Pevic Organs Prolapse
With the gradual increase in life expectancy in developed countries over the past century, obstetrician-gynecologists are expected to be familiar with disorders of the elderly population. Pelvic organ prolapse (POP) and urinary incontinence (UI) are common conditions affecting many adult women today.
Pelvic organ prolapse is the abnormal descent or herniation of the pelvic organs from their normal attachment sites or their normal position in the pelvis. The pelvic structures that may be involved include the uterus (uterine prolapse) or vaginal apex (apical vaginal prolapse), anterior vagina (cystocele), or posterior vagina (rectocele). Many parous women may have some degree of prolapse when examined; however, most prolapses are not clinically bothersome without specific pelvic symptoms, and they may not require an intervention.
In this article, the authors discuss the clinical presentation, pathophysiology, evaluation, and management of pelvic organ prolapse.
History of the Procedure
Pelvic organ prolapse and its consequences have been reported since 2000 BC. Hippocrates described numerous nonsurgical treatments for pelvic organ prolapse. In 98 CE, Soranus of Rome first described the removal of the prolapsed uterus when it became black. The first successful vaginal hysterectomy for the cure of uterine prolapse was self-performed by a peasant woman named Faith Raworth, as described by Willouby in 1670. She was so debilitated by uterine prolapse that she pulled down on the cervix and slashed off the prolapse with a sharp knife. She survived the hemorrhage and continued to live the rest of her life debilitated by urinary incontinence. From the early 1800s through the turn of the century, various surgical approaches have been described to correct pelvic organ prolapse.
Pelvic organ prolapse is a defect of a specific vaginal segment characterized by descent of the vagina and associated pelvic organ. Patients may present with varying degrees of prolapse. In the most severe case (complete pelvic organ prolapse), the pelvic organ protrudes completely through the genital hiatus. In such cases of pelvic relaxation, multiple defects are associated in the anterior, lateral, posterior, and apical compartments.
The exact prevalence of pelvic organ prolapse is difficult to determine. However, the lifetime risk of requiring at least 1 operation to correct incontinence or prolapse is estimated at approximately 11%.  About 200,000 inpatient procedures are performed annually in the United States. 
Pelvic floor defects may be created as a result of childbirth and are caused by the stretching and tearing of the endopelvic fascia and the levator muscles and perineal body. Pregnancy itself, without vaginal birth has been sited as a risk factor as well. A study by Handa et al suggests that vaginal birth and operative vaginal birth increase an individual’s risk for urinary incontinence and pelvic organ prolapse 5-10 years after delivery when compared with cesarean delivery without labor. 
Partial pudendal and perineal neuropathies are also associated with labor. Impaired nerve transmission to the muscles of the pelvic floor may predispose the muscles to decreased tone, leading to further sagging and stretching. Therefore, multiparous women are at particular risk for pelvic organ prolapse. Genital atrophy and hypoestrogenism also play important contributory roles in the pathogenesis of prolapse. However, the exact mechanisms are not completely understood. Prolapse may potentially result from pelvic tumors, sacral nerve disorders, and diabetic neuropathy.
Other medical conditions that may result in prolapse are those associated with increases in intra-abdominal pressure (eg, obesity, chronic pulmonary disease, smoking, constipation). Certain rare abnormalities in connective tissue (collagen), such as Marfan disease, have also been linked to genitourinary prolapse.  A thorough evaluation and definition of all support defects is of critical importance because most women with pelvic organ prolapse have multiple defects. 
In a 1999 study of Swedish women aged 20-59 years, Samuelsson and colleagues found that, although signs of pelvic organ prolapse are frequently observed, the condition seldom causes symptoms.  Minimal pelvic organ prolapse generally does not require therapy because the patient is usually asymptomatic. However, vaginal or uterine descent at or through the introitus can become symptomatic. Symptoms of pelvic organ prolapse may include a sensation of vaginal fullness or pressure, sacral back pain with standing, 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. Optimally, surgeons should plan the most appropriate procedures necessary to correct all defects in the same surgical setting. When a patient presents with complaints of pelvic organ prolapse, a detailed history and a site-specific assessment of all pelvic floor defects are critical to the evaluation. Patients are often referred for asymptomatic prolapse. Shull’s axiom that “the asymptomatic patient cannot be made to feel better by medical or surgical therapy” provides good advice.  The gynecologist’s responsibility is to address the individual needs and wishes of the patient.
