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P e lv i C o rg A n P ro l A P s e
O vE R v I E w
Pelvic organ prolapse (POP) is the descent of the genital organs beyond their normal anatomical confines� It is caused by
herniation through deficient pelvic fascia or due to weaknesses or deficiency of the ligaments or muscles or blood or nerve
supply to the pelvic organs� Most studies are cross-sectional and therefore look at prevalence� The incidence and natural
history of the condition is not well understood as there is a lack of prospective longitudinal data� Conservative management
involves the use of pessaries, but surgery is the most appropriate option for the physically fit woman�
Definition Prevalence
A prolapse is a protrusion of an organ or structure Pelvic organ prolapse is a very common problem with
beyond its normal confines (Figure 17.1). Prolapses a prevalence of 41–50 per cent of women over the age
are classified according to their location and the of 40 years. There is a lifetime risk of 7 per cent of
organs contained within them. having an operation for prolapse and a lifetime risk of
11 per cent of having an operation for incontinence
or prolapse. The annual incidence of surgery for POP
Classification
is within the range of 15–49 cases per 10 000 women
Anterior vaginal wall prolapse years, and it is likely to double in the next 30 years.
• Urethrocele: urethral descent
• Cystocele: bladder descent
• Cystourethrocele: descent of bladder and urethra Grading
Posterior vaginal wall prolapse
Three degrees of prolapse are described and the lowest
• Rectocele: rectal descent
or most dependent portion of the prolapse is assessed
• Enterocele: small bowel descent
while the patient is straining:
(a)
(c)
Figure 17.1 (a) A rectocele; (b) vault prolapse;
(c) uterovaginal prolapse�
Congenital
Two per cent of symptomatic prolapse occurs in
nulliparous women, implying that there may be a
congenital weakness of connective tissue. In addition,
genital prolapse is rare in Afro-Caribbean women,
(b)
suggesting that genetic differences exist.
Endopelvic fascia is derived from the paramesonephric ducts (The levator muscles are described in Chapter 1, The
and is histologically distinct from the fascia investing the pelvic gynaecological history and examination�)
musculature, although attachments exist between the two�
157 Pelvic organ prolapse Treatment 157
Prevention
Treatment
Shortening the second stage of delivery and reducing
The choice of treatment depends on the patient’s
traumatic delivery may result in fewer women
wishes, level of fitness and desire to preserve coital
developing a prolapse. The benefits of episiotomy and
function.
hormone replacement therapy at the menopause have
Prior to specific treatment, attempts should
not been substantiated.
be made to correct obesity, chronic cough or
158 Pelvic organ prolapse Treatment 158
(a) (b)
Figure 17.4 (a) Ring pessary and (b) shelf pessary�
159 Pelvic organ prolapse Treatment 159
Surgery Rectocele
Posterior repair (colporrhaphy) is the most commonly
The aim of surgical repair is to restore anatomy
performed procedure. A posterior vaginal wall
and function. There are vaginal and abdominal
incision is made and the fascial defect allowing the
operations designed to correct prolapse, and choice
rectum to herniate through is identified and closed.
often depends on a woman’s desire to preserve coital
With the rectal position restored, any redundant
function (Figure 17.6).
vaginal epithelium is excised and the incision closed.
Cystourethrocele
Enterocele
Anterior repair (colporrhaphy) is the most commonly
The surgical principles are similar to those of anterior
performed surgical procedure but should be avoided
and posterior repair, but the peritoneal sac containing
if there is concurrent stress incontinence. An anterior
the small bowel should be excised. In addition, the
vaginal wall incision is made and the fascial defect
pouch of Douglas is closed by approximating the
allowing the bladder to herniate through is identified
peritoneum and/or the uterosacral ligaments.
and closed. With the bladder position restored, any
redundant vaginal epithelium is excised and the
incision closed.
Conservative
Annual Uterovaginal
Soiling Lump
review
constipation
Sacrohysteropexy
Manchester repair Conservative
treatment
Cystourethrocele
Vault
Urinary
Preserve vaginal Vaginal
symptoms
function repair
Colposuspension
Sacral vertebrae
Symphysis
Rectum
Vagina
Discussion
What risk factors does she have for the development of prolapse?
• She has a chronic cough and her job involves heavy lifting.
Both these factors increase abdominal pressure.