Pelvic floor relaxation and Uterovaginal

prolapse

Abel G( MD,MPH)
Diredaw University
 INTRODUCTION
1/3 of adult women suffer some sort of pelvic floor
relaxation
1/3 of these undergo surgery
Represent the major long term morbidity of vaginal
delivery
The most prevalent syndrome of pelvic floor dysfn
Urinary incontinence
Anal incontinence
Pelvic organ prolapse
Normal anatomy
Anatomy of pelvic support system
1.Pelvic floor:
2. BONY PELVIS

1.Pelvic floor: is composed of

a) Levator ani complex
b) Endopelvic fascia
 LEVATOR ANI COMPLEX
Complex of two striated muscles
- Iliococcygus
- Pubococcygeus (pubovisceralis )
NERVE SUPPLY
1) Pudendal nerve
- Ventral root of 2nd ,3rd ,4th sacral nerve
2) Direct innervations
- Cranial surface of levator ani from the 3rd and 4th
sacral motor nerve roots
 ENDOPELVIC FASCIA
Fibrous connective tissue layer that reaches diffusely through
out the pelvis
Parts :-
1. Parametrium
2. Paracolpium
3. Pubocervical fascia
4. Fascia of Denonvillier ( Rectovagina fascia)
Condensations
1. Cardinal and Uterosaccral
2. Vesicouterine ligament
3. Pubovesical ligament
Function: - Suspend and stabilize the uterus and vagina
 2) BONY PELVIS
Provides anchoring site to the pelvic floor muscle
and endopelvic fascia .
Anchoring points
Pubic ramus
Ischial spines
Sacrum
Damage to
- Muscle
- Nerves
- Pelvic connective tissues
Results in
- Pelvic floor relaxation
- Pelvic organ prolapse
Relaxation
- sagging of the levator ani
- widening of the levator hiatus
- tension & relaxation of the connective tissue
- pelvic floor relaxation and UVP
Definition
Pelvic organ prolapse a descent of one of
the pelvic organs (uterus, vaginal apex,
bladder, rectum) and its associated vaginal
segment from its normal location.
 Cause
Multifactorial
Proven risk factors include
- Age
- Menopausal status
- Increasing parity
- Obesity
- History of pelvic surgery, specifically hysterectomy
- CT diseases (UVP in the young/ virgins/ nulliparas )
- Chronic coughing- lung disease & straining -chronic constipation
- Occupational activity requiring repetitive heavy lifting
Types of POP
Anterior Vaginal Wall Defects
Apical Prolapse
Posterior Vaginal Wall Prolapse
 Anterior Vaginal Wall Defects
Anterior vaginal prolapse describes an anterior
vaginal wall defect where the bladder is associated
with the prolapse. It is also known as a cystocele
Urethrocele describes a distal anterior vaginal wall
defect where the urethra is associated with the
prolapse. It is essentially a very distal anterior wall
defect
Paravaginal/midline/transverse prolapse indicate the
location of anterior vaginal wall defect
 Apical Prolapse
Uterine prolapse
Vaginal vault prolapse (posthysterectomy)
Enterocele describes an apical vaginal wall
defect in which bowel is contained within the
prolapsed segment . Generally occurs in
posthysterectomy women, but can occur with
the uterus in situ.
UVP
Enterocele
Posterior Vaginal Wall Prolapse
Posterior vaginal wall prolapse describes a
posterior vaginal wall defect. It is also known
as a rectocele
Cystocele and rectocele
 Symptoms of POP
Sensation of vaginal fullness
Sensation of pressure
Sensation of "something falling out," or
Sensation of "heaviness."
Sensation of "sitting on a ball."
Discomfort in the vaginal area
Presence of a soft, reducible mass bulging into the
vagina and distending through vaginal introitus
With straining or coughing, increased bulging and
descent of the vaginal wall.
 Symptoms
Back pain & pelvic pain are often also associated with POP
Urinary symptoms are also common
Feeling of incomplete emptying of the bladder,
Stress incontinence,
Urinary frequency, hesitancy ,a need to push the bladder up in order to
void (splinting).
Defecatory symptoms may also occur, more commonly in
posterior vaginal prolapse.
The sense of incomplete emptying,
Need to strain or manually splint in the vagina or on the perineal body
in order to defecate.
Pelvic Examination
Goal:- 1. Explain the cause of symptom
2. Staging
3. Suggest treatment options
Position: - lithotomy
- semi-upright with straining
Materials: - Univalve or Sims' speculum
- Sponge forceps
* Each part of the vagina should be examined separately
 Physical exam.
The anterior and posterior compartments are best examined
with the use of a univalve or Sims' speculum.
The speculum is placed posteriorly to retract the posterior
wall downward when examining the anterior compartment
and
Placed anteriorly to retract the anterior wall upward when
examining the posterior compartment.
A rectovaginal examination may be useful in evaluating the
posterior compartment to distinguish a posterior vaginal
wall defect from a dissecting apical enterocele or a
combination of both.
During the evaluation of each compartment, the patient is
encouraged to perform Valsalva so the full extent of the
prolapse can be ascertained.
Additional Investigation:-
- Urine Analysis
- Urine Culture
- Q-tip test to check urethral hypermobility
- EUA
- Voiding diary
- Uroflometry
- Residual urine
- Cytometrogram
- Urodynamic testing with reduction with pessaries
- IVP
Staging of pelvic organ prolapse
Two general classifications are used to describe and
document the severity of pelvic organ prolapse.

