Pelvic Organ Prolapse Case File

Pelvic Organ Prolapse Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 33

A 55-year-old G3P3 woman complains of a 1-month history of pelvic pressure and feeling as though there is “something falling out of my vagina.” She underwent a total abdominal hysterectomy 10 years ago for symptomatic uterine fibroids. She had three vaginal deliveries. She denies other medical problems. She has no urinary incontinence or dysuria. On examination, her blood pressure (BP) is 120/70 mm Hg, heart rate (HR) is 90 beats per minute (bpm), respiratory rate (RR) is 12 breaths per minute, temperature is 98°F (36.6°C), height is 5 ft 1 in, and weight is 160 lb. Her breasts are nontender and without masses. Her heart and lung examinations are normal. On pelvic examination, her external genitalia are somewhat atrophic but without lesions. At the introitus, a mucosal bulging is seen, which increases in size with the patient bearing down. This mass is reducible upon digital pelvic examination. Upon inspection with one blade of the speculum, both the anterior vaginal wall and posterior vaginal wall show no evidence of bulging. There are no adnexal masses. The physician places a cotton tip applicator into the urethra, but there is no movement of the applicator with Valsalva. On rectal examination, there is normal sphincter tone.

» What is the most likely diagnosis?

» What is the underlying etiology?

» What are the options for therapy?

ANSWER TO CASE 33:

Pelvic Organ Prolapse                                           

Summary: This 55-year-old G3P3 woman, who underwent a total abdominal hysterectomy previously, has a 1-month history of pelvic pressure and a sensation of “something falling out of her vagina.” On examination, there is vulvar atrophy. There is a mucosal bulging through the introitus. The remainder of the pelvic examination including the rectal examination and Q-tip test is normal.

• Most likely diagnosis: Vaginal vault prolapse.
• Underlying etiology: Enterocele with small bowel in hernia sac behind the vaginal cuff.
• Options for therapy: Pessary device or surgical fixation of the vagina to a sturdy structure such as the sacrospinous ligament, the uterosacral ligaments, or the sacrum.

ANALYSIS

Objectives

1. Understand the anatomical support of the pelvic organs provided by the pelvic diaphragm and endopelvic fascia.
2. Describe the types of pelvic organ prolapse (POP) based on location: cystocele (anterior), enterocele (central), rectocele (posterior), paravaginal (lateral).
3. Describe the symptoms of the various types of POP defects and treatment options.

Considerations

This 55-year-old patient has a sensation of something falling out of the vagina. She has had three vaginal deliveries and a total abdominal hysterectomy in the past, both of which are risk factors for developing POP. On examination, the vaginal cuff is noted at the introitus. Examination of the anterior compartment (bladder) is normal in support, including Q-tip test. If the urethra were not well supported, the finding of urethral hypermobility might be present causing the urethral Q-tip to rotate through a large angle on Valsava. The posterior compartment is also well supported (rectum). There is no mention of the lateral support. Almost inevitably, an enterocele is present associated with vaginal vault prolapse. It is unlikely that conservative measures, such as pelvic muscle strengthening exercises, will alleviate this patient’s symptoms. This patient is overweight at 160 lb. Some studies suggest that a 10% decrease in weight may significantly decrease prolapse symptoms. Thus, this patient should be counseled regarding weight loss, which may alleviate symptoms, or at the least, reduce surgical risks and make the procedure technically easier to accomplish. Therefore, the best treatments include either pessary, which is a synthetic device used to act as a “hammock” to suspend the pelvic organs, or surgery. Surgical repair includes dissection and ligation of the hernia sac associated with the enterocele. Fixation of the vagina is then achieved to a sturdy structure such as the sacrospinous ligament or the uterosacral ligaments (vaginal approach), or abdominal sacrocolpopexy (fixing the vaginal cuff to the sacrum using a synthetic mesh).

