1. Case Report
Katrina Marie D. Soto

2. General Data G.S. 63 year old G3P3 (3003) Married Roman Catholic
Housewife

3. Introital mass
Chief Complaint

4. Past Medical History No comorbids (hypertension, DM, Asthma, COPD)
No previous surgeries
No allergies

5. Personal and Social History
Non-smoker
Non-alcoholic beverage drinker

6. Family History (+) Bronchial Asthma- maternal side
(-) Hypertension, Diabetes mellitus, asthma

7. Menstrual History Menarche: 17 years old
Regular intervals (28-30 days)
Duration: 3 days
2 pads per day
(+) occassional dysmenorrhea
Menopause for the past 19 years (1981)

8. Gynecologic History Coitarche: 18 years old Sexual Partners: 2
Denied sexual activity
(+) occassional vaginal bleeding
No foul smelling vaginal discharge
Denied OCP or IUD use
Pap Smear 2009: normal

9. OB History
G3P3 (3003)
1970 –full term- female- ~7lbs- NSD- Isabela hospital- no fetomaternal complications
1971 –full term- female- ~8lbs- NSD- Isabela hospital- no fetomaternal complications
1981 –full term- female- ~7lbs- NSD- Isabela hospital- no fetomaternal complications

10. History of Present Illness
3 yrs PTA
(+) pea sized introital mass, spontaneously reducible, more prominent on straining
(-) pain, fever, changes in urinary or bowel habits, vaginal bleeding, vaginal discharge
Consult done at Isabela hospital where patient was given unrecalled medications (suppository)

11. HPI
Interim
Patient followed up every 6 months, (+) persistence of introital mass
1 yr PTA
Noted increase in the size of the mass (~size of a fist)
Manually reducible
(+) feeling of incomplete voiding, incontinence, frequency, minimal vaginal bleeding no bowel changes

12. HPI Consult with AMD TVS: normal
Advised surgery but patient deferred due to financial constraints
(+) persistence of symptoms but with regular follow up every 6 months  Admission

13. Review of Systems
Unremarkeable

14. Physical Examination
Conscious, coherent, not in cardio-respiratory distress,
BP: 110/70mmHg CR: 68/min, regular RR: 20/min, regular T: 36.8oC Wt 58 kg Ht 168cm BMI 22.7
Skin: warm with good skin turgor
Head: skull normocephalic, atraumatic
Eyes: pink palpebral conjunctivae, anicteric sclerae
Neck: supple neck, with no palpable neck mass, no neck vein engorgement

15. Physical Examination
Lungs: symmetrical chest expansion, no rib retractions, clear and equal breath sounds
Heart: adynamic precordium, normal rate, regular rhythm, no murmurs
Abdomen: Symmetrical, flabby , NABS, soft, no direct/indirect tenderness, no masses palpated
Full and equal pulses, no cyanosis
External exam: (+) introital mass, smooth mucosa, no ulcerations or bleeding noted.

16. Salient Features Subjective Objective (+) 63 year old G3P3 (3003)
(+) 3 year history of gradually enlarging introital mass
(+) 1 year history of frequency, incontinence, feeling of incomplete voiding, occ vaginal bleeding TVS: normal
No comorbids or previous surgeries
Menopause for 19 years
G3P3 (3003) NSD, 7-8 lb babies
Conscious, coherent not in cardiorespiratory distress
BP: 110/70mmHg CR: 68/min, regular RR: 20/min, regular T: 36.8oC Wt 58 kg Ht 168cm BMI 22.7
Abdomen: Symmetrical, flabby , NABS, soft, no direct/indirect tenderness, no masses palpated
External exam: (+) introital mass, smooth mucosa, no ulcerations or bleeding noted.

