Pelvic Organ Prolapse(POP)

By Worku.G
(Clinical Midwifery Professional specialist)
For 3rd year regular Midwifery students
Debark University
2025

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OUTLINE

Definition
Risk factors
Pelvic support
Types and classifications
Clinical features
Evaluation
management

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 POP
POP is defined as the descent of one or more of the anterior vaginal wall, posterior
vaginal wall, the uterus (cervix) or the apex of the vagina (vaginal vault after
hysterectomy).

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POP
POP is not life threatening, it can impose a significant burden of social & physical
restrictions of activities, impact on psychological well–being, and overall quality
of life.

A fusion of anatomic, physiologic, and biomechanical principles is important for

better treatment for prolapse

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 Epidemiology

Up to 11% of women before the age 80 undergo surgery for uterovaginal prolapse

Up to 50% of women over the age of 50 have physical findings consistent with some
degree of POP, < 20% seek treatment .

POP defined solely by patient symptoms, prevalence rates range from 3 to 6 % in US.

Recent estimates predict an increased demand for prolapse surgery by 45% in the next
30 years.

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Risk Factors

 Parity
 the increase in the
(especially number
vaginal of strongest
delivery) women over the age 35 having their first
risk factor
child damage to CT (Computed tomography) & muscles (disruption)
Direct
the demographic shift to an older population.
Indirect damage Pudendal nerve &pelvic floor muscles
Doubled among women who have had a sub-total hysterectomy and
More common after forceps delivery
almost eight times more likely in women who have had a previous vaginal
Iatrogenic
hysterectomy, or four or more children
menopause
Caesarean
Advanced agesection is partially protective
Connective tissue disorders
 Raised intra abdominal pressure
Smoking
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Risk factor

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 Anatomy of the Pelvic support
The normal position, support, and suspension of pelvic organs rely on an interdependent
system of bony, muscular, & connective tissue element.

Partially vertical orientation of the pelvic inlet deflects force onto the superior symphysis
pubis.

The pelvic organs rest on the pelvic floor muscles and are held in place with the help of
the endopelvic fascia.

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Pelvic floor muscles
Made up of the levator ani & coccygeus muscles.

In state of contraction ,close urogenital hiatus ,lift pelvic organs & relieve strain
on pelvic fascia

Create a hammock ዕንደ አልጋ የሚንጠለጠል -like sling ወንጭፍ between the pubis
& coccyx, are attached laterally along the pelvic sidewalls.

The levator ani muscle is tonically contracted, providing a firm shelf posteriorly
to support the pelvic contents and aiding with urinary and fecal continence

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Endopelvic fascia

 Network of, small vessels, lymphatics, & nerves

 Surrounds &supports the pelvic organs &the vagina.

 Allows dissipation of musculoskeletal force

 Suspends uterus & vagina from pelvic side walls

 Include ligaments and septa

 Uterosacral Ligaments(Rectal pillar).

 Cardinal (Mackenrodt's) Ligaments :Lateral cervical ligament.

 Pubocervical Ligaments(Bladder pillar).

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Septum

Pubocervical Septum or Fascia

Rectovaginal Septum (Denonvilliers' fascia)

 Pericervical Ring(Supravaginal septum)

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Fascial

The way fascial structures support the pelvic structures is

considered at three levels.
Three levels of vaginal support (Delaney's )
Level I: Supports the cervix and upper vagina
 The uterosacral and cardinal ligaments.
Level II: The mid-vagina
 Anteriorly by pubocervical fascial and posteriorly by rectovaginal fascial.
Level III: Supports the lower vagina
 Posteriorly by attachments of the rectovaginal fascia to perineal body together with
some fibres from the pubococcygeus muscle.

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LIGAMENT

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Types of POP
Anterior vaginal wall prolapse

Apical compartment : Cervical /Uterine prolapse

Vaginal vault (cuff scar) prolapse

Posterior vaginal wall prolapse

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Types of pelvic organ prolapse

Cystocele—The bladder drops into the vagina.

Urethrocele: when the defective fascia involves the urethra
Enterocele—The small intestine bulges into the vagina.
Rectocele—The rectum bulges into the vagina.
Uterine Prolapse—The uterus drops into the vagina.
Vaginal Vault Prolapse—The top of the vagina loses its support and drops
after hysterectomy.

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Halfway Grading System Devised by Baden
and Walker with Respect to the Prolapse

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THE POP-QUANTIFICATION

Uses six points along the vagina (2 points on the anterior, middle,& posterior
compartments)
The anatomic position of the 6 defined points should be measured in cm, i.e. more
objective
Proximal to the hymen (-ve) or distal to the hymen (+ve ), with the plane of the
hymen zero.
 Three other measurements ; the genital hiatus, perineal body, & the total vaginal
length.
This system is a physical examination tool and does not assign the specific
location of fascial defects.

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Ordinal Stages of Pelvic Organ Prolapse

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Evaluation
The correct management of POP depends on a
careful evaluation of each patient
The history should begin with the patient's
perception of the problem
A careful micturition, defecation, & sexual history
Past surgical history; especially previous attempts to
correct pelvic organ prolapse
Medical history

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Primary and Secondary Symptoms at Each Site
Used in the Baden-Walker Halfway System

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 Pelvic Examination

 General physical examination

 Position during examination, which can best demonstrate POP in that patient & which the woman can
confirm.

