The descent of one or more of the anterior vaginal wall, posterior vaginal wall, cervix or apex of vagina/vaginal vault
Downward displacement of pelvic organs, resulting in protrusion of the uterus and/or different vaginal compartments and their surrounding organs, such as bladder, rectum or bowel.
Classification
Anterior compartment
- Descent of anterior vaginal wall and usually bladder
Apical
- Descent of the uterus and cervix, or vaginal cuff after hysterectomy
- May include small intestine (enterocele) within peritoneal sac
Posterior compartment
- Descent of posterior vaginal wall and usually rectum – may also include small bowel or uterus
Procidentia
- Total vaginal eversion with complete uterine or vaginal cuff prolapse
Epidemiology
- Very common in ageing – asymptomatic prevalence as high as 30 – 60 % in women over 50.
- Symptomatic prevalence around 5 %
- Anterior compartment most often affected > posterior > apex.
- However, as severity of anterior prolapse increases, likelihood of concomitant apical prolapse increases also.
- Minimal progression over time seems to be the norm in surveilled patients.
Risk factors
- Age
- Parity (vaginal delivery +)
- Bigger children
- Collagen disorders
- Family history
- Hysterectomy
- Chronic cough
- Obesity
- Smoking
- Constipation
- Race – Caucasian/Hispanic
Pathophysiology
Anatomic support of pelvic organs in women provided by:
- Endopelvic fascia and ligaments
- Uterosacral and cardinal ligaments most important ligaments
- Perineal membrane
- Levator ani muscle (puborectalis, pubococcygeus, iliococcygeus) – this is the primary support
Prolapse occurs with weakness in any of the supports.
Pelvic organs prolapse through the urogenital hiatus – opening of levator ani muscles through which urethra, vagina and rectum pass.
- Urogenital hiatus widens with trauma or denervation
If pelvic floor musculature is damaged, as in childbirth, the ligamentous and fascial attachments become much more important.
- These ligaments weaken with ageing, as well as trauma and chronic straining.
Loss of level 1 support (uterosacral and cardinal ligaments, paracolpium and parametrium) leads to apical prolapse.
Loss of level 2 support (paravaginal fascial attachments to ATFP and levator ani white line) lead to anterior prolapse generally.
Symptoms
Presence of sensation of a vaginal bulge is most specific symptom
Pelvic discomfort or pressure
Need to reduce prolapse to pass urine or open bowels
Vaginal discharge or spotting
Dyspareunia
Urinary and bowel symptoms must be explored, but:
- Poor correlation between these symptoms and severity of prolapse – obstructive urinary symptoms and splinting for defecation main reliable ones
Other salient points on history:
- Level of bother – guides treatment
- Presence of SUI now or previously – as cystocele progresses, SUI may be ‘masked’ due to kinking of urethra
- Sexual function and ongoing plans for sexual activity
- Previous surgery
- Gynae-oncological risk factors – abnormal or post-menopausal bleeding, cervical screening
- Symptoms markedly increase when prolapse is beyond hymenal ring.
Examination and grading
General examination including habitus and frailty.
Female pelvic exam:
- External exam – oestrogenisation (pallor, loss of labial and vulvar fullness, no moisture, caruncle)
- Urethra – stenosis, caruncle, prolapse
- Periurethral – diverticulum, glands, abscesses, malignancy
- Exclude pelvic mass / bimanual exam
- Pelvic floor assessment – tenderness, pain
- Incontinence – cough with a full bladder, standing and supine, prolapse reduced if needed
Assess for prolapse:
- Warmed lubricated half-speculum
- Examine all compartments – anterior, posterior, apical ; with and without straining
- Assessment standing also
Baden-Walker classification
Practical and easy, but less rigorous, some inter-observer reliability and lacks detail.
- Grade 1 – halfway to hymen
- Grade 2 – at level of hymen
- Grade 3 – halfway past hymen
- Grade 4 – maximal
POP-Q
- Precise, objective system
- Defines POP relative to fixed reference point – hymen
- Prolapse should be recorded at maximal strain
- Stage determined by most distal component
- Measurements are in cm
- Hymen = 0, below the hymen is positive, above the hymen is negative
- 3 measurements (gh, pb, tvl) at rest, 6 points at maximal prolapse
A = fixed point which is normally 3 cm proximal to hymen
B = most distal point of prolapse
a = anterior
p = posterior
Aa = anterior vaginal wall 3 cm proximal to hymen – roughly urethrovesical junction
Range is – 3 to + 3. Is usually – 3 in normal. Maximal prolapse be maximal + 3.
Ba = most distal point of anterior prolapse
Range is – 3 in normal, to as high as the C measure in procidentia.
