1. Pelvic Prolapse and Lower Urinary Tract Symptoms
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital

2. Vaginal Prolapse
Anterior vaginal prolapse – cystocele, urethral hypermobility, cystourethrocele
Middle vaginal prolapse – apical prolapse, enterocele (bowel herniation), uterine prolpase, vault prolapse
Posterior vaginal prolapse – rectocele (rectal herniation)

3. Anatomical classification of Pelvic prolapse

4. Prevalence of pelvic prolapse
11.1% of all women by age 80 years
Comprise 16.3% of the indications for hysterectomy
Patients often initially present to urologists with complaint of stress urinary incontinence

5. Vaginal support
Vaginal vault – supported by cardinal and uterosacral ligaments
Uterine support – broad ligaments attached to lateral pelvic wall
Mid vagina – supported by lateral attachments to pubococcygeal muscles
Distal vagina – embedded in connective tissue of perineal membrane and attached to urogenital diaphragm structures

6. The vaginal support

8. retroverted uterus: 1st sign attenuation, stretching
                                          
                                                    
retroverted uterus: 1st sign
attenuation, stretching or
Breakage ??

9. ut cx
130o b LP sp u r v

11. Sagittal view
Coronal view

12. Pathophysiology of cystocele
Weakened pubocervical fascia at the medial edge of the levator muscle
Detachment of lateral vaginal wall from the pelvic side wall at the white line of arcus tendineus fascia

13. Pelvic organ support & prolapse

15. Classification of cystocele
Anatomical grade: Gr I: Bladder descent toward introitus with straining
Gr II Bladder to introitus with straining
Gr III Bladder outside of introitus with straining Gr IV Bladder outside of introitus at rest
VCUG grade: GrI: Just below inferior ramus
Gr II: 2-5 cm below inferior ramus
Gr III: Outside introitus and exterior

16. Cystocele

17. Cystocele
Central defect: 5-15%, result from attenuation of the levator hiatus fascia
Lateral defect: 70-80%, disruption of lateral attachments to vesicopelvic or pelvic side wall
Combined central and lateral defects

18. Symptomatology of Anterior Vaginal prolapse
Gr I and Gr 2 cystocele: asymptomatic or stress urinary incontinence
Gr III and Gr IV cystocele: vaginal mass, lower abdominal fullness, frequency urgency, stress urinary incontinence, dysuria, leaning forward to void, residual urine sensation, frequent cystitis, dyspareunia, ureteral obstruction

19. Physical examination of vaginal prolapse
Pelvic examination in supine and standing position
Evaluate concomitant types of prolapse: rectocele and uterine prolapse
Ask the patient to strain and relax with blade retraction of rectum or finger pushing the cervix upward
Reduce cystocele to test stress incontinence

20. Differential diagnosis of cystocele
Urethral diverticulum
Ectopic ureterocele
Cystourethrgraphy identified descent of bladder base and evaluate the urethrovesical angle
MRI: diagnosis of cystocele with or without combination of enterocele or rectocele

21. Cystourethrography of Cystocele

22. Urodynamic study
Multichannel pressure flow study:evaluate detrusor dysfunction, stress urinary incontinence, and voiding efficiency
Provocative maneuvers: coughing, walking, jumping, straining to demonstrate SUI
Detecting detrusor overactivity in patients with symptom of urge incontinence
Residual urine volume determination

23. Uterine prolapse and cystocele causing bladder outlet obstruction

24. Reduction of prolapse relieves BOO in patient with SUI

25. Cystocele and Stress urinary incontinence
High grade cystocele masks intrinsic sphincteric deficiency in 50-80% women
Correction of cystocele without concomitant anti-incontinence surgery may unmask ISD and cause SUI
Use of pessary test or vaginal pack for prolapse reduction and detecting genuine stress urinary incontinence

26. Cystourethroscopy and Lower urinary tract ultrasound
Examination of bladder and urethral pathology, such as stone, tumor, stricture
Bladder neck incompetence and intrinsic sphincter deficiency should be suspected
Measurement of striated urethral sphincter component and bladder neck hypermobility by transrectal sonography of bladder & urethra

27. Female Urethral Incompetence
Bladder neck incompetence
Urethral incompetence

28. Urethral Ultrasound in ISD and Cystocele

29. Surgical procedure for cystocele
Gr I: observation in asymptomatic women or bladder neck suspension when treating SUI
High grade cystocele with SUI: anterior colporrhaphy with pubovaginal sling
Correct uterine prolapse or rectocele concomitantly to prevent exacerbation of vaginal prolapse after colporrhaphy

30. Techniques of cystocele repair
Raz 4 corner suspension
Vaginal sling procedure
Pubovaginal sling procedure with colporrhaphy
Fascial patch repair to levator ani muscles and vaginal cuff or pubocervical fascia
Burch colposuspension

31. Technique of Anterior colporrhaphy

32. Urodynamic point-of-view in cystocele repair
Correct cystocele with adequate increased urethral resistance but not obstructing bladder outlet
Patient with large cystocele may have detrusor underactivity and void by abdominal straining
Accurate assessment of detrusor and urethral function during urodynamic study

33. Detrusor underactivity in Cystocele

34. Complications of cystocele repair
Bladder injury during vaginal wall dissection
Ureteral injury during placing plication sutures
Urethral injury during dissection or suture passage
Infection and fascia rejection
Ureteral obstruction
Stress urinary incontinence becomes prominent after cystocele repair

