may improve minor degree prolapse in postmenopausal women.
• Pelvic floor exercises in an attempt to strengthen the muscles (Kegel exercises).
• Pessary treatment.
Pessary Treatment
It should be emphasized that the pessary cannot cure prolapse but relieves the symptoms by
stretching the hiatus urogenitalis, thus preventing vaginal and
uterine descent.
Indications of use are:
Early pregnancy — The pessary should be placed inside up to 18 weeks when the uterus
becomes sufficiently enlarged to sit on the brim of the pelvis.
• Puerperium — to facilitate involution.
• Patients absolutely unfit for surgery especially
with short life expectancy.
• Patient’s unwillingness for operation.
• While waiting for operation.
• Additional benefits: Improvement of urinary symptoms (voiding problems, urgency).
SURGICAL MANAGEMENT OF PROLAPSE
Anterior colporrhaphy
The operation is done under general or epidural anesthesia.
The patient is placed in lithotomy position.
Vulva and vagina are to be swabbed with antiseptic solution.
The perineum is to be draped with sterile towel and legs with leggings.
Bladder is to be emptied by metal catheter.
Vaginal examination is done to assess the type and degree of prolapse.