Quality of life assessment by standardized questionnaires (eg, Pelvic Floor Distress Inventory – short form 20, Pelvic Floor Impact Questionnaire – short form 7, Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire – PISQ 12) are also helpful in determining appropriate treatment. A detailed sexual history is crucial, and focused questions or questionnaires should include quality-of-life measures. Voiding difficulties and urinary frequency, urgency, or incontinence are common symptoms associated with pelvic organ prolapse. If present, these symptoms should be investigated because advanced prolapse may contribute to lower urinary tract dysfunction, including hydronephrosis and obstructive nephropathy. Surgery for the correction of incontinence may also be less successful in patients with pelvic organ prolapse. 
Voiding dysfunction is also common for some patients with advanced degrees of pelvic organ prolapse because they may often have concomitant descent of the anterior vaginal wall. An anatomic kinking of the urethra may cause obstructive voiding and urinary retention. The preoperative evaluation should include determination of the postvoid residual urine volume to exclude obstruction as a consequence of urethral kinking or incomplete emptying secondary to poor bladder contractility.
A thorough preoperative assessment can prevent many postoperative complications. The author has previously reported on a series of patients with significant anterior vaginal wall prolapse who exhibited urinary retention. Each patient underwent preoperative prolapse reduction testing using a pessary. This test was found to have high sensitivity, specificity, and positive predictive value for the postoperative cure of urinary retention. In this series, reconstructive pelvic surgery cured most patients with urinary retention problems. 
Note significant medical history (eg, obesity, asthma, long-term steroid use) that may have contributed to prolapse or urinary incontinence. If possible, attempting to correct some of these problems before any surgical treatment may be wise. Recurrences may be more likely if such conditions are not addressed.
A site-specific physical evaluation is essential. Methods for noting pelvic floor relaxation include (1) the Baden halfway system, (2) the International Continence Society (ICS) classification using the Pelvic Organ Prolapse Quantification (POPQ) system, and (3) the revised New York Classification (NYC) system. [11, 12, 13]
Most clinicians routinely use the ICS classification (POP-Q) system, which is classified as follows:
- Stage 0 – No prolapse
- Stage I – Descent of the most distal portion of prolapse is more than 1 cm above the level of the hymen.
- Stage II – Maximal descent of prolapse is between 1 cm above and 1 cm below the hymen.
- Stage III – Prolapse extends more than 1 cm beyond the hymen, but no more than within 2 cm of the total vaginal length.
- Stage IV – Total or complete vaginal eversion
Evaluate the patient in both the lithotomy and standing positions, during relaxation, and during maximal straining. To perform the evaluation, place a standard double-bladed speculum in the vaginal vault to visually examine the vagina and cervix. The speculum is removed and taken apart, leaving only the posterior blade, which is then replaced into the posterior vagina, allowing visualization of the anterior wall. The monovalve speculum is then everted to view the posterior wall. Note the point of maximal descent of the anterior, lateral, and apical walls in relation to the ischial spines and hymen. Next, place 2 fingers into the vagina such that each finger opposes the ipsilateral vaginal wall, and ask the patient to bear down. After evaluating the lateral vaginal support system, assess the apex (cervix and apical vagina). Repeat the examination with the patient standing and bearing down to note the maximum descent of the uterine prolapse.
Next, grade the strength and quality of pelvic floor contraction, asking the patient to tighten the levators around the examining finger. Assess the external genitalia, noting estrogen status, diameter of the introitus, and length of perineal body. Perform a careful bimanual examination and note uterine size, mobility, and adnexa. Lastly, perform a rectal examination, assessing the external sphincter tone and checking for the presence of rectocele or enterocele.
When the patient has significant anterior vaginal wall prolapse (cystocele), it is important to exclude the development of postoperative potential incontinence (PI) prior to management of pelvic organ prolapse. By definition, PI is the development of incontinence only when the prolapse is reduced. This unmasking of urinary incontinence is a result of a possible unkinking of the urethra with the prolapse reduced. If potential incontinence is not addressed before reconstructive surgery, up to 30% of patients may become incontinent after surgical repair. 