35. Postoperative Care
Foley catheter and vaginal pack removed at day 1 or 2
Check residual urine after voiding till volume is less than 100ml
Keep on antibiotics for 3 weeks to prevent synthetic material infection or abscess
Laxatives and avoid abdominal straining

36. Postoperative urinary incontinence
Intrinsic sphincteric deficiency is unmasked after cystocele correction
De novo detrusor overactivity
Urethral kinking due to improper placement of pubovaginal sling
Videourodynamic study and transrectal sonography are indicated and a second sling can be applied at distal urethra for ISD
Urethrolysis to relieve urethral obstruction

37. Transrectal sonography of ISD after repair of cystocele

38. Apical Vaginal prolapse (Enterocele)
Peritoneal herniation at vaginal apex
Sometimes difficult to differentiate from large cystocele or high rectocele
Acquired enterocele (5-27%) after Burch culposuspension and leave a wide open cul-de-sac, or after hysterectomy and a weakened vaginal apex
Can be prevented during pelvic surgery

39. Apical Enterocele

40. Symptomatology of Enterocele
Mass at or beyond introitus
Perineal pressure, vaginal mucosal erosion
Mass will reduce spontaneously at supine

41. Physical examination of Enterocele
Examined in supine and standing positions
Ask patient to cough and strain, with finger or blade retraction of bladder or rectum
Posterior vaginal wall length is normal in enterocele,but shortened in vault prolapse
Check rectocele to find the presence of apical vaginal prolapse

42. Physical examination of Vaginal Cuff Prolapse

43. Treatment of Enterocele
High peritonealization and approximation of uterosacral ligaments, obliteration of hernial sac and cul-de-sac
When vaginal ulceration, vaginal surgery, or pelvic prolapse surgery is planned
Abdominal approach or transvaginal approach is feasible

44. Transabdominal repair of Enterocele

45. Transvaginal Repair of Enterocele
More direct and less morbid
All component of vaginal prolapse should be repaired concomitantly
Dyspareunia due to vaginal shortening should be addressed
Approximation of levator ani at posterior vaginal wall can preserve vaginal depth

46. Transvaginal repair of Enterocele

47. Complication of Enterocele repair
Small intestine injury – adhesion of small bowel after previous pelvic surgery or irradiation
Rectal injury – careful vaginal wall dissection can prevent it
Bladder perforation – in combined cystocele with enterocele
Ureteral injury – during applying purse-string suture at herniac sac

48. Vaginal vault prolapse
Due to vaginal apex weakness after previous hysterectomy
Patients often have sensation of mass protruding from vagina
Perineal pressure
Dyspareunia
Difficult urination and vaginal reduction to facilitate voiding

49. Pelvic examination of Vault Prolapse
Posterior vaginal wall foreshortening
Careful differential diagnosis from enterocele, surgical procedure is similar
Nonsurgical procedure – a pessary
Urodynamic study to investigate detrusor function and stress urinary incontinence

50. Pessary

51. BL
vagina
rectum

52. bl cx r
USL

53. Uterosacral Ligament

54. AC Richardson: Breaks, not attenuation or stretching
Site-specific defects
Clin Obstet Gynecol 1993; J Pelvic Surg 1995

57. Surgical procedures for Vaginal Vault Prolapse
Abdominal sacraocolpopexy – securing vaginal vault to sacrum using autologous, allogenic,or synthetic material to bridge the gap
Transvaginal levator myorrhaphy – high approximation of levator uterosacral ligament complex at midline
Sacrospinous ligament fixation
Colpocleisis – closure of vagina in sexually inactive women

58. Transabdominal Sacrocolpopexy

59. Transvaginal Levator myorrhaphy

60. Sacrospinous fixation

61. Uterosacral ligament suspension

62. Uterosacral ligament suspension

63. Uterine prolapse Perineal pressure Dyspareunia Mass at introitus
Urinary incontinence
Difficult urination
Constipation

64. Examination of uterine prolapse
Evaluated in supine and standing position
Voiding cystourethrography for cystocele and urethrovesical angle
MRI to detect concomitant enterocele or rectocele
Urodynamic study in supine (after reduction) and sitting position for voiding function and presence of ISD

65. Uterine prolapse

66. Surgical treatment
Abdominal or vaginal hysterectomy with apical vaginal fixation to prevent postoperative vaginal vault prolapse
Transvaginal levator myorrhaphy
Repair other component of pelvic prolapse including cystocele, enterocele, rectocele by myorrhaphy or synthetic mesh or cadaveric fascia

67. Posterior vaginal wall prolapse
Rectocele results from a weakened rectovaginal septum and perineal body
Stool becoming stuck during defecation
Chronic constipation
Perineal pressure
Backache
Fecal incontinence

68. Rectocele

69. Grading of Rectocele Gr I (A) Protrusion with straining
(B) Protrusion does not reach introitus
Gr II Protrusion to introitus
Gr III Protrusion outside introitus

70. Surgical repair of Rectocele
To restore rectovaginal septum and perineal body
Risk of rectal injury and dyspareunia secondary to vaginal tightening
Repair the transverse perineal muscles by sutures at superficial and deep perineal muscles
Not to close vagina too tightly

71. Technique of Rectocele repair