Standard Treatment Guidelines For Pelvic Organ Prolapse

Genital prolapse is a common gynecological operative problem. It can occur at any age, but is more common in multipara as a result of injury to pelvic floor muscles and fascia during childbirth and age related estrogen deficiency in postmenopausal women. In young age and nulliparous women it may be related to collagen deficiency or congenital elongation of cervix.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Pelvic Organ Prolapse. Following are the major recommendations :

Definition

Pelvic organ prolapse is the downward displacement of one of the pelvic organs from its normal location. All forms of prolapse are described in relation to the vagina:

Anterior compartment prolapse

 Cystocele: involves proximal 2/3rd of anterior vaginal wall with descent of bladder

 Urethrocele: involves distal 1/3rd of anterior vaginal wall with descent of the urethra

Posterior compartment prolapse

 Rectocele: involves proximal 2/3rd of posterior vaginal wall with descent of rectum

 Perineal Descent: Defect in perineal body

Central compartment/Apical Prolapse

 Uterine prolapse: descent of the uterus and the vagina along with it

 Vault prolapse: descent of the vaginal apex

 Enterocele: herniation of small bowel loops along with descent of pouch of douglas

When To Suspect / Recognise :

The following history should arouse a suspicion of pelvic organ prolapse:

 Vaginal bulge/ Protrusion - Reducible//irreducible

 Pelvic discomfort:

- weakness perineal region/ dragging- bearing down sensation

- low back ache relieved by lying down

 Urinary symptoms:

- Stress incontinence

- Frequency/ urgency/ nocturia

- urinary retention/ incomplete voiding

 Defecation problems

- Difficulty in emptying rectum, tenesmus, splinting

- Incomplete evacuation of the faeces

- Fecal Incontinence

 Sexual Function/ dyspareunia

 Vaginal discharge - leucorrhoea, blood stained discharge

Systemic symptoms of precipitating diseases such as chronic bronchitis, asthma, constipation, abdominal mass, ascites etc. should be asked for.

Examination Of The Patient

General Physical examination

• BMI

• Gait

Abdominal examination

• mass per abdomen/free fluid, organomegaly, hernial sites

Neurological examination (S2-4)

• Bulbocavernous / anal wink reflex

Local examination

Patient should be asked to hold urine to demonstrate SUI, and examination can be made in dorsal lithotomy/standing position depending upon the prolapse severity

• Perineum: scars/introital laxity

• Prolapsed part: location, ulceration, growth, pigmentation, keratinization

• Rugosities, sulci

Per-speculum (P/S) Examination

• Ask the patient to strain and visualise the entire prolapse

• Note the type and degree of prolapse in all segments (anterior, posterior, central)

• In anterior segment prolpase, differentiate if it is paravaginal/ central

• Check for cervical changes

- elongation and hypertrophy of cervix, atrophy

- decubitus ulcer

- keratinisation

- discharge – colour/blood stained

• Measure the size of introitus and utero-cervical length

Per-vaginum (P/V) Examination

• The prolapsed part is reduced and bimanual examination performed

• Uterus size , mobility any other palpable mass is noted

• Tone of levator ani and Integrity of perineal body is noted

• Occult SUI observed if any

Rectovaginal examination

• Help differentiate between enterocele and rectocele

Differential Diagnosis :

- Local mass/ cysts arising from vagina, Gartner’s cyst

- Fibroid polyp

- Chronic inversion of uterus

Situatin 1 (Non-metro with limited resources)

Diagnosis

- Diagnosis is clinical, confirmed by P/S, P/V, and rectovaginal examination.

Investigations

Routine Investigations

1. CBC, blood grouping and RH typing

2. FBS, PPBS

3. Blood urea, serum creatinine

4. ECG, chest X-ray

5. Urine- R/M and C/S ith limited resources)

Special Investigations

1. USG of abdomen and pelvis to rule out associated pelvic pathology and renal problems due to pressure effect on ureter

2. Papanicolou smear

3. Endometrial aspiration and ECC (if abnormal uterine bleeding)

4. Cervical or ulcer biopsy is done when malignancy is suspected

5. IVP – where kinking of ureter is suspected in long standing cases and residual volume of urine is more than 100 ml

Treatment Approach

1. Non-surgical Management

a. Physiotherapy

b. Vaginal Pessaries

2. Surgical

Physiotherapy

- Useful in minor degrees of uterovaginal prolapse

- During 6 months following delivery

• PFMT (Pelvic Floor Muscle Training) - Kegel’s exercise – Patient is taught to voluntarily contract the levator ani muscle and external anal sphincters and hold for 5 seconds each, 15-20 times per session, three sessions a day.