To test for potential incontinence, a cystometrogram is performed, and the bladder is retrograde filled to maximum capacity (or at least 300 mL) with sterile water or saline while the pelvic organ prolapse is replaced and elevated digitally or with an appropriately fitted pessary. If the patient leaks urine during Valsalva or with cough, the patient may benefit from an anti-incontinence procedure performed concomitantly with the pelvic organ prolapse surgery.
This approach of performing adequate testing (urodynamics) prior to management of pelvic organ prolapse (especially during sacrocolpopexy surgery) is supported by several studies.  However, other authors have challenged the accuracy and predictability of urodynamics prior to open sacrocolpopexy (Colpopexy and Urinary Reduction Efforts [CARE] trial) and advocated a prophylactic Burch colposuspension be performed concomitantly with sacrocolpopexy to reduce postoperative development of stress urinary incontinence.  In a recent study of practice questionnaire of American Urogynecological Society (AUGS) members, most clinicians (57%) would not perform a prophylactic anti-incontinence procedure (Burch colposuspension) at the time of sacrocolpopexy, illustrating the existing ongoing debate on the issue of preoperative testing and management of PI. 
Appropriate management of significant pelvic organ prolapse that is bothersome to the patient includes a trial of pessary or surgery. For patients in whom conservative management has failed, a variety of surgical approaches to correct pelvic organ prolapse are available.
When planning the appropriate approach, the surgeon must consider operative risk, coital activity, and vaginal canal anatomy. The following list illustrates variables that must be considered.
Important considerations for nonsurgical or surgical decision making
See the list below:
- Medical condition and age
- Severity of symptoms
- Patient’s choice (ie, surgery or no surgery)
- 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.
Knowledge of the anatomy of the pelvis is essential to understanding prolapse. Teleologic reasoning aids in the understanding of pelvic organ prolapse. The pelvic floor evolved in primates, particularly humans, who as bipeds spend most of their waking hours in the upright position. As the name suggests, 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.
Furthermore, knowledge of the biaxial orientation of the vagina and uterus is critical to understanding the anatomic and functional relationships and to proper surgical restoration of the pelvic supports.
In the supine position, the upper vagina is almost horizontal and superior to the levator plate.  The uterus and apical vagina have 2 principal support systems. Active support is provided by the levator ani; passive support is provided by the condensations of the endopelvic fascia (ie, uterosacral-cardinal ligament complex, pubocervical fascia, 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 the urethra, vagina, and rectum pass.
Contraindications to surgical correction of pelvic organ prolapse are based on the patient’s comorbidities and her ability to tolerate surgery. Patients with mild pelvic organ prolapse do not require surgery because they are usually asymptomatic.
See the list below:
- Urine sample, clean midstream to rule out infection in patients with incontinence and prolapse
- BUN, creatinine, glucose, and calcium recommended in patients with compromised renal function, or if polyuria is present
- Urine cytology in patients with microscopic hematuria to exclude bladder neoplasm.
See the list below:
- If the uterus is to be preserved, ultrasonographic imaging is strongly recommended.
- Some surgeons have used MRI, contrast radiology, and ultrasonography to describe the nature of the support defects. Patients with defecatory dysfunction may benefit from defecating proctography and proctosigmoidoscopy. Colonic transit studies are indicated in patients with motility disorders. Dynamic MRI defecography can be used to provide defecatory and high-quality soft tissue imaging; however, this expensive test has not been shown to change clinical decision making.
See the list below:
- In patients who are planning to undergo LeFort colpocleisis (see Surgical Management of Apical Vaginal Prolapse and Uterine Prolapse section), cervical cytology and either pelvic ultrasonography or endometrial biopsy is recommended to rule out endometrial pathology.
- Urodynamic testing can be considered to evaluate urinary incontinence and to rule out potential incontinence.
- Cystoscopy is recommended for patients with symptoms of bladder pain, hematuria, or urinary urgency/frequency who are not responding to medications.
- Cervical cytology should be considered if cervical screening is not current. (See Cervical Cancer.)
Nonsurgical (conservative) management of pelvic organ prolapse is recommended by both the Agency for Health Care Policy and Research and the ACOG Committee on Practice Bulletins  and should be attempted before surgery is contemplated. Conservative management confers several advantages: it is safe and inexpensive, it is not usually associated with morbidity and mortality, it is minimally invasive, it can lead to a high patient satisfaction, and it may be used for patients awaiting surgery or patients who are not interested in surgical management. Pelvic muscle exercises (PMEs) and vaginal support devices (pessaries) are the main nonsurgical treatments for patients with pelvic organ prolapse.
