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2242the pelvic organs from their normal attachment sites or their normal position in the pelvis.
The floor of the pelvis is the lowest boundary on which all the pelvic and abdominal contents rest.
The pelvic floor is composed of a sling of several muscle groups (levators) and ligaments (endopelvic fascia) connected at the perimeter to the 360° ovoid bony pelvis.
A defect of the apical segment of the vagina.
Characterized by eversion of the vagina with attendant descent of the uterus.
The vagina is typically involved.
The term for the condition ref2241ed to as uterovaginal prolapse.
Patients may present with varying degrees of descent.
In procidentia, the most severe case, the uterus protrudes through the genital hiatus.
UP is often associated with concomitant defects of the vagina in the anterior, posterior, and lateral compartments.
Lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is approximately 11%.
Approximately 50% of asymptomatic women presenting for annual gynecologic examination have at least stage 2 prolapse.
Pelvic floor defects are caused by childbirth resulting in the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body.
Partial pudendal and perineal neuropathies are also associated with labor, pairing nerve transmission to the muscles of the pelvic floor and may predispose them to decreased tone, leading to further sagging and stretching.
Multiparous women are at particular risk.
Genital atrophy and hypoestrogenism also play important roles in the pathogenesis of prolapse.
Pelvic prolapse may also result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy, and be associated with increases in intra-abdominal pressure due to obesity, chronic pulmonary disease, smoking, and constipation.
Abnormalities in connective tissue, such as Marfan disease, have also been linked to genitourinary prolapse.
Most women with UP have multiple defects leading to PR.
Minimal UP generally does not require therapy because the patient is usually asymptomatic.
Uterine descent of the cervix at or through the introitus can become symptomatic.
Symptoms of UP include : sensation of vaginal fullness or pressure, sacral back pain, vaginal spotting from ulceration of the protruding cervix or vagina, coital difficulty, lower abdominal discomfort, and voiding and defecatory difficulties.
Typically, the patient feels a bulge in the lower vagina or the cervix protruding through the vaginal introitus.
Identification of concomitant pelvic defects before surgery facilitates simultaneous repair of other defects and minimizes the chance for recurrence.
Assessment of all pelvic floor defects are critical to the evaluation.
A sexual history is crucial as noting voiding difficulties and urinary frequency, urgency, or incontinence.
Advanced prolapse may contribute to lower urinary tract dysfunction, including hydronephrosis and obstructive nephropathy.
Urinary retention is also common for patients with uterine prolapse because they often have associated descent of the anterior vaginal wall.
The kinking of the urethra may cause obstructive voiding and urinary retention.
A medical history of obesity, asthma, or long-term steroid use may contribute to prolapse or urinary incontinence.
Physical evaluation is essential for noting pelvic floor relaxation include and classification systems: stage I is defined as descent of the uterus to any point in the vagina up to 1 cm proximal to the hymen; stage II, as descent from 1 cm proximal to the hymen, to the hymen, or up to 1 cm distal to the hymen; stage III, as descent beyond 1 cm distal to the hymen; and stage IV, as total uterine prolapse or uterine procidentia.
The patient is evaluated in both the lithotomy and standing positions, during relaxation and maximal straining.
With significant anterior vaginal wall prolapse, cystocele, it is important to exclude the development of postoperative potential incontinence prior to management of uterine prolapse.
This unmasking of urinary incontinence is a result of a possible unkinking of the urethra with the prolapsed reduced.
Up to 30% of patients may become incontinent after surgical repair.
Patients may benefit from an anti-incontinence procedure performed concomitantly with the uterine prolapse surgery.
The primary management of severe UP is surgical.
Surgical repair should consider operative risk, coital activity, and vaginal canal anatomy and other risks:
Medical condition and age
Severity of symptoms
Patient’s choice
Patient’s suitability for surgery
Presence of other pelvic conditions requiring simultaneous treatment, including urinary or fecal incontinence
Presence or absence of urethral hypermobility
Presence or absence of pelvic floor neuropathy
History of previous pelvic surgery
In the supine position, the upper vagina is almost horizontal and superior to the levator plate.