1. The "1/2 way" system designed by Baden and Walker with

0 referring to no prolapse,
1 halfway to the hymen,
2 at the hymen,
3 halfway out of the hymen and
4 referring to total prolapse (ie, procidentia)
2. The POP-Q system 1996
- Most reproducible
- One-fixed point of reference
- Six-defined points
- Terms like cystocele and rectocele are replaced with
anterior and posterior vaginal wall
- Vaginal length, genital hiatus and perineal body are
measured
- Points above the hymen negative and
- Points below hymen positive values are given
 Prolapse in each segment is measured relative to the
hymen, which is a fixed anatomic landmark that can
be identified consistently.
Six points are located with reference to the plane of
the hymen:
two on the anterior vaginal wall (points Aa and Ba),
two in the apical vagina (points C and D), and
two on the posterior vaginal wall (points Ap and Bp).
All POP-Q points, except total vaginal length (tvl), are
measured during patient Valsalva and should reflect
maximum protrusion.
 Anterior Vaginal Wall Points
Point Aa
Point that lies in the midline of the anterior vaginal wall and
is 3 cm proximal to the external urethral meatus. This
corresponds to the proximal location of the urethrovesical
crease. In relation to the hymen, this point's position ranges,
by definition, from 3 (normal support) to +3 cm (maximum
prolapse of point Aa).
Point Ba
This point represents the most distal position of any part of
the upper anterior vaginal wall from the vaginal cuff or
anterior vaginal fornix to point Aa. It is 3 cm in the absence
of prolapse. In a woman with total vaginal eversion post-
hysterectomy, Ba would have a positive value equal to the
position of the cuff from the hymen.
 Point BP
This point represents the most distal position of
any part of the upper posterior vaginal wall from
the vaginal cuff or posterior vaginal fornix to
point Bp. By definition, this point is at 3 cm in
the absence of prolapse. In a woman with total
vaginal eversion post-hysterectomy, Bp would
have a positive value equal to the position of the
cuff from the hymen.
 Apical Vaginal Points

Point C
The two apical points, C and D, which are located in the proximal vagina, represent
the most proximal locations of a normally positioned lower reproductive tract. Point C
defines a point that is at either the most distal edge of the cervix or the leading edge
of the vaginal cuff after total hysterectomy.
Point D
This term defines a point that represents the location of the posterior fornix in a
woman who still has a cervix. It is omitted in the absence of a cervix. This point
represents the level of uterosacral ligament attachment to the proximal posterior
cervix and thus differentiates uterosacral-cardinal ligament support failure from
cervical elongation. The total vaginal length (TVL) is the greatest depth of the vagina
in centimeters when point C or D is reduced to its fullest position.
Posterior Vaginal Wall Points

Point Ap
Point in the midline of the posterior vaginal wall that
lies 3 cm proximal to the hymen.
Relative to the hymen, this point's range of position
is by definition 3 (normal support) to +3 cm
(maximum prolapse of point Ap).
The POP-Q system
3. Traditional staging
Graded by assessing the level f descent in relation to
the ischial spine and interoitus/ hymenal ring
First degree:- external cervical os descends to the ischial spine
Second degree:- descends to the level b/n the ischial spine and interoitus
Third degree:- descends beyond the hymenal ring
MANAGEMENT:-FOUR modes of Mx.
1. Expectant
2. Non-Surgical
a. Kegels exercise
b. Pessaries
3. Surgical
a. Abdominal
b. Vaginal
4. Pharmacologic
a. Estrogen
b. Rx of promoting factors
c. Modification of urinary complaint
1.Expectant
- Mildly symptomatic and asymptomatic.
- Patient counseling
- Rx of worsening condition
- Estrogen replacement
- Pelvic floor exercise
- Periodic evaluation
2.Non-surgical Mx
a. kegel exercise
- In early stage prolapse
- aimed to tighten and strengthen the pubococcygeus muscles
b. Estrogens
- In postmenopausal women, local estrogen therapy for a number of
months may improve the tone, quality, and vascularity of the
musculofascial supports.
c. Pessarry
Indication:
a. Prolapse in non-pregnant
- medically unfit
- Awaiting definite surgery
- offered but declined
b. Genuine Stress incontinence
- Dx and Rx
c. pregnancy
- uterine prolapse
- incompetant Cervix
Pessary
Fitting:
a. Largest size
b. Well estrogenized epithelium
Complication:
- Vulvovaginal inflammation
- Ulceration
- Erosion and fistula formation
d.Surgical Mx
-> 100 kinds of operations
-Primary Rx in advanced and symptomatic
 Anterior Vaginal Prolapse

1) Anterior Vaginal colporhaphy is the most

common surgical treatment for anterior vaginal
prolapse
2) Site specific (paravaginal) defect repair is
currently recommended, can be done vaginally or
abdominally
Posterior vaginal wall prolapse
1.Posterior Colporrhaphy
*3 goals
- plication of levator ani in the midline
- narrowing of vaginal caliber.
- extensive perineorraphy
S/E -Dyspareunia-21-50%
-Sexual dysfuction-18-27%
2.Identification of defect & repair
-Cure rate -82%-2years follow up
-Dyspareunia -66%
Apical prolapse
Vaginal operations
- sacrospinous ligament suspension
- iliococcygeal fixation
- high uterosacral ligament suspension (high
McCall culdoplasty.
Abdominal sacral colpopexy
In case of UVP who has completed family vaginal
hysterectomy can be done
 Obliterative Vaginal Operations (Colpocleisis
and Le Fort's Operation)

These are used primarily for severe

uterovaginal prolapse in elderly patients and
chronically ill patients who no longer desire
coital function.
It has the advantage of being done with either
regional or local anesthesia and generally well
tolerated
 Thank you