Pelvic muscle exercises can improve pelvic floor muscle tone and stress urinary incontinence, but in any prospective, randomized trials no evidence indicates that improvement of pelvic floor muscle tone leads to regression of pelvic organ prolapse. 
Vaginal support devices (pessaries) are manufactured from medical-grade silicone and are safe, cost-effective, and minimally invasive options for treating patients with pelvic organ prolapse. A study of pessary use showed that 75% of urogynecologists used pessaries as first-line therapy for prolapse.  Pessary use has few contraindications: lack of patient’s ability to comply with follow-up and instructions (eg, dementia), vaginal fistulas, uterovaginal erosions, and undiagnosed uterovaginal bleeding. An important adjunct is application of topical estrogen prior to pessary use, particularly if signs of hypoestrogenism (atrophic vaginitis) exist. Once the pessary is in place, continued vaginal estrogen cream application (ie, 1-2 times per week) or application of a vaginal estrogen ring once every 3 months is indicated, unless estrogen is contraindicated (ie, estrogen-dependent breast tumors). Vaginal erosions are indications for temporary pessary removal and treatment with topical estrogen.
A study by Cheung et al found that prolapse symptoms and quality of life were improved in women with symptomatic stage I to stage III POP using a vaginal pessary in addition to pelvic floor exercises. 
Many different types of pessaries can be used. Pessaries may be classified as supportive (eg, ring), or space-occupying (eg, doughnut, cube, Inflatoball). In 2000, a survey of the American Urogynecologic Society (AUGS) members showed that the most common pessaries in use today are the ring (with or without support), Gellhorn, doughnut, and cube. Other types are the Inflatoball (Milex Products, Inc, Chicago, Ill), and Smith, Hodge, Risser, and Shaatz pessaries.
In one study, the severity of pelvic organ prolapse was associated with the type of pessary that can be successfully fitted.  Thus, ring pessaries were used more successfully with stage II (100%) and stage III (71%) pelvic organ prolapse. The stage IV prolapse was most successfully treated with Gellhorn pessaries (64%). The Smith, Hodge, and Risser pessaries may help retrodisplacement of the uterus and should be used for patients with a well-defined pubic notch and an adequate vaginal width. The smallest pessary that reduces pelvic organ prolapse should be used. A well-supported pessary should not be visible at the introitus, and the patient should not feel vaginal pressure or discomfort while ambulating with the pessary in place. The ring pessary should fit snugly between the posterior fornix and the symphysis pubis. The pessary should not obstruct urinary flow.
A patient who is able to manipulate the pessary on her own may remove the pessary each night and replace it in the morning, or at least 1-2 times per week. If the pessary falls out with Valsalva maneuvers or with abdominal straining (eg, constipation), a larger pessary or a different pessary type may be fitted. Vaginal odor and discharge is common and it may be alleviated by the use of Trimo-San gel (Milex Products, Inc, Chicago, Ill). Vaginal bleeding should always be investigated by inspection for vaginal erosions, and endometrial biopsy and Papanicolaou test may be required.
After a successful pessary fitting, 50% of patients will continue to use the pessary beyond the first year of use. The primary reasons for pessary discontinuation, which occurred in 40% of patients, were patient inconvenience and inadequate relief of symptoms. In the author’s experience, women with more severe degrees of pelvic organ prolapse (stages III-IV) are more likely to continue pessary treatment and women with concomitant stress urinary incontinence symptoms and mild-to-moderate pelvic organ prolapse (stages I-II) are more likely to undergo surgery.
The recommended management strategy for severe symptomatic pelvic organ prolapse for patients who failed or refused a trial of pessary management is surgery. A variety of surgical approaches are available to correct pelvic organ prolapse.
Surgical Management of Anterior Vaginal Wall Prolapse
A thorough history and physical examination should distinguish a central or a transverse vaginal defect from a paravaginal defect. However, most patients have a combination of these.
