Pelvic Organ Prolapse (POP)

Pelvic organ prolapsed is defined as the protrusion (or) herniation of pelvic organ into (or) herniation of pelvic organ into or out of the vagina that occurs due to failure of the anatomic supports. depending on the organs that herniated various terms are used.

1. Uterine prolapse: descent of the cervix and uterus 

2. Anterior vaginal wall prolapse: cystocele-herniation of urinary bladder; Urethrocele -herniation of urethra

3. Posterior vaginal wall prolapse enterocele -herniation of perineum of the pouch of Douglas; Rectocele-herniation of rectum

4. Procidentia: prolapse of the entire uterus and vagina

Risk factors

1.Age

2.Parity

3.Vaginal delivery

4.Weakening of pelvis supports

• Multiple pregnancy
• Menopause
• Hysterectomy Previous surgery for Pelvic Organ Prolapse

5.Chronic increase in intra-abdominal pressure

Smoking

• Constipation
• Chronic lung disease
• Obesity
• Occupational

6.Anterior and posterior vaginal wall prolapsed

Cystocele: it is a downward displacement of the bladder toward the vaginal orifice resulting from damage to the anterior vaginal support structures. It usually results from injury and strain during child birth. 

The condition usually appears some years later when genital atrophy associated with aging occurs , but youger. multiparous, premenopausal women may also be affected. 

Rectocele It is an upward pouching of the rectum that pushes the posterior wall of the vagina forward.

Both rectocele and perineal lacerations, which occurs because of muscle tears below the vagina, may affect the muscle and tissue of the pelvis floor and may occurs during. Sometimes the laceration may completely server the fibers often anal sphincter (complete tear). 

Urethrocele bulge in th lower one third of the anterior vagina wall.

Enterocele: it is protrusion of the intestinal wall into the vagina. prolapse results from weakening of the supportive structures of the uterus.

Clinical manifestation

Due to cystocele and urethrocele

•  Anterior vaginal wall to budge downward
• Sense of pelvic pressure
•  Fatigue
•  Urinary problem: incontinence . Frequency and urgency of urination

For rectocele

•  Rectal pressure
•  Constipation uncontrollable gas . Fecal incontinence
• Ulceration and bleeding
• Dyspareunia.

 

MANAGEMENT :- 

Pelvic floor exercise

Kegel exercise, which involve contracting or tightening the vaginal muscle are prescribed to help strength these weakened muscle The exercise are more effective on the early stages of a cystocele Kegel exercise are easy to perform and are recommended for all women, including those with strong pelvic floor muscle. 

Vaginal pessary :-

A pessary can be used to avoid surgery this devices is inserted into the vagina and positioned to keep an organ, such as the bladder, uterus or intestine, properly aligned when a cystocele, rectocele or prolapsed has occured.

Several types of pessaries are available. smith-hodge or ring pessary is usually used.

Pessary is commonly used for prolapsed in pregnancy, for women awaiting surgery. the pessary has to be cleaned every 3-4 days and reinserted. Addition use of vaginal oestrogen cream reduces the chance of ulceration.

Surgical management

 Reconstructive procedures :- 

• Surgery for anterior and posterior vaginal wall prolapsed :- Anterior colporrhaphy placation of pubovesicocervical fascia. The common site-specific repair: pubocervical fascia to arcus tendineus .

•  Posterior vaginal wall-plication of rectovaginal fascia site specific repair-perirectal fascia at the site of defect.

• Perineorrhaphy- approximation of pubovaginalis repair of perineal body.

• Mccall's caldoplasty: placation of uterosacrals, attaching, uterosacrals to vagina vault.

• Maskowitz procedure: (abdominal)-purse-string placation of pertneum of POD usually the uterus and the cervix lie at right angles to the long axis of the vagina with body of the uterus inclined slightly forward

Medical management

Surgery and pessaries are two options for treatment, with surgery, the uterus is sutured back into place and repaired to strength and tighten the muscle bands. in post menopausal women, the uterus may be removed or repaired by clopopexy. clopoclesis or vaginal closure: It may be an option for women who do not wish to have sexual intercourse or to bear children and want to avoid hysterectomy.