PELVIC ORGAN PROLAPSE

Aishwarya Rathva
2nd mpt
Definition

• Pelvic organ prolapse is a buldge of pelvic organs and their associated

vaginal segment into or through the vagina.

• Normally, external OS lies at the level of ischial spine & internal os at the
upper border of pubic symphysis. So any descent of uterus from these
levels is a case of prolapse.
 Vaginal birth:
• Risk of POP is increased 1-2 times with each
vaginal delivery.
Risk factors Pregnancy:
associated with • High progesterone level causing laxity of pelvic

Pelvic Organ tissue.

Age:
Prolapse(POP) • In women aged 20—59 years , the incidence
of POP roughly doubled with each decade.

Menopause:
• Hyperestrogenism.
 Connective tissue disease:
• Marfan syndrome,
• Ehlers- Danlos syndrome.
• (Ratio of collagen I to Collagen III & IV is decreased)
Risk factors associated Chronically increased intra abdominal pressure:
with Pelvic Organ • COPD

Prolapse(POP) •
•
Chronic constipation
Obesity
• Repeated heavy lifting

Pelvic floor trauma:

• Forceps/Vacuum Delivery
• Episiotomy
 Spina Bifida
Risk factors Occulta.
associated with
Pelvic Organ Cigarette
Prolapse(POP) smoking.
CLINICAL TYPES OF PELVIC ORGAN PROLAPSE
Vaginal
Prolapse
Anterior Wall

Anterior Wall
Cystocele:
• The cystocele is formed by laxity and 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
rectovaginal 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.
Vault Prolapse

Secondary vault prolapse:

• This may occur following either vaginal or abdominal hysterectomy.
• Undetected enterocele during initial operation or inadequate primary repair usually
results in secondary vault prolapse.
Uterine Prolapse
 Uterovaginal prolapse
Congenital prolapse
• Prolapse of the uterus, cervix, and upper vagina. • There is usually no cystocele.
• This is the most common type. Cystocele occurs first • The uterus herniates down along with inverted
followed by traction effect on the cervix causing upper vagina.
retroversion of the uterus. Intra-abdominal pressure • This is often met in nulliparous women and hence
has got piston like action on the uterus thereby
called nulliparous prolapse.
pushing it down into the vagina.
• The cause is congenital weakness of the supporting
structures holding the uterus in position.
Complex prolapse
Is one when prolapse is associated with some other specific defects.
It includes the following:
• Prolapse with urinary or fecal incontinence,
• Nulliparous prolapse,
• Recurrent prolapse,
• Vaginal and rectal prolapse or prolapse in a frail woman.
Clinical Features
Symptoms:
• Buldge symptoms:
• Sensation of vaginal buldging or protrusion.
• Seeing or feeling a vaginal or perineal buldge
• Pelvic or vaginal pressure.
• Heaviness in pelvis or organ
• Urinary symptoms:
• Incontinence
• Frequency
• Urgency
• Weak or prolonged urinary stream.
• Hesitancy
• Feeling of incomplete emptying
Clinical Features

Bowel symptoms:
• Incontinence of flatus or liquid/ solid stoll.
• Feeling of incomplete emptying.
• Hard straining to defecate.
• Urgency to defecate.
• Feeling of blockade or obstruction during defecation.

Sexual symptoms:
• Dyspareunia.
• Decreased lubrication.
• Decreased sensation.
• Decreased arousal or orgasm.
Clinical Features

Pain symptoms:
• Pain in vagina , bladder
and rectum.
• Pelvic pain.
• Low back pain.
 History:

Prolapse history (mechanical symptoms, lump, bulge, obstruction, pressure, back ache)

Urinary history (frequency, nocturia, urgency, stress incontinence, urge incontinence, voiding symptoms)

Bowel symptoms (constipation, digitation/splinting, faecal incontinence, tenesmus)

Sexual Function (sexual activity, dyspareunia, obstruction, incontinence)

Obstetric / Gynaecological / Surgical history

Past medical history, co-morbidities and BMI

Observation and palpation: Vaginal, rectal, rectovaginal for any
visible abnormalities or signs of prolapse.

Pelvic Examination

Conduct a bimanual examination to assess pelvic support structures.

Palpate for any masses or abnormalities.

 Bladder should be emptied.

Pelvic Position is Lithotomy.

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.
Levator ani muscle tone is assessed by placing examining fingers (index and middle) inside the
vagina and thumb outside. The muscle (pubovaginalis) is palpated in the lower third of vagina.
Patient is asked to squeeze the anus and the muscle tone is felt.

Patient Positioning:

The patient should be in a comfortable position, usually lying on their back with knees bent and
feet flat on the table.

Palpation Technique:

Insert one or two fingers into the vagina (or rectum if doing a rectal examination).