17. Initial Assessment 63 year old G3P3 (3003)
Pelvic Organ Prolapse Stage III

18. Differential Diagnosis
Pedunculated myoma
Cervical Polyp
Bartholin’s Duct Cyst
Soft tissue tumors (lipoma, leimyomas, sarcomas)

19. Pelvic Organ Prolapse

20. Epidemiology 3rd most common indication for hysterectomy
estimated lifetime risk of 11% to undergo surgery for prolapse or incontinence (Olsen, 1997)
Prevalence increases with age (Olsen, 1997)
there was a 100-percent increased risk of prolapse for each decade of life (POSST)
physiologic aging, degenerative processes and hypoestrogenism

21. Risk Factors Multiparity
Vaginal birth – most frequently cited risk factor (Swift, 2005) risk of POP increased 1.2 times with each vaginal delivery
Menopause (aging, hypoestrogenism)
Chronically increased intra abdominal pressure (COPD, obesity, constipation)
Pelvic floor trauma
Race
Connective Tissue disorders
originates from multiple causes and develops gradually over a span of years

22. Definition
Prolapse is the downward displacement of one of the pelvic organs from its normal location that results in vaginal wall protrusion or bulge
cystocele, cystourethrocele, uterine prolapse, rectocele, and enterocele have traditionally been used to describe the protrusion location
more clinically useful to describe prolapse in terms of what one actually sees: anterior vaginal wall prolapse, apical vaginal wall prolapse, cervical prolapse, posterior vaginal wall prolapse, perineal prolapse, and rectal prolapse.

24. POP-Q

25. POP-Q Staging
Stage 0 No prolapse; anterior and posterior points are all -3 and C (cervix) or D (posterior fornix) is between - TVL (total Vaginal length) and - (TVL - 2) cm.
Stage I The criteria for stage 0 are not met, and the most distal prolapse is >1 cm above the level of the hymen (< -1 cm).
Stage II The most distal prolapse is between 1 cm above and 1 cm below the hymeneal ring (at least one point is - 1, 0, or +1).
Stage III The most distal prolapse is between >1 cm below the hymeneal ring, but no further than 2 cm less than TVL.
Stage IV Represents complete vault eversion; the most distal prolapse protrudes to at least (TVL - 2 ) cm.
International Continence Society Stages of Pelvic Organ Prolapse Determined by Pelvic Organ Prolapse Quantification System Measurements

26. Baden-Walker Halfway System
Grade 0 Normal position for each respective site
Grade 1 Descent halfway to the hymen
Grade 2 Descent to the hymen
Grade 3 Descent halfway past the hymen
Grade 4 Maximum possible descent for each site
also used to classify prolapse on physical examination and is in widespread clinical use.

27. Pathophysiology
Pelvic organ support is maintained by complex interactions between the levator ani muscle, vagina, and pelvic floor connective tissue
the upper vagina lies nearly horizontal in the standing female
upper vagina is compressed against the levator plate during periods of increased intra-abdominal pressure (flap valve effect)
when the levator ani muscle loses tone, the vagina drops from a horizontal to a semi-vertical position. This widens or opens the genital hiatus and predisposes pelvic viscera to prolapse. Without adequate levator ani support, the visceral fascial attachments of the pelvic contents are placed on tension and are thought to stretch and eventually fail.

28. Relevant Anatomy

29. The axes of pelvic support
Three support axes
Upper vertical axis (cardinal-uterosacral ligament complex)
Horizontal axis leads to lateral and paravaginal supports two platforms pubocervical fascia and rectovaginal septum
Lower vertical axis supports the lower third of the vagina, urethra and anal canal

30. DeLancey’s three levels of vaginal support
Apical suspension
Upper paracolpium suspends apex to pelvic walls and sacrum
Damage results in prolapse of vaginal apex
Midvaginal lateral attachment
Vaginal attachment to arcus tendineus fascia and levator ani muscle fascia
Pubocervical and rectovaginal fasciae support bladder and anterior rectum
Avulsion results in cystocele or rectocele
Distal perineal fusion
Fusion of vagina to perineal membrane, body and levators
Damage results in deficient perineal body or urethrocele

31. Perineum
Anterior pubic arch, posterior coccyx tip, lateral ischiopubic rami, ischial tuberosities and sacrotuberous ligaments frame the perineum into a diamond shape
Divided into two angulated triangles
Posterior anal triangle contains the anal canal
Anterior urogenital triangle contains the vagina and urethra