The purpose of anterior vaginal repair, or anterior colporrhaphy, is to plicate the vaginal muscularis fascia overlying the bladder (pubocervical fascia) to diminish the bladder and anterior vaginal protrusion. Anterior colporrhaphy is indicated especially for patients with a central vaginal defect. The vaginal mucosa is incised in the midline, and then it is sharply dissected away from the pubocervical fascia laterally to the inferior pubic ramus. Several layers of interrupted delayed absorbable sutures are placed laterally on the pubocervical fascia in a mattress fashion. Excess vaginal mucosa is trimmed and the resulting vaginal mucosa is closed with running or interrupted sutures.
Paravaginal defect repair may be performed laparoscopically, abdominally, or vaginally. In this procedure, the retropubic space of Retzius is entered to reattach the anterolateral vaginal sulcus with its overlying endopelvic fascia to the obturator internus and pubococcygeus muscles and fascia at the level of the arcus tendineus fascia of the pelvis (ATFP) bilaterally, and thus restores the lateral vagina to its normal place of attachment (DeLancey’s level II support).
For a discussion of mesh augmented vaginal repairs, see Future and Controversies
Surgical Management of Posterior Vaginal Wall Prolapse
Posterior vaginal repair (posterior colporrhaphy) is performed to repair the posterior vaginal defect, usually a rectocele. Traditionally, posterior colporrhaphy has been performed via a transvaginal approach and involves posterior colpoperineorrhaphy with levator ani muscle plication. In this surgery, the rectovaginal fascia is plicated in the midline, thus eliminating the posterior vaginal protrusion, and the excess vaginal mucosa is excised and repaired with absorbable sutures.
Defect-specific, or site-specific defect repair, was introduced by Richardson in 1972. It attempts to identify and repair specific areas of deficiency in the rectovaginal fascia. This type of repair does not attempt to plicate the levator ani fascia and, thus, may be associated with a lower incidence of postoperative morbidity. Transanal repair is performed mainly by colorectal surgeons. This technique involves plication of the rectal muscularis fascia and its attachment to the bilateral levator ani muscles. Transvaginal posterior vaginal repair is generally recommended over transanal repairs (see Outcome and Prognosis). Posterior vaginal repair using synthetic (eg, Vicryl) or allogenic materials have variable results and have not been shown to improve surgical outcome.
Surgical Management of Apical Vaginal Prolapse and Uterine Prolapse
The main abdominal operations performed for apical vaginal prolapse and uterine prolapse are abdominal sacral colpopexy and total abdominal hysterectomy with high uterosacral ligament suspension. These operations allow fixation of the upper vagina or the uterus to the sacrum, with the help of grafts and sutures through the anterior sacral ligament (presacral fascia) at the level of the sacral promontory or at S1-S2. Biomechanical anatomic studies suggest that the strongest presacral fascia is found at the sacral promontory.  The abdominal approach allows a higher vaginal fixation in the pelvis and provides durable repairs with an adequate vaginal length. Few reports in the literature describe uterine suspension for women who elect to retain their uterus, and no long-term data are available to make this practice a recommendation.
Abdominal approach.View Media Gallery
Sacrocolpopexy repair for apical vaginal prolapse
This procedure may be performed by an open laparotomy or laparoscopic approaches. The graft is sutured to the posterior and anterior vaginal wall after the peritoneum covering the vagina is dissected from the vaginal wall. The peritoneum covering the sacral promontory is incised and the vascular structures are avoided (particularly the common iliac and the middle sacral vessels) by performing careful blunt and sharp dissection. The graft is sutured over the anterior sacral longitudinal ligament over the S2-S3 vertebrae or preferentially over the sacral promontory, thus correcting the apical vaginal prolapse. The peritoneum over the presacral space is closed and the graft is peritonealized to prevent mesh erosions.
A variety of grafts have been used for sacropexy procedures (eg, harvested fascia lata abdominal fascia, cadaveric fascia lata, Marlex, Prolene, Gore-Tex, Mersilene, Vipro-II) with variable success rates (see Future and Controversies section on vaginal mesh). The ideal biocompatible material used should be chemically and physically inert, durable, noncarcinogenic, noninflammatory, readily available, and inexpensive.
The synthetic polypropylene mesh has been shown to be superior to autologous fascia lata.  Multifilament mesh (ie Gore-Tex, Mersilene) has been associated with chronic inflammation that can be detrimental compared to monofilaments, which produce an acute inflammatory reaction and formation of fibrous tissue. Moreover, mesh with large pore size (>75 micrometers) allows ingrowth of fibroblast, collagen and blood vessels, and allows for macrophage and leukocyte infiltration and passage, thus decreasing the chance of mesh infection and mesh erosion. 
