PELVIC ORGAN PROLAPSE (481 GYN).ppt
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Transcript PELVIC ORGAN PROLAPSE (481 GYN).ppt
PELVIC ORGAN
PROLAPSE
Dr. Hazem Al-Mandeel
481 GYN
Department of Obstetrics & Gynecology
Objectives
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To define pelvic organ prolapse
Recognize pelvic anatomy
Determine the Pathophysiology
Discuss the predisposing factors
Understand the grading systems
Be aware of the options of management
Pelvic Organ Prolapse
• Is the descent of the pelvic organs as a
result of the loss of muscular and fascial
structural support .
Anatomic Supports
• Muscular : Levator Ani (Pelvic Floor Ms.)
• Ligaments : Uterosacral-Cardinal Complex
• Fascial : Endopelvic (Pubocervical &
Rectovaginal)
Levator Ani
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Major structure of pelvic floor
Anterior/posterior orientation
Perforated by urogenital hiatus
Consists of : Pubococcygeus
Iliococygeus
Puborectalis
Coccygeus
Endopelvic Fascia
• Fibromuscular layer
• Local condensations are ligaments
• Principal ligaments are Uterosacral
Cardinal
• Pubocervical and Rectovaginal Fascia
important in specific surgical correction
Pathophysiology
• Direct Trauma to pelvic soft tissues
• Neurological injury
• Connective tissue disorders
Predisposing Factors
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Hereditary (genetic) predisposition
Race: White > Black > Asian
Pregnancy and Vaginal Childbirth
Age and Menopause
Raised intra-abdominal pressure (e.g.:
obesity, cough, constipation, lifting, etc)
• Iatrogenic: surgical procedure
Types of Pelvic Organ Prolaopse
1. Urethra
2. Bladder
3. Uterus/ Vaginal Vault
4. Small Bowel
5. Rectum
6. Perineum
Compartments
• Anterior : Cystocele
Urethrocele
• Middle : Uterine prolapse
Enterocele/vault prolapse
• Posterior : Rectocele
Rectal prolapse
Classification of Prolapse
• Baden Walker (1972)
• Each site graded from 1 – 4
• POPQ: quantifies using specific points
• Measured relation to the hymenal ring
• More widely used
Symptoms of Prolapse
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Pelvic pressure
Pelvic pain
Feeling of a “lump”
Back pain
Urinary dysfunction
Bowel dysfunction
Complications of Prolapse
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Bleeding
Infection
Recurrent UTI’s
Urinary obstruction
Renal failure
Associated conditions
• Urinary Incontinence : Stress
Urge
Mixed
• Fecal Incontinence : sphincter injury
Options of Management
• No Treatment ( pelvic floor exercise)
• Conservative: such as
Physiotherapy or Pessary
• Surgical Treatment
Aims of prolapse surgery
• Alleviate symptoms
• Restore normal anatomy
• Restore normal visceral function
• Avoid new bladder or bowel symptoms
• Preserve sexual function
• Avoid surgical complications
Classisfication of prolapse
surgery
• Vaginal
• Abdominal
Primary
Primary
Vaginal hysterectomy
Paravaginal repair
Anterior/Posterior repair
Hysteropexy
Secondary
Sacrospinous fixation
Iliococcygeus fixation
Uterosacral fixation
• Laparoscopic
All of the Abdominal
procedures +/reinforcement
Secondary +- reinforcement
Sacrocolpopexy
Uterosacral/Sacrospinous
fixation
Recurrent+/- reinforcement
Synthetic mesh/autologous/
donor/Xenograft
Conclusions
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Pelvic organ prolapse is common
Results from injury to soft tissue and nerves
Childbirth most significant association
Treatment requires understanding of anatomic
relationships
• Treated with a combination of physio/pessary and
often complex surgery