Ask the patient to perform a Kegel exercise (squeeze the pelvic floor muscles) and then relax.
 MMT
• Abdominal muscle MMT
 • Recommended by the International Continence Society as it
standardizes terminology and is most objective, site specific
and anatomical.
• Prolapse in each segment is measured relative to the hymen.
Pelvic organ • Six points are located with reference to the plane of the

prolpase
hymen:
• Two on the anterior vaginal wall (points Aa and Ba),

quantification • Two at the apical vagina (points C and D), and

• Two on the posterior vaginal wall (points Ap and Bp) .
(POP-Q) • Genital hiatus (Gh), perineal body (Pb), and total vaginal
length (TVL) are also measured.
• All POP-Q points, except TVL, are measured during
patient Valsalva and should reflect maximum protrusion.
Points Description Range
Aa Anterior wall 3cm from hymen -3cm to +3cm

Ba Most dependent portion of rest of anterior vaginal wall -3cm to +TVL

C Cervix or vaginal cuff ±TVL

D Posterior fornix(if no prior hysterectomy) ±TVL OR omited

Ap Posterior wall 3cm from hymen -3cm to +3cm

Bp Most dependent portion of rest of posterior vaginal wall -3cm to +TVL

TVL Greatest depth of vagina when its apex is at normal position 11cm

Gh Middle of external urethral meatus to posterior midline hymen 4cm

Pb Posterior margin of genital hiatus to mid anal opening 3cm

• After collection of site
specific measurement ,
these are arranged in
grid system of charting
and stages are assigned
according to the most
dependent portion of
prolapse.
POP-Q
Staging
System
• Stage 0: No prolapse is
demonstrated. Points Aa, Ap,
Ba, and Bp are all at − 3 cm
and either point C or D is
between − TVL (total vaginal
length) cm and − (TVL − 2) cm
(i.e., the quantitation value
for point C or D is ≤ − [TVL −
2] cm).
 • Stage I: The criteria for stage 0 are not met, but the most
distal portion of the prolapse is > 1 cm above the level of
the hymen (i.e., its quantitation value is < − 1 cm).

POP-Q • Stage II: The most distal portion of the prolapse is ≤ 1 cm

proximal to or distal to the plane of the hymen (i.e., its
Staging quantitation value is ≥ − 1 cm but ≤ + 1 cm).

System • Stage III: The most distal portion of the prolapse is > 1 cm
below the plane of the hymen but protrudes no further
than 2 cm less than the total vaginal length in centimeters
(i.e., its quantitation value is > + 1 cm but < + [TVL − 2] cm).
Stage IV: Essentially, complete eversion of
the total length of the lower genital tract
is demonstrated. The distal portion of the
prolapse protrudes to at least (TVL − 2)
cm (i.e., its quantitation value is ≥ + [TVL
− 2] cm). In most instances, the leading
edge of stage IV prolapse will be the
cervix or vaginal cuff scar.
Baden-Walker Halfway System for the Evaluation of Pelvic Organ
Prolapse on Physical Examination

Grade
Grade 0 Normal position for each respective site
Grade 1 Descent halfway to the hymen
Grade 2 Descent to the hymen
Grade 3 Descent halfway past the hymen
Garde 4 Maximum possible descent for each site
DEGREES OF UTERINE PROSLAPSE (CLINICAL)

• Normal: External os lies at the level of ischeal spines. No

prolapse.
• First degree: The uterus descends down from its normal
anatomical position but the external os still remains above
the introitus.
• Second degree: The external os protrudes outside the vaginal
introitus but the uterine body still remains inside the vagina.
• Third degree : The uterine cervix and body and the fundus
descends to lie outside the introitus.
• Procidentia involves prolapse of the uterus with eversion of
the entire vagina.
• PAD TEST

•Preparation:.
•Instruct the patient to refrain from any bladder irritants (like caffeine) before the test.
•Baseline Measurement:
•Have the patient wear a clean, dry pad. This pad should be weighed before the test
to establish a baseline weight.
•Activity Period:
•Ask the patient to engage in normal daily activities for a specified period (usually 24
hours).
•Alternatively, you can have them perform specific tasks that typically provoke
incontinence (e.g., walking, coughing, sneezing).
•Post-Activity Measurement:
•After the activity period, have the patient remove the pad and weigh it again.
•The difference in weight between the pre- and post-test measurements indicates the
amount of urine lost.
Physiotherapy management
• Although not yet proven, it is believed that better education of
women prior to childbirth with active pelvic floor muscle education
will help in the prevention or delay of prolapse and its symptomology
• Appropriate management in labour should also reduce the obstetric
risk factors. Most patients with mild prolapse will benefit from
physiotherapy directed at strengthening the pelvic floor muscles
 Reference

• Physiotherapy in gynaecology – jill mantle, jeanette haslam

•Thank you