The uterus and apical vagina are actively supported by the levator ani; passively supported by the endopelvic fascia, which is the uterosacral-cardinal ligament complex, the pubocervical fascia, the rectovaginal septum and their attachments to the pelvis and pelvic sidewalls through the arcus tendineus fascia pelvis.
The levator ani muscles are fused posteriorly to the rectum and attach to the coccyx.
The genital hiatus is the perforation on the pelvic floor through which passes the urethra, vagina, and rectum.
Contraindications to surgical correction of uterine prolapse are based on the patient’s comorbidities and ability to tolerate surgery.
Patients with mild UP do not require surgery because they are usually asymptomatic.
Pregnancy and vaginal delivery after prolapse surgery may require additional surgical repair for recurrent pelvic organ prolapse.
Contraindications to uterine preservation surgery include: uterine fibroids, history of cervical dysplasia, postmenopausal vaginal bleeding, abnormal menstrual bleeding, hereditary nonpolyposis colonic cancer, familial cancer, BRCA positive, current or past history of selective estrogen receptor modulators or any patient who cannot comply with routine gynecologic surveillance.
Patients with mild uterine prolapse are usually asymptomatic and do not require therapy.
Symptomatic patients initially opt for conservative management.
Pessaries may be used in patient’s who are poor surgical candidates, or in those opposed to surgery.
Pelvic exercises, Kegel exercises, are included in the nonsurgical management of uterine prolapse.
Topical estrogen is important in the conservative management.
The primary management strategy for severe UP is surgery.
Surgical plans should consider surgical risks, coital activity, and normal vaginal anatomy, and must be tailored to the individual patient.
Considerations include whether the operation is performed abdominally, vaginally, or laparoscopically and whether a hysterectomy should be performed.
While a hysterectomy is not necessarily for surgical repair, it is often removed to provide better access to the uterosacral, cardinal, sacrospinous, and anterior sacral ligaments.
Kegel exercises performed routinely can improve pelvic floor muscle tone and stress urinary incontinence, but no evidence indicates that improvement of pelvic floor muscle tone leads to regression of uterine prolapse.
Vaginal support by pessaries is a useful management tool for conservative treatment of uterine prolapse.
Pessary use is contraindicated with acute pelvic inflammatory disease and may be associated with pain.
Many different types of pessaries are available.
Recurrent vaginitis is a relative contraindication of pessary use and may require removal if it occurs.
An important adjunct is application of topical estrogen to the everted vagina, particularly if signs of hypoestrogenism exist.
Sacrocolpopexy may be performed laparoscopically versus open: sacrocolpopexy.: the two groups have similar complication rates and reoperative rates.
Robotic sacrocolpopexy has become more common than laparoscopic sacrocolpopexy, related to advancing technology, better instrument dexterity, 3-dimensional (3D) vision, and forgoing the need for a skilled surgical assistant.
A higher mesh erosion is associated with concomitant total hysterectomy, but no strong evidence shows that performing a supracervical hysterectomy at the time of sacrocolpopexy decreases the erosion rate.
Vaginal surgery is pref2241ed in some cases when the patient desires to avoid any incision, or if the patient has a history of complex abdominal surgeries.
Vaginal surgery with laparoscopic surgery patients have shorter recovery time.
Vaginal approach is pref2241ed for the correction of incontinence to avoid a combined abdominal vaginal approach.
Vaginal procedures to suspend the prolapsed vaginal apex are: sacrospinous ligament fixation, high uterosacral ligament fixation, and iliococcygeus fascia suspension.
Sacrospinous ligament fixation to the vaginal apex is usually performed on the patient’s right side to avoid the rectosigmoid.
Uterine prolapse surgery generally involve a concomitant hysterectomy.
In patients who desire to keep the uterus, or desire a future pregnancy, a uterine preservation surgery may be performed.
Surgical procedures have success rates varying between 70-97%,.
Procedures include:
Vaginal hysteropexy
Sacrospinous hysteropexy
Vaginal mesh hysteropexy
Abdominal sacral hysteropexy
Laparoscopic sacral hysteropexy
Laparoscopic uterosacral hysteropex