1. Pelvic Floor Prolapse
M L Padwick MD FRCOG

2. IN THE NAME OF GOD

3. What is prolapse ?
Prolapse is a condition in which organs, which are normally supported by the pelvic floor, namely the bladder, bowel and uterus, herniate or protrude into the vagina. This occurs as a result of damage to the muscles and ligaments making up the pelvic floor support. At least half of women who have children will experience prolapse in later life.

8. Statistics ratio surgery for prolapse vs incontinence: 2:1
prevalence of 31% in women aged yrs
20% of women on gynaecology waiting lists
11% lifetime risk of at least one operation
re-operation in 30% of cases

9. Factors associated with pelvic floor prolapse
age
parity
big babies
menopause
obesity
occupation
home delivery
family history

10. Diagnostic Approach
fig4

11. Pathophysiology
Table 1

12. Pathogenesis childbirth connective tissue disorders menopause
chronic intra-abdominal pressure
iatrogenic (hysterectomy)

13. What are the symptoms of pelvic floor prolapse?
This depends on the types and the severity of the prolapse.
Generally, most women are not aware of the presence of mild prolapse.
When prolapse is moderate or severe, symptoms may include sensation of a lump inside the vagina or disturbance in the function of the affected organs, such as:

14. Bladder stress incontinence urgency frequency incomplete emptying
dribbling
recurrent urine infections

15. Bowel low back pain or discomfort incomplete emptying constipation
manual decompression
incontinence of flatus

16. Sexual problems looseness and lack of sensation
difficult entry and expulsion
discomfort or painful intercourse
vaginal bleeding in neglected cases

17. Other can see and feel it back ache dragging sensation
increased discharge
skin irritation

18. How can prolapse be prevented?
appropriate antenatal and intrapartum care
regular postnatal pelvic floor exercises to compensate for childbirth damage
in postmenopausal women, oestrogen cream helps maintain tissue strength

19. Living with pelvic organ prolapse
Avoid standing for long periods of time.
Do pelvic floor exercises
Prevent or correct constipation
Wear a girdle
Try yoga
Wear a pantyliner or incontinence pad
Explore alternatives to sexual intercourse
Carry wet wipes

20. Pelvic organ prolapse Non-surgical treatments
Physiotherapy - pelvic floor exercises and
Hormone Replacement Therapy (HRT) - may be local oestragens
Vaginal Pessaries - many choices but regular checks and changes needed and best combined with oestragen creams

21. Genital prolapse and Pelvic floor muscle exercises
Summary
We found no RCTs or observational studies of sufficient quality examining the effects of pelvic floor muscle exercises on the symptoms of genital prolapse.
Comment
Although pelvic floor muscle exercises appear to be effective in reducing the symptoms of urinary stress incontinence (see benefits of pelvic floor muscle exercises in stress incontinence chapter), their usefulness in the treatment of genital prolapse is unproven.

22. — A good multivitamin and mineral tablet
Nutrititon.
Supplements
The supplement programme below should be taken for at least three months in order to achieve best results
Your supplement plan
— A good multivitamin and mineral tablet
— Vitamin C with bioflavonoids (1000mg twice a day)
— Vitamin A (as beta-carotene at 25,000iu per day)
— Proanthocyanidins (50 mg per day)
— Manganese (5mg per day)
— Cranberry supplement (only needed for stress incontinence)
At the end of three months you should reassess your condition and adjust your supplement programme accordingly.

24. Nonsurgical Management

25. Nonsurgical Management

26. The Surgical Management of Prolapses
Restoration of pelvic structures to normal anatomical relationship
Restore and maintain urinary &/or faecal continence
Maintain coital function
Correct co-existing pelvic pathology
Obtain a durable result
Principles of Pelvic Reconstructive Surgery

27. The Surgical Management of Prolapses
Patient assessment
Careful history
Physical examination
Neurological assessment
Urodynamic evaluation
Anorectal investigations

28. The Surgical Management of Prolapses
Surgeons' own expertise, experience and preference
Pre-op voiding or bowel dysfunction
Duration of efficacy
Complications
Learning curveof life factors
First or repeat surgery
The need to treat other pathology
Fitness of the patient
Underlying pathology
Success rates for different procedures
Factors affecting choice of operation

29. The Surgical Management of Prolapses
Uterovaginal prolapse is multifactorial in origin
Treatment needs to be individualised
Approach often needs to be multidisciplinary
Quality of life assessment is essential
Summary - Female Pelvic Organ Prolapse

30. Types Of Surgery Anterior and posterior repairs Vaginal hysterectomy
Laparoscopic vaginal vault suspension (± mesh)
Laparoscopic sacrocolpopexy
Laser Vaginal Rejuvenation
Designer Laser Vaginoplasty
Vaginal approach to prolapse repair incorporating mesh
Laparoscopic paravaginal repairs

33. Total colpocleisis procedure often coupled with a tension free vaginal tape (TVT) sling procedure for urinary incontinence

34. Sacrocolpopexy and paravaginal repair for total pelvic floor prolapse