Grafts are placed from the vaginal cuff, or the amputated cervical stump to the presacral fascia with permanent suture in a tension-free fashion. The graft is peritonealized and some surgeons obliterate the rectovaginal pouch (pouch of Douglas) to prevent future enterocele.
The Marion-Moschcowitz procedure entails a spiral suture placed around the rectovaginal pouch to close it circumferentially. The Halban procedure involves placement of several sutures in the sagittal plane that close the anterior and posterior leaves of the pouch of Douglas. Whether performing a total hysterectomy at the time of sacralcolpopexy increases the chance of vaginal exposure or erosions is debatable. Erosion rates vary from 6.9-27% with concurrent hysterectomy to 1.3-4.7% with a prior hysterectomy. [29, 30, 31] At this time, no strong evidence shows that performing a supracervical hysterectomy at the time of sacrocolpopexy decreases the erosion rate; however, the authors favor this approach in patients with no evidence of cervical dysplasia.
Vaginal surgery is preferred by many surgeons because the patient may have a shorter recovery time and it may take less intraoperative time compared with abdominal surgery. The most common vaginal procedures to suspend the prolapsed vaginal apex are sacrospinous ligament fixation, modified McCall culdoplasty, iliococcygeus suspension, and high uterosacral ligament suspension.
Sacrospinous ligament fixation
Sacrospinous ligament fixation is usually performed on the patient’s right side to avoid rectum and sigmoid colon injury. The right perirectal space is dissected, and a window is made to expose the coccygeus muscle overlying the sacrospinous ligament on the right side with the help of Breisky-Navratil retractors. The ischial spine is palpated with the index finger and 2 pulley sutures of permanent or delayed absorbable material are placed through the sacrospinous ligament, 2 fingerbreadths medial to the ischial spine to avoid injury to the pudendal neurovascular bundle. In the authors’ cadaveric studies, they found that the location of the pudendal nerve and the sacral nerves that innervate the levator ani significantly varied in the area of the sacrospinous ligament. Their study suggests that a safe and nerve-free zone for placement of the sacrospinous ligament sutures is situated approximately in the middle of the sacrospinous ligament, more than 2.6 cm medial to the ischial spine. 
The passage of sutures through the sacrospinous ligament may be facilitated by a series of instruments that include the long-handled Deschamps ligature carrier, Miya hook ligature carrier,  or the Capio suture-capturing device (Boston Scientific, Natick, Mass). The sacrospinous ligament pulley sutures are then attached to the vaginal vault and tied to pull up the vaginal cuff.
Sacrospinous ligament suspension procedure for apical vaginal prolapse.View Media Gallery
Sacrospinous ligament suspension procedure for apical vaginal prolapse: Following retroperitoneal dissection and exposure of the coccygeus muscle (sacrospinous ligament [SSL] complex), a permanent suture is placed 2 fingerbreadths medial to the ischial spine through the SSL, which is attached to the posterior vagina by a figure-eight stitch. When the stitch is tied, the vagina is drawn up to the SSL at the level of the ischial spine.
Endopelvic fascia repair
Endopelvic fascia repair (or modified McCall culdoplasty) aims to suspend the prolapsed vaginal vault to the endopelvic fascia. The vaginal apex is opened, the enterocele sac is dissected, the redundant sac is excised, and the enterocele is reduced. Next, the bilateral uterosacral ligaments are identified and up to 3 modified McCall sutures are placed to incorporate the posterior vaginal vault, the peritoneum, the uterosacral ligaments, and the endopelvic fascia of the upper vagina and rectum. Sutures are then tied, thus securing the vaginal vault to the upper portion of the endopelvic fascia, and ensuring an adequate closure of the cul-de-sac peritoneum.
Iliococcygeus suspension was describe initially by Inmon in 1963  and has the purpose of suspending the vaginal vault to the fascia of the iliococcygeus muscle in patients with attenuated uterosacral ligaments. Iliococcygeus muscle is a component muscle of the levator ani; it originates from the arcus tendineus levator ani and inserts into the anococcygeus raphe and the coccyx. The procedure is similar to the sacrospinous ligament fixation; however, the securing suture is placed into the iliococcygeus fascia bilaterally 1-2 cm caudad and posterior to the ischial spine.
