Uterovaginal prolapse

It is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis.

Muscles, ligaments, and other structures hold the uterus in the pelvis. If these muscles and structures are weak, the uterus drops into the vaginal canal

Women who have uterine prolapse frequently have other organs that are displaced.

A cystocele results when a prolapsed bladder bulges through the anterior vaginal roof.

A urethrocoele occurs when the urethra prolapses through the anterior vaginal wall.

An enterocoele when bowels prolapse through the posterior vaginal roof and

A Rectocele occurs when the rectum bulges through the posterior vaginal wall.

The floor of the pelvis is the lowest boundary on which all the pelvic and abdominal contents rest.

The pelvic floor functions to support the pelvic and abdominal viscera and help maintain control of their contents.

It has two major components which are interdependent: the muscle and fascia.

Muscle

Levator ani muscles consist of puborectalis, pubococcygeus and iliococcygeus (coccygeus) muscles on each side which together form a muscular floor to the pelvis. The striated muscle of levator ani is under voluntary control but is a unique striated muscle in having a resting tone.

Levator Ani Muscle

As with other striated muscles its strength can be increased by exercise as with pelvic floor physiotherapy.

Contraction of the muscles results in a forward elevation of the pelvic floor which is important in their role in continence.

This forward elevation helps to increase the angulation between bladder and urethra anteriorly and rectum and anal canal posteriorly.

Increase in this angulation is one of the fundamental mechanisms which aid continence.

Fascia

Fascia envelopes levator ani, attaches it to bone at its origin and holds the two muscles together in the midline. The urethra, vagina and rectum perforate this midline fascia.

The striated muscle of the pelvic floor, in common with other striated muscles throughout the body, undergoes a gradual denervation with age. This denervation will result in a gradual weakening of the muscle over time.

While some of the aging effect can be counteracted by muscle training, the impact of denervation will be to diminish the number of neurones which can stimulate muscle fibres to contract.

Pelvic floor muscle denervation is increased by vaginal delivery, particularly if the active second stage of labour is prolonged.

Thus, the pelvic viscera are supported both by the levator ani muscle below and the fascial attachments which are condensed in some areas and are often referred to as ligaments – the uterosacral, cardinal and round ligaments being examples.

Ligaments of the uterus

Mainly

• Lateral cervical, Cardinal or Mackenrodt’s ligament.
• Uterosacral ligament.

Childbirth:

Especially repeated vaginal deliveries caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Partial pudendal and perineal neuropathies are also associated with labour.

The perineal body (or central tendon of perineum) is a pyramidal fibromuscular mass in the middle line of the perineum at the junction between the urogenital triangle and the anal triangle. In females, it is found between the vagina and anus, and about 1.25 cm in front of the latter.

Congenital:

Certain rare abnormalities in connective tissue (collagen) e.g. Marfan disease, some women who have increased joint elasticity also have pelvic fascia stretchiness e.g. extreme form is Ehrlers Danlos syndrome.

Normal aging:

With increasing age fascial tissues become stiffer and more liable to rupture the fascia of the pelvic floor will provide weaker support with advancing years.

Endocrine:

Women often declare that prolapse symptoms are worse around the time of menstruation. This is thought to be secondary to higher progesterone levels increased fascial elasticity. Lack of estrogen especially after menopause leading to vagina atrophy.

Increased intra-abdominal Pressure:

Anything that puts pressure on the pelvic muscles, including

• Chronic cough
• Obesity
• Long-term constipation
• Intra-abdominal and pelvic tumors
• Weight lifting

Feeling of heaviness or pulling in the pelvis or feeling like you are sitting on a small ball.

This feeling is typically posture-dependent, usually getting worse with long periods of standing.

Uterus and cervix that stick out through the vaginal opening.

Urinary retention.

Other urinary symptoms: Frequency, urgency, urge incontinence usually arise from repeated bladder infections. Stress incontinence and voiding difficulties especially in the presence of a cystocele.

Low backache

Bowel Symptoms: urgency to defecate, feeling of incomplete emptying, hard straining to defecate, etc.

Coital problems: Prolapse often does not interfere with normal sexual activity. Some couples find that the loss of tone in the vagina leads to sexual dissatisfaction for both parties.

Vaginal bleeding and ulceration (decubitus ulcer).

Keratinization of the vagina.

1. Traditional staging/grading system
2. Baden–Walker half way grading system (1972).
• Consists of 4 stages
• Lacks precision and reproducibility
• Hymen is used as a fixed anatomical landmark
3. Pelvic Organ Prolapse Quantification staging system. (POP-Q) (1996/2002)

Traditional

First degree: There is descent of the cervix into the vagina but not beyond the introitus.

Second degree: Descent of the cervix beyond the introitus at rest or on straining.

Third degree: Descent of the cervix and the whole uterus outside the vulva. This type of prolapse is sometimes referred to as Procidentia..

Vault prolapse: Prolapse of the vaginal vault which occurs following hysterectomy.