 Valsalva Maneuver

 Provocative maneuvers are also useful -----Sacroiliac (SI)

 All aspects of vaginal support should be carefully surveyed & each area of vaginal anatomy should be
described separately

 Inspection; Prolapse may be internal (proximal to the hymen) or external (distal to the hymen) at rest

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Pelvic Examination
Identify the dominant prolapse and replace it for site-speciflc examination of the
vaginal support
tongue blade or Ayre spatula, speculum,large cotton swab, sponge stick, or, in
advanced cases, by attaching a tenaculum
Inspect the vaginal epithelium for rugae & atrophy
The lateral vaginal sulci
Pressure ulcers
Rectovaginal examination while straining
Evaluate for Perineal descent & perineum

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Pelvic Muscle Function Assessment

Assess basal & contraction muscle tone of the anal sphincter complex &
puborectalis muscle

Assess bladder neck hypermobility

Imaging ; MRI & U/S

 Rectal Exam under Anesthesia (EUA) with Cystoscopy, Vaginoscopy

 Before starting the surgery, an intraoperative assessment is crucial to finalize

surgical planning

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Nonsurgical Management of POP

No surgery should be done unless the patient experiences a sufficient degree of morbidity
Preventative measures should be the most widely applied techniques
The physician's job is to educate the patient regarding options of treatment
Expectant management
Pelvic floor exercises,
weight loss,
Rx of chronic diseases,
physical therapy,
cessation of smoking, &
 estrogen therapy
periodic examinations

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PELVIC FLOOR MUSCLE TRAINING (KEGEL)

• Pelvic floor muscle training exercises (Kegel), the systematic contraction of the
levator ani muscle.

• improve pelvic function, Pelvic floor muscle training has been shown to improve
symptoms associated with stress, urge, and mixed urinary incontinence

• Good results are generally achieved with 45 to 60 exercises per day, divided into
two to three sets.

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PESSARIES
Pessaries are devices that are placed in the vagina to restore normal pelvic
anatomy and decrease prolapse symptoms.
can be fitted in most women with prolapse, regardless of prolapse stage or site of
predominant prolapse.

A temporary or permanent solution for the appropriate patient

the greater the degree of prolapse & the more strenuous the daily activities of the
patient, the less likely it is for a pessary to be a permanent solution.

The utility of these devices is directly proportional to the efforts of the physician
and the patient

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 Indications
Medically unfit for surgery
To gain relief from symptoms while awaiting surgery/desire to
Two
avoidcategories
surgery of pessaries :
Support and space
pregnancy–related filling
prolapse
The ring pessary
Prolapse (with diaphragm)
and incontinence is a commonly used
in elderly women
support pessary,
Feel more and during a specific activity.
comfortable
the Gelhorn
 As a pessary
diagnostic test to is a commonly
relieve symptomsused space–filling
thought to be due topessary.
prolapse.

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 Follow-up

Patients should return one to two weeks after their pessary fitting to assess
satisfaction with the device and symptom improvement.

 Thereafter, women who perform self-care may return annually for examination.

 Other women should generally return every three months for pessary removal,
cleaning, and examination.

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Surgical Management

The management of advanced and symptomatic prolapse

Only those patients who request definitive Mgt. should be considered surgical candidates

Once the decision is made to operate, quality-of-life goals need to be established

Setting realistic expectations & goals with the patient prior to prolapse repair is
important

A careful preop evaluation is crucial in determining whether surgical repair is the right
Rx choice for an individual & if so, w/h procedure is most appropriate.

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Surgery
In general, there are two types of surgery:

1. Obliterative surgery and

2. reconstructive surgery

The surgical approach includes vaginal, abdominal & laparoscopic routes

For most primary reconstructions, the vaginal operative route is superior to any
other approach.

All the major support anatomic landmarks and tissues are accessible vaginally

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Obliterative surgery

Obliterative surgery narrows or closes off the vagina to provide support for
prolapsed organs.

Vaginal sex is not possible after this procedure.

Obliterative surgery has a high success rate.

Good choice if you do not plan to have vaginal sex in the future and want an
easily done procedure

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Reconstructive surgery

 The goal of reconstructive surgery is to restore organs to their original position.

This is the most common type of pelvic organ prolapse surgery.

Some types of reconstructive surgery are done through an incision in the vagina.

Others are done through an incision in the abdomen or with laparoscopy.

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surgical mesh

Surgical mesh is used in some types of reconstructive surgery to reinforce or

support prolapsed organs.

Fixation or suspension using your own tissues (uterosacral ligament suspension

and sacrospinous fixation)—Also called native tissue repair

 this surgery uses your own tissues to treat uterine or vaginal vault prolapse.

The prolapsed part is attached with stitches to a ligament or to a muscle in the

pelvis.

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Reconstructive surgery
• Colporrhaphy—Used to treat prolapse of the anterior (front) wall of the vagina
and prolapse of the posterior (back) wall of the vagina.

• This type of surgery is done through the vagina.

• Stitches are used to strengthen the vagina so that it once again supports the
bladder or the rectum.

• Sacrocolpopexy—Used to treat vaginal vault prolapse and enterocele. It can be

done with an abdominal incision or with laparoscopy.

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Reconstructive surgery
• Surgical mesh is attached to the front and back walls of the vagina and then to the
sacrum (tail bone).

• This lifts the vagina back into place.

• Sacrohysteropexy—Used to treat uterine prolapse if you do not want a

hysterectomy.

• Surgical mesh is attached to the cervix and then to the sacrum, lifting the uterus
back into place.

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Postoperative care

Irrigation & prophylactic antibiotics

vaginal pack
sexual pelvic rest for 6 weeks
Straining to void & defecate should be minimized
Lifting should be restricted to those things that can be accomplished with
available strength.

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Progresses

• Cure rates range from 78% to 100%

• Advantages over transvaginal procedures are

• less paravaginal scarring & denervation

• fixation of the entire vaginal apical area by a permanent piece of material to a

stable structure (the anterior sacral ligament)

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Complications

 Erosions of graft material or suture material

 Intraoperative hemorrhage

 Postoperative ileus

 Intra–abdominal adhesions

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 Better

THANK
Better
YOU!
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