Pelvic organ prolapse


Defined as protrusion of pelvic organs into or out of the vagina as a result of loss of support of the anterior or posterior vaginal wall or its apex.

Confers a 12.6% lifetime risk for surgical correction.

Occurs when a woman has symptoms associated with some measurable anatomic change in pelvic anatomy.

Female pelvic floor disorders are a spectrum of abnormalities which include pelvic organ prolapse and urinary incontinence.

Pelvic organ prolapse occurs when the uterus descends into the lower vagina or vaginal walls protrude beyond the vaginal opening.

May involve the bladder, rectum small intestine, colon or uterus.

Associated with vaginal bulge symptoms as well as urinary, bowel, or sexual dysfunction.

Iin the most advanced form there is eversion of the prolapse through the vaginal introitus.

Reported prevalence varies widely ranging from 3 to 50%.

Affects up to half of all women over 50 years of age.

58% of women who deliver vaginally, 43% of women with cesarean delivery, and 12% of nulliparous women have pelvic floor dysfunction.

47% of women in the second or third trimester of pregnancy have some degree of uterine prolapse.

Uterine prolapse refers the protrusion of the uterus into the vagina and at times outside the vagina and due the loss of support from the ligaments and muscles surrounding the uterus.

Approximately 14% of women have uterine prolapse.

Concurrent pelvic floor disorders are common in women who seek vaginal prolapse surgery with up to 73% reporting urinary incontinence, including stress incontinence or involuntary loss of urine with coughing, sneezing, or physical activity.

Uterine prolapse incidence increased with the number of vaginal deliveries, delivery of a large infant, increased age, heavy lifting, chronic cough, chronic constipation and obesity.

Lifetime risk of 30-50%.

2% of women are symptomatic with pelvic organ prolapse.

The widespread clinical practice of preoperative vaginal estrogen to help surgical outcome has not been confirmed by systemic reviews.

7-19% of women receive surgical repair.

Women with pelvic floor prolapse have pelvic connective tissues with decreased collagen and higher collagen turnover rates than women without prolapse.

The pudendal nerve is subject to injury with pelvic floor dysfunction.

Women have a 11% risk of surgery for prolapse or urinary incontinence by age 80.

Nearly 300,000 women undergo surgery each year in the U.S. and approximately 30% will have a second procedure within 4 years.

One third of women who have surgery for prolapse require a second surgery.

2-42% of women experience prolapse following prolapse surgery within two years.

Adequate support is required in the upper vagina for a durable repair.

Most surgical procedures for pelvic organ relapse is performed transvaginally, with approximately 80 to 90% of cases, with the remainder performed abdominally: vaginal hysterectomy and suspension of the upper vagina.

Uterus conserving procedures, such as sacrospinoushysteropexy, in which the cervix is sutured to a suspensory ligament with outcomes that are comparable traditional vaginal hysterectomy with vaginal suspension

Commonly associated lower urinary tract dysfunction.

Patients report feeling of pressure and bulging from the vagina along with bowel, bladder and sexual dysfunction.

Stage of prolapse determined by comparison of the position of the prolapsed vagina during a Valsalva maneuver with the position of the hymen.

Prolapse above the hymen is rarely of symptomatic nature.

The severity of symptoms is not always proportional to the degree of prolapse.

A study comparing the incidence and progression of prolapse in women who delivered vaginally versus women who underwent a cesarean section following the onset of labor revealed little difference in the groups in the incidence of new or worsened prolapse with 32% versus 35%, respectively for new prolapse and 17% versus 8%, respectively for worsening prolapse.

Pessary therapy is minimally if invasive, but has a high level of adverse effects such as discomfort, pain, and excessive discharge and as many as 24 to 49% of women discontinue therapy within 12 to 24 months.

Surgery intended to repair vaginal compartments into which pelvic organs prolapse anteriorly, posteriorly or apically.

Surgery for a pelvic organ relapse prolapse is associated with surgical complications and as many as two out of 10 women with pelvic organ prolapse experience recurrent bothersome pelvic organ prolapse symptoms.

In a randomized controlled trial among patients with symptomatic pelvic organ prolapse aninitial strategy of pessary therapy, compared with surgery did not meet criteria for noninferiority with regard to patient improvement at 24 months.

Abdominal sacrocolpopexy involves attaching the vaginal apex to the sacral anterior llongitudinal ligament reinforced with a graft, that is usually synthetic mesh.

Sacrospinalis ligament fixation and the uterosacral ligament vaginal vault suspension are the primary utilized vaginal procedures for correcting apical prolapse.

The sacral spinous ligament fixation procedure suspends the vaginal apex to the sacralspinous ligament using an extraperitoneal

approach while the uterosacral ligament vaginal vault suspension suspends the vaginal apex bilaterally to the proximal uterosacral ligaments using an intraperitoneal approach

In a randomized trial of women undergoing pelvic prolapse surgery randomized to sacrospinous ligament fixation or uterosacral ligament suspension: two years after vaginal surgery for prolapse and stress urinary incontinence neither surgical approach was significantly superior to the other for functional,anatomical or adverse outcomes and perioperative behavioral therapy with pelvic floor muscle training did not improve urinary symptoms at six months or prolapse outcomes at two years (Barber MD et al).

Sacrocolpopexy is surgical approach for apical prolapse.

Sacrocolpopexy success ranges from 58-100% at 6 months after surgery.

Some women have concomitant stress incontinence while others do not associated a result of the obstructive effect of the prolapsed pelvic organs causing urethral kinking.

Following pelvic prolapse surgery, new pelvic floor symptoms may develop an pre-existing pelvic floor symptoms may improve worsen or remain unchanged.

Behavioral therapy with pelvic floor muscle training is an effective treatment for pelvic floor symptoms with incontinence cure rates up to 78%.

Behavioral therapy with pelvic floor muscle training can improve prolapse stage by up to 17%.

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