Pelvic Organ Prolapse Quantification Staging System

Stage 0: No prolapse is demonstrated

Stage 1: the most distal portion of the prolapse is more than 1 cm above the level of the hymen

Stage 2: The most distal portion of the prolapse is 1 cm or less proximal or distal to the hymenal plane

Stage 3: The most distal portion of the prolapse protrudes more than 1 cm below the hymen but protrudes no farther than 2 cm less than the total vaginal length (for example., not all of the vagina has prolapsed)

Stage 4: Vaginal eversion is essentially complete

Detailed history and physical examination helps to determine under lining problems which must be managed first if present.

See symptoms above for common presenting complaints

Examination involves

• General and sytemic examination to detect any pathology outside of the pelvis. Systemic diseases in the cardiovascular, pulmonary or other systems can influence choice of management.
• Abdominal examination to rule out abdominal mass
• Where there is no obvious prolapse, the patient might be asked to bear down or cough.
• Vaginal examination with the Sim's speculum
• Pelvic bimanual examination to evaluate the pelvis for any masses that may be contributory to the prolapse.
• These examinations should be done with the patient in an horizontal position, if however, the prolapse is not obvious despite the woman bearing down/coughing, then these evaluations may be done in the upright position.

Treatment

Nonsurgical treatments

Used when symptoms of pelvic organ prolapse are mild or when childbearing is not complete. They can be used in women who have other serious chronic health problems, such as heart or lung disease, that make a surgical procedure more dangerous.

They include:

• Weight loss (to take stress of pelvic structures)
• Avoiding heavy lifting
• Kegel exercises (pelvic floor exercises that help strengthen the vaginal muscles)
• Estrogen replacement therapy- Post menopausal women
• Pessaries

Kegel exercises:

Squeeze the same muscles you would use to stop your urine. Your belly and thighs should not move.

Hold the squeeze for 3 seconds, then relax for 3 seconds.

Start with 3 seconds, then add 1 second each week until you are able to squeeze for 10 seconds.

Repeat the exercise 10 to 15 times a session. Do three or more sessions a day.

Pessaries:

Are removable devices inserted into the vagina that fits under the cervix and helps push up and stabilize the uterus and cervix.

They come in different sizes and should be fitted carefully.

They are sometimes used to see what the effect of surgery for pelvic organ prolapse will be on urinary symptoms. This is called a "pessary test."

If you have a problem with incontinence with a pessary inserted, a separate surgery to fix the incontinence problem may be done at the same time as a prolapse surgery.

Pessaries are sometimes used to treat uterine prolapse in young women during pregnancy. In this instance, the pessary holds the uterus in the correct position before it enlarges and becomes trapped in the vaginal canal.

Pessaries can be removed daily, weekly, or monthly for washing with regular soap and water.

Side effects include: Vaginal erosions or ulcers which if found, pessaries should be removed until the lesions have healed, and affected areas should be treated with topical estrogen.

Surgical treatments

Operations that aim to lift up and attach the uterus or vagina to a bone towards the bottom of the spine or a ligament within the pelvis:

• Sacrocolpopexy
• Sacrospinous fixation
• Iliococcygeus suspension
(Can be done by Open or Laparoscopic surgery)

Sacrocolpopexy:

Sacrocolpopexy (sacral colpopexy) is specifically intended for apical or vaginal vault prolapse.

Can be done by Open abdominal or Laparoscopic surgery

It is the suspension of the vaginal apex (or vaginal cuff) to the sacral promontory.

In women with concomitant uterine prolapse, hysterectomy can be performed at the time of surgical repair.

Sacrospinous fixation:

Usually done after vaginal hysterectomy.

Suturing of the vault of the vagina to the sacrospinous ligament.

Done usually on the right to avoid injury to rectum and sigmoid colon.

Pelvic Floor repairs:

For Cystocele, Rectocele, Urethrocele etc. Done through vaginal route.

Posterior Colporrahaphy: For rectocele and enterocele

Anterior Colporrhaphy: For repair of cystocele

Colpoperineoraphy

Mesh repair surgeries:

A mesh patch is sewn over the weakened region of tissue.

Hysterectomy:

The uterus is removed, either through the abdomen (abdominal hysterectomy) more commonly or through the vagina (vaginal hysterectomy).

Colpocleisis:

Closing off the vagina. May be considered in very poor medical health condition or if there have been several operations previously that have been unsuccessful.

Vaginal intercourse is no longer possible after this operation.

Manchester repair (Forthegill operation):

This includes

• Amputation of the cervix
• Anterior colporrhaphy
• Posterior colpoperineorrhaphy

Not usually done because of the complications. Performed in women who are yet to complete their family. Abdominal delivery usually advised following this procedure.

Complications of Manchester include:

Cervical incompetence: leading to miscarriages or premature deliveries

Cervical dystocia or rigidity: leading to prolonged labour and all the attendant problems

Dyspareunia: Usually from the operation on the posterior wall of the vagina.

There is a 25–30% possibility of prolapse recurrence following surgery.

Chances of the prolapse recurrence increase in presence of obesity, overweight, constipation, chronic cough or undertaking heavy physical activities.

Prolapse may also occur in another part of the vagina.