• Vaginal cones of successively increasing weights 20 to 100 gms can be used to hold inside for 15 minutess.

Pessary Treatment

It is non-surgical and palliative and can be used in following situations:

• Patients awaiting surgery/ to help healing of decubitus ulcer

• Associated medical disorders contraindicating surgery

• Refusal of surgery

• Pregnancy

Types of pessary: depending on availability one can use

• Support pessaries (Ring, Hodge)

• Space occupying type (Donut, Gelhorn)

Surgery

Indications of Surgery

• Stage I & II prolapse, if symptomatic e.g.,

– Small cystocele with significant SUI

– Constant dragging sensation due to cervical descent

– Small rectocele with definite pocket on P/R and splinting is required by the patient to defecate

• Stage III/ IV prolapse even if asymptomatic

– As risk of generally obstructive voiding leading to post void residual urine and recurrent UTI

– Ureteral kinking and dilatation may lead to impaired renal function

Pre Operative Preparation

1. Vaginal tampoons to reduce the prolapse and replace the organ back. It helps to prevent kinking of ureter and congestion of organs and increase the blood flow.

2. Estrogens (oral/local) if atrophic vagina

3. Correction of anemia if present

4. Treatment of UTI if present

5. Treat diabetes and hypertension if present

6. Treat other systemic infection if present

7. Enema (bowel evacuation night before surgery)

8. Prophylactic antibiotics

Factors determining the choice of surgery

Type of operation selected depend upon

• Age

• Life style

• Which symptoms and related pelvic floor disorders are most bothersome for her

• Patients desire to preserve menstrual and reproductive function

• Her desire to have sexual function

• Her preferred route of surgical access

• Degree, type, and components of prolapse

•Co-existing adnexal/ uterine pathology eg. TO mass, myomas, ovarian tumors

• Coexisting medical and surgical conditions

• Previous history of pelvic surgery

Surgical Options

Anterior Compartment Defect:

- Anterior colporraphy

- Para vaginal repair

Posterior Compartment Defect:

- Posterior colporraphy and colpoperineorraphy

- Site-specific repair of posterior vaginal wall defects

Central Compartment Defect: Choice of operations in this defect is varied:

Vaginal

- Fothergill’s repair and Shirodker’s modification of Fothergill

- Posterior culdoplasty and vault suspension with or without vaginal hysterectomy

- Sacrospinous fixation with or without vaginal hysterectomy

- Colpocleisis if patient does not desire coital function

Abdominal

- Abdominal sling operations (Shirodker, Purandre)

- Abdominal Colposacropexy with or without Hysterectomy

Referral Criteria

Patients with following high risk factors should be referred to higher centers:

1. Previous history of pelvic surgery

2. Presence of urinary or fecal incontinence

3. Presence of urethral hypermobility

4. Presence of pelvic floor neuropathy

5. Co morbid medical conditions

Situation 2 (Metro situations where advance technology is available)

Diagnosis

Diagnosis of POP can be made as in situation 1.

However, a Pelvic Organ Prolapse Quantification (POPQ) system can be used to quantify prolapse to have a uniform internationally used terminology. This system quantifies prolapsed based on the topographic position of six defined vaginal points: 2 anterior, 2 apical & 2 posterior with measurements of Genital Hiatus (GH), Perineal Body (PB), and Total Vaginal Length (TVL). It is a useful tool to enhance communication among clinicians/ researchers, to follow objectively changes in an individual patient over time, and to assess the success and durability of various surgical and non-surgical treatments.

Investigation

Tertiary centres can use imaging procedures like cystourethrography, perineal ultrasound, MRI studies, pelvic neuro-muscle physiology testing with concentric needle/ single fibre electromyography, if available, for identification of discrete fascial defects to plan appropriate surgical strategy.

Treatment

Tertiary centers can use

 Laparoscopic approach for

- vaginal vault suspension

- paravaginal repairs

 Mesh augmented prolapsed repair in following situations:

- Nonexistent or suboptimal autologous tissue

- Need to augment weak or absent endopelvic tissue

- Connective tissue disorder

- Unavoidable stress on the repair (eg, chronic lifting, chronic obstructive pulmonary disease, chronic straining to defecate, obesity)

- Need to bridge a space such as sacral colpopexy

- Concern about vaginal length or caliber

- Denervated pelvic floor

- Recurrent prolapse