32. External genital muscles and the Urogenital diaphragm

33. Clinical Evaluation Bulge Symptoms
Urinary Symptoms - stress urinary incontinence (SUI), urge urinary incontinence, frequency, urgency, urinary retention, recurrent urinary tract infection, or voiding dysfunction
GI symptoms- constipation
Sexual dysfunction
Pelvic and back pain
Comparing Symptoms to Degree and Location of Prolapse
Although POP has been associated with several different types of symptoms, the presence and severity of symptoms does not correlate well with advancing stages of prolapse. In addition, many common symptoms do not differentiate between compartments. Several studies have shown a poor predictive value among symptoms, the degree of their severity, and the degree of prolapse in a particular vaginal compartment (Ellerkmann, 2001; Jelovsek, 2005; Kahn, 2005; Weber, 1998). Thus, when planning surgical or nonsurgical therapy, realistic expectations should be set with regard to relief of symptoms. A patient should be informed that some symptoms cannot predictably be improved.

34. Physical Examination
full body systems evaluation to identify pathology outside the pelvis
Initial pelvic exam  dorsal lithotomy position
vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalities
neurologic examination of sacral reflexes is performed using a cotton swab (bulbocavernosus reflex and anal wink)
Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina  true anatomy

35. Physical Examination Speculum exam Pop Q examination
(1) Does the protrusion come beyond the hymen?; (2) What is the presenting part of the prolapse (anterior, posterior, or apical)?; (3) Does the genital hiatus significantly widen with increased intra-abdominal pressure?
Pop Q examination
Bimanual examination is performed to identify other pelvic pathology
Assessment of pelvic floor musculature

36. Anterior compartment defects
Urethral hypermobility
Distal 4 cm of anterior vaginal wall
Cotton swab test
If describes an arc greater than 30 degrees from horizontal with valsalva
Results in genuine stress incontinence
Cystocele

37. Evaluation of a cystourethrocele

38. Cystocele
Main support of urethra and bladder is the pubo-vesical-cervical fascia
Essentially a hernia in the anterior vaginal wall due to weakness or defect in this fascia
Symptoms include pelvic pressure and bulge or mass in the vagina
Surgical repair is the treatment of choice

39. Posterior compartment defects
Rectocele
Perineal deficiency
Bulbocavernous and superficial transverse muscle heads retracted
Perineal descent
Sagging and funneling of the levator ani around the perineum such that anus becomes most dependent
Difficulty with defecation

40. Rectocele
Chiefly a hernia in the posterior vaginal wall secondary to weakness or defect in the rectovaginal septum
Symptoms include difficulty evacuating stool, a vaginal mass, and fullness sensation
Rectovaginal exam confirms diagnosis

41. Evaluation of a rectocele

42. Rectocele
Damage generally due to excessive pushing in childbirth or chronic constipation
Surgical treatment if symptomatic
Posterior Colporrhaphy
Laxatives and stool softeners
Temporary relief

43. Apical defects Uterine prolapse Vault prolapse Enterocele
Normal cervix located in upper third of vagina
Degree of prolapse measured by position of cervix at maximum intraabdominal pressure, without traction
Complete uterovaginal prolapse is called procidentia
Vault prolapse
Enterocele

44. Uterine prolapse
Weakness of endopelvic fascia and detachment of cardinal and uterosacral ligaments
Complains of severe pelvic or abdominal pressure, bulge or mass, and low back pain
Surgical management includes hysterectomy and vaginal cuff or apex suspension
Estrogen replacement important

45. Enterocele
A true hernia of the rectouterine or cul-de-sac pouch (pouch of Douglas) into the rectovaginal septum
Descent of bowel in a peritoneum-lined sac between posterior vaginal apex and anterior rectum
Can occur anteriorly as well
Symptoms of fullness and vaginal pressure or palpable mass
Bowel peristalsis confirms diagnosis

46. Enterocele Commonly found in association with other defects
Surgical approach
Vaginal
Abdominal
Laparoscopic
Ligation of hernia sac and obliteration of the pouch of Douglas

47. Approach to Treatment
asymptomatic or mildly symptomatic, expectant management is appropriate
for women with significant prolapse or for those with bothersome symptoms, nonsurgical or surgical therapy may be selected.