High uterosacral ligament suspension
High uterosacral ligament suspension aims to suspend the prolapsed vaginal vault bilaterally to the uterosacral ligaments. Similarly to the modified McCall culdoplasty procedure, the enterocele sac is dissected, the redundant sac is excised, and the enterocele is reduced. The uterosacral ligaments are identified, and 2-3 delayed absorbable sutures are placed through the middle portion of the uterosacral ligaments (at approximately the level of the ischial spine) taking care to avoid ureteral injury.The distal portions of the uterosacral ligaments are plicated across the midline with 1-3 permanent sutures to obliterate the cul-de-sac. Each uterosacral ligament suture is then passed through the full thickness of the posterior vaginal wall. The vaginal vault is then closed medial to uterosacral sutures. Tying the vault suspension sutures will suspend the vagina deep into the pelvis, up to the level of the ischial spine. Cystoscopy should be performed at the end of each procedure to rule out ureteral injury.Manchester procedureManchester procedure for pelvic organ prolapse is indicated for patients with anterior vaginal defects, an elongated cervix, no evidence of uterine descent, and those who wish to retain their uterus. This procedure was developed initially to shorten the duration of exposure to general anesthesia and consists of an anterior colporrhaphy, amputation of the cervix, and elevation of the upper vagina using transverse cervical ligament sutures.Other proceduresVaginal obliterative procedures, partial (LeFort) colpocleisis and total colpocleisis, are indicated for patients who are not able to tolerate general anesthesia or long surgical procedures, and who are not contemplating sexual activity. These procedures may be performed under local analgesia with intravenous sedation or local anesthesia. Since the uterus is retained with partial colpocleisis, preoperative uterine evaluation is indicated prior to surgery (see Preoperative Details).With the LeFort colpocleisis, a rectangular portion of anterior and posterior vaginal mucosa is removed. The anterior pubocervical septum is sutured to the posterior rectovaginal septum using Lembert inverting sutures and, as the approximation is continued progressively on each side, the most dependent portion of the prolapse is gradually inverted. A perineorrhaphy is also usually performed to support the inverted vagina and help prevent pelvic organ prolapse recurrence.Total colpocleisis procedures are performed for patients with posthysterectomy vaginal vault prolapse. These procedures do not intend to correct an enterocele since they are both extraperitoneal procedures. Also, these procedures carry risk of postoperative de novo stress urinary incontinence, and thus a concomitant anti-incontinence procedure may be performed in at-risk patients prior to closing the vagina.Preoperative DetailsIn most patients, surgery for pelvic organ prolapse repair is an elective procedure. Preoperatively, a thorough discussion with the patient should lead to patient acknowledgment of the possibility of incomplete resolution or recurrence of pelvic organ prolapse and complications of surgery (eg, injury to bladder, urinary dysfunction, urinary retention, possible need for prolonged catheterization). The vaginal tissue wall may be optimized with vaginal estrogen for 1-2 months prior to the surgery. Women with pelvic organ prolapse and pelvic pain and sexual dysfunction need to be counseled that, while pelvic organ prolapse surgery repairs the anatomic vaginal defect, surgery does not necessarily lead to relief of pelvic pain or improvement of sexual function.The choice of procedure depends largely on the surgeon’s experience and preference, but other factors to consider are the patient’s general health status, degree and type of pelvic organ prolapse, need for preservation or restoration of coital function, concomitant intrapelvic disease, and desire for preservation of menstrual and reproductive function. Patients who wish to retain their uterus and who are not candidates for prolonged general anesthesia (eg, patients with worsening cardiac function), may undergo a Manchester Repair or a LeFort colpocleisis. A Papanicolaou test, ultrasonography, and endometrial biopsy should be performed prior to surgical repair to rule out any pathology.Intraoperative DetailsThe pelvic surgeon’s challenge is to recreate normal anatomy while maintaining normal genitourinary function. Intraoperatively, gynecologic surgeons may reassess the anatomy, noting the strength and consistency of the various support structures (eg, uterosacral ligaments). If these structures are weak, stronger reattachment sites may be used for the correction of the pelvic organ prolapse, such as the sacrospinous ligament or the presacral fascia. In addition, a concomitant culdoplasty may avoid the formation of a future enterocele.Next: Postoperative Details
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