Ap = posterior vaginal wall 3 cm proximal to hymen
Range is – 3 in normal to + 3 is maximal prolapse
Bp = most distal point of posterior prolapse
Range is – 3 in normal, to C maximum
C = most distal edge of cervix or vaginal cuff, measurement relative to hymen
e.g. – 7 or – 8 in normal setting
D = posterior fornix of cervix / pouch of Douglas, roughly level of uterosacral attachment
e..g usually one less than C approximately. Can’t be measured if hysterectomy.
gh = distance between middle of urethra and posterior hymenal ring (about 3 usually)
pb = distance from posterior genital hiatus to mid anus (about 3 usually)
tvl = length of vagina from posterior fornix to hymen, when C/D are fully reduced at rest (about 7 – 9)
POP-Q stage overall defined as below – 1 to 4
Ref – Neurourol. Urodynam. 36:10–34, 2017 –
Incontinence and prolapse
- Approximately 40 % of patients with prolapse describe SUI, and up to 70 % may demonstrate it at UDS.
- Occult SUI can often be ‘unmasked’ with prolapse reduction.
- Concurrent ‘prophylactic’ Burch colposuspension at time of sacrocolpopexy reduced SUI rates post-operatively.
- Consider UDS prior to any intervention if any history of urinary symptoms.
- Simple flow rate and PVR should always be assessed at a minimum.
Concomitant sling?
- NNT is 2 for symptomatic or urodynamic SUI, 6 – 9 for occult SUI, and > 12 for no SUI.
- SUI rates lower with combined procedure, but at cost of voiding dysfunction rates being higher and other adverse effects.
- EAU – offer simultaneous surgery if symptomatic, if asymptomatic or occult warn them about risk of developing de novo SUI but benefit of combined ‘prophylactic’ procedure may be outweighed by risk.
Management options
The goal of management is to restore the normal anatomy and function of the vagina and pelvic supports, urinary and GI tract.
Options for all prolapses:
- Conservative / observation
- Pessary
- Physiotherapy
- +/- topical oestrogen
Surgical principles:
- Fix all affected compartments at same time (especially apex)
- +/- anti-incontinence procedure
- How to define success? patient reported outcomes – pre-op consent and counselling crucial
- Anatomical success ≠ patient success and vice versa
- Pre-operative standardised information sheets useful
Anterior prolapse:
- Anterior fixation
- Lithotomy, IDC, weighted speculum, Lonestar
- Hydrodissection with marcaine and adrenaline
- Midline vaginal incision – apex of the defect to 1.5 cm from meatus
- If concurrent sling, stop 3 cm from meatus, and do separate mid urethral incision for sling
- Dissect vaginal wall off pubocervical fascia and expose defect with Metz – tips of scissors outwards
- Plication interrupted 2-0 PDS sutures placed and then sequentially tied whilst bladder reduced
- Excess anterior vaginal wall can be trimmed then closed with absorbable suture
- Cystoscopy and passage ureteric catheter / view jets
- Packing
Above technique is for central defect – can add para-vaginal repair for lateral defects.
Risks:
- De novo OAB / SUI
- Bleeding – rare
- Bladder or ureteric injury – rare – check with cystoscopy prior to finishing
- Dyspareunia
- Change in bowels / constipation
- Recurrence / failure – 20 %
- No improvement in symptoms
For level 1 / apical prolapses:
- Abdominal sacrocolpopexy
- Open/lap/robot
- Gold standard
- Mesh often used
- Transvaginal
- Sacrospinous ligament fixation (higher rates anterior recurrence)
- Uterosacral ligament suspension
- Ileococcygeus suspension
- Vaginal hysterectomy
- Colpoclesis – obliterative
- Very effective but preclude sexual intercourse
- Useful for elderly, frail
Sacrocolpopexy:
Indicated especially in active young women – maintains functional vaginal length
- Lower midline or Pfannenstiel, with vagina accessible, IDC, consider ureteric caths
- Open peritoneum and pack away small bowel, pack sigmoid to left, exposing sacral promontory (medial to right ureter)
- Incision of posterior peritoneum over sacral promontory – care to avoid veins and middle sacral vessel
- Identification of white anterior longitudinal ligament
- Place 3 x 0-prolene sutures in ALL for use later
- Sponge stick in vagina, and dissection of anterior vaginal wall off bladder (vesicovaginal space)
- T or Y shaped mesh – short arm tacked to vaginal apex with interrupted 2-0 prolene, then long arm placed on sacral with pre-placed ligament sutures
- Peritoneum over sacrum closed
Risks:
- Bleeding
- Dyspareunia
- Bladder, ureteric, colonic injury
- Ileus
- DVT/PE
- Mesh erosion – 3 %