48. Conservative treatments
Obstetric care to protect pelvic floor
Decreased pushing times
Avoid forceps, major lacerations
Permit passive descent
General lifestyle changes
Smoking cessation and cough cessation
Routine use of Kegel pelvic floor exercises
Regular physical activity
Proper nutrition
Weight loss
Avoid constipation and repetitive heavy lifting
Hormone replacement therapy

49. Non Surgical Pessaries are the standard nonsurgical treatment for POP.
reserved for women either unfit or unwilling to undergo surgery
2 types
Support
Space filling
Serious complications such as erosions into adjacent organs are rare with proper use and usually result only after years of neglect. At each return visit, the pessary is removed and the vagina is inspected for erosions, abrasions, ulcerations, or granulation tissue

50. Non Surgical
Pelvic floor muscle exercise  limit progression and alleviate prolapse symptoms (Kegel Exercises)
women learn to consciously contract muscles before and during increases in abdominal pressure, which prevents organ descent
regular muscle strength training builds permanent muscle volume and structural support

51. Principles of reconstructive pelvic surgery
Site-specific repair
Rebuild weakened endopelvic fascia, repair fascial tears, and reattach prolapsed tissues to stronger sites
Goal is a vagina of normal depth, width and axis
Denervation or muscle trauma cannot be corrected surgically

52. Surgical Obliterative Reconstructive
Lefort colpocleisis and complete colpocleisis
removing extensive vaginal epithelium, suturing anterior and posterior vaginal walls together, obliterating the vaginal vault, and effectively closing the vagina.
technically easier, require less operative time, and offer superior success rates (91-100%)
Reconstructive
restore normal pelvic anatomy and are more commonly performed than obliterative procedures for POP.

53. What was done to the patient
Vaginal Hysterectomy with anterior and posterior colporrhaphy

54. Current Clinical Practice Guidelines (ACOG, 2007)

55. Based on good and consistent scientific evidence (Level A)
The only symptom specific to prolapse is the awareness of a vaginal bulge or protrusion. For all other pelvic symptoms, resolution with prolapse treatment cannot be assumed.
Pessaries can be fitted in most women with prolapse, regardless of prolapse stage or site of predominant prolapse.
Cadaveric fascia should not be used as graft material for abdominal sacral colpopexy because of a substantially higher risk of recurrent prolapse than with synthetic mesh.

56. Stress-continent women with positive stress test results (prolapse reduced) are at higher risk for developing postoperative stress incontinence after prolapse repair alone compared with women with negative stress test results (prolapse reduced).
For stress-continent women planning abdominal sacral colpopexy, regardless of the results of preoperative stress testing, the addition of the Burch procedure substantially reduces the likelihood of postoperative stress incontinence without increasing urgency symptoms or obstructed voiding.
For women with positive prolapse reduction stress test results who are planning vaginal prolapse repair, tension-free vaginal tape (TVT) midurethral sling (rather than suburethral fascial plication) appears to offer better prevention from postoperative stress incontinence.

57. Based on limited or inconsistent scientific evidence (Level B)
Clinicians should discuss the option of pessary use with all women who have prolapse that warrants treatment based on symptoms. In particular, pessary use should be considered before surgical intervention in women with symptomatic prolapse.
Alternative operations for uterine preservation in women with prolapse include uterosacral or sacrospinous ligament fixation by the vaginal approach, or sacral hysteropexy by the abdominal approach.
Hysteropexy should not be performed by using the ventral abdominal wall for support because of the high risk for recurrent prolapse, particularly enterocele.

58. Round ligament suspension is not effective in treating uterine or vaginal prolapse.
Compared with vaginal sacrospinous ligament fixation, abdominal sacral colpopexy has less apical failure and less postoperative dyspareunia and stress incontinence, but is also associated with more complications.
Transvaginal posterior colporrhaphy is recommended over transanal repair for posterior vaginal prolapse

59. Based primarily on consensus and expert opinion (Level C)
Clinicians should discuss with women the potential risks and benefits in performing a prophylactic anti-incontinence procedure at the time of prolapse repair.
Women with prolapse who are asymptomatic or mildly symptomatic can be observed at regular intervals, unless new bothersome symptoms develop.
For women who are at high risk for complications with reconstructive procedures and who no longer desire vaginal intercourse, colpocleisis can be offered.
Cystoscopy should be performed intraoperatively to assess for bladder or ureteral damage after all prolapse or incontinence procedures during which the bladder or ureters may be at risk of injury

60. Thank You.