APPROACH TO:

Pelvic Organ Prolapse                                              

DEFINITIONS

CYSTOCELE: Defect of the pelvic muscular support of the anterior vagina allowing the bladder to descend into the vagina. Often the urethra is hypermobile. This is an anterior POP defect.

ENTEROCELE: Defect of the pelvic muscular support of the uterus and cervix (if still in situ) or the vaginal cuff (if hysterectomy). The small bowel and/or omentum descend into the vagina. This is a central POP defect.

RECTOCELE: Defect of the pelvic muscular support of the rectum, allowing the rectum to impinge into the vagina. The patient may have constipation or difficulty evacuating stool. This is a posterior POP defect.

PARAVAGINAL DEFECT: Defect in the levatorani attachment to the lateral pelvic side wall leading to lack of support of the vagina, known as a lateral pelvic defect.

CLINICAL APPROACH

Pelvic organ prolapse has a prevalence of 30% to 50% in parous women with 4% to 8% becoming symptomatic, particularly those over the age of 40 years, and with greater incidence after menopause. The symptoms vary and can include a heaviness or pressure sensation in the pelvis, a bulging mass (central), difficulty voiding or incomplete bladder emptying, urinary incontinence (anterior), constipation or having to use one’s fingers to apply pressure on the vagina as a splint to achieve a bowel movement (posterior), sexual dysfunction or pain with intercourse (see Figure 33– 1).

The pelvic diaphragm, a muscular and ligamentous network, which attaches from the pubic bone to the sacrum to the lateral pelvic side walls acts to support the pelvic organs. The pelvic diaphragm consists of multiple muscles such as the pubococcygeus, puborectalis, and levatorani. The bladder sits on the pelvic diaphragm and defects will lead to its descent from the normal location. Known risk factors for POP include multiple vaginal births, aging, prior pelvic surgery, hysterectomy, constipation, irritable bowel syndrome, genetic predisposition, lack of estrogen, and obesity. Potential, but still debated, risk factors include episiotomy, high birth weight infants, chronic cough, exercise, heavy lifting, and lower education.

Physical examination can be revealing and indicate what type of defect is present. The examination should be conducted with the patient in the lithotomy as well as standing positions. The bladder should be examined for support, with a cystocele noted if it is bulging into the vagina. When the patient bears down, it should be noted whether the bladder moves further downward. Additionally, a cotton applicator tip may be placed into the urethra and the angle of excursion of the Q-tip should be observed at rest and with Valsalva. Hypermobility includes a resting urethral angle > 30° or a maximal angle strain during Valsava > 30°. The rectum should likewise be examined both vaginally and with a rectal examination. The perineal body is often attenuated and weakened with a posterior defect. If the patient has her uterus and cervix, then its position should be noted in relationship to the hymenal ring. With bearing down, the cervix may descend. Various systems are used to grade the degree of uterine prolapse; one such system is to delineate mild (above the hymen), moderate (at the hymen), complete (beyond the hymen). Sometimes the entire uterus is prolapsed out of the patient’s introitus, the so-called procidentia. Women who have had a hysterectomy previously are at risk for vaginal cuff prolapse due to failure to fix the vagina to supporting cardinal or uterosacral ligaments. A paravaginal defect is assessed by palpating the lateral aspects of the vagina for its support and mobility.

Figure 33–1. Note the types of anatomic pelvic organ prolapse such as cystocele and rectocele.

Once the extent and type of POP is discerned, the patient can be counseled about therapy. In general, mild POP defects can be treated with pelvic floor strengthening exercises and observation. More significant defects may be treated by pessary devices, which act as a hammock to support the pelvic structures. Different pessary devices are made for different types of defects (see Figure 33– 2, pessary). Surgical approaches to vaginal vault prolapse from an enterocele include resection of redundant tissue, identification of hernia sac and resection if applicable, and then support of the pelvic muscular defect either with suture to a ligamentous support, or using synthetic mesