Definition.

Descent of one or more pelvic organs (uterine cervix, vaginal apex [after
hysterectomy], anterior vagina, posterior vagina, or cul-de-sac peritoneum) through the
pelvic floor into the vagina.
• Incidence. Half of parous women have prolapse on
examination; 10% of women will undergo surgery for prolapse or urinary inconti- nence
in their lifetime. Prolapse is the most common indication for hysterectomy in women
after age 55.

• Pelvic support. The vagina and uterus have three levels of support in the pelvis: (1) the
uterus, cervix, and upper vagina are supported by cardinal and uterosacral ligaments; (2)
the arcus tendinus fascia (white line) and the levator ani fascia support the midvagina;
and (3) the peri- neal muscles and membrane support the distal vagina. The levator ani
complex of muscles (see Chapter 2) provides the major support for the pelvic organs.

• Etiology:
1 Vaginal parity. Pregnancy, labor, and vaginal delivery may result in
various degrees of damage to pelvic support structures, including the ligaments, fascia,
muscles, and their nerve supply.
2 Race. Prolapse occurs more frequently among white
women than Asian and black ones. Inherited differences in pelvic architecture and the
quality of supporting muscles/connective tissue are thought to be responsible.
3
Estrogen deficiency. Pelvic tissues are estrogen sensitive. Pro- lapse often becomes
symptomatic during the menopausal years as collagen fibers deteriorate.
4 Chronic
conditions that cause repeated increases in intra- abdominal pressure (obesity, “smokers’
cough,” heavy lifting, con- stipation) can contribute to significant pelvic relaxation.
5
Connective tissue disease. Chronic steroid use, Ehlers–Danlos syndrome, and other
related conditions can disrupt normal, collagen- based, pelvic tissue support.

Diagnosis

• History. Each woman’s condition should be assessed to ascertain the nature, severity,
and progression of her symptoms in addition to coexisting medical conditions, prior
obstetric events and past/present medications.

• Symptoms. Mild degrees of genital prolapse are often asymptomatic, but the most
common complaint is an annoying bulge at the vaginal introitus. Due to the effects of
gravity, some women experience minimal symptoms in the morning with progressively
more bulging as the day goes on. Patients may note incomplete bladder or rectal
emptying.

• Pelvic examination. Uterine procidentia is obvious, but most patients have less
pronounced prolapse:

1 Lithotomy. The labia are spread and the protrusion identified. The patient is then asked
to strain as though attempting defecation and also to cough. What appears first at the
introitus may suggest the location of the major defect. Rectovaginal examination may
indicate an enterocele that bulges into the space between the rectum and upper posterior
vaginal wall, or a distal defect near the perineum. 2 Standing. If the patient suggests that
her prolapse is not being seen at its worst extent, she can be asked to strain while in the
stand- ing position.

Classification and management

Several systems (Baden-Walker, POP-Q) have been developed to clas- sify pelvic organ
prolapse:
• Women with mildly symptomatic prolapse can be counseled that treat- ment
is appropriate only when symptoms warrant it. Non-specific pelvic pressure or back pain
may not be alleviated with treatment anyway.

• Pessaries can be used to avoid surgery or improve symptoms while awaiting surgical
correction. The goal of fitting is to provide satisfac- tory reduction of the protrusion,
without causing discomfort or adversely affecting bladder function.

• Pelvic floor muscle training (Kegel exercises) is a simple, non- invasive intervention
that is commonly recommended as adjunct therapy for women with prolapse and related
symptoms.
• Total vaginal hysterectomy (TVH, see Chapter 17) alone is not a treatment
for prolapse, but is commonly performed to provide vaginal access to the uterosacral
ligaments for suspension of the vaginal apex.

Cystocele (Figure 20.1)
Surgical options
1 Anterior colporrhaphy involves

vaginally plicating the endopelvic fascia in the midline to provide support and raise the
bladder to correct its anatomic position.
2 Paravaginal repair replaces the anterolateral
vaginal wall to its anatomic position.
3 TheMcCall
culdoplastyshortenstheuterosacralligamentsandreat- taches them to the vaginal apex.

Rectocele (Figure 20.1)
Surgical options
Posterior colporrhaphy mimics the

anterior procedure with a midline plication of endopelvic fascia. Perineorrhaphy is
commonly required due to an attenuated perineal body or widened genital hiatus.

Enterocele (Figure 20.1)
Surgical options
As an enterocele is a true herniation of

the peritoneal cavity at the pouch of Douglas which bulges into the rectovaginal septum,
repair is usually performed at the same time as posterior colporrhaphy. The hernia sac is
visualized as the vagina is separated from the rectum and it must be dissected free of
underlying tissue. The neck of the hernia is then isolated and sutured. Fixing the
uterosacral ligaments to the sac will help prevent recurrence.

Uterine procidentia (Figure 20.1)
Surgical options
TVH is common, but anterior

and posterior colporrhaphy generally do not provide sufficient long-term apical
support:
1 Sacrospinous ligament suspension (SSLS) may be concomitantly performed
vaginally by suspending the fascia of the apex to one or both ligaments.
2 Abdominal
sacrocolpopexy with total abdominal hysterectomy (TAH) is another reasonable option
that has less apical failure, post- operative dyspareunia, and stress incontinence than
SSLS, but is asso- ciated with longer surgical time, longer patient recovery, and more
short- and long-term complications. Laparoscopic and robotic-assisted techniques are the
preferred option due to reduced recovery times.
3 Colpocleisis (Lefort procedure) is
usually reserved for very elderly women or those at high risk for complications. In this
limited opera- tion, the anterior and posterior vaginal walls are sutured together, making
vaginal intercourse effectively impossible.

Posthysterectomy vaginal vault prolapse

Surgical options

Laparoscopic or robotic-assisted sacrocolpopexy has emerged as the preferred option

over the abdominal approach for surgeons with advanced minimally invasive surgical
skills, but the learning curve is protracted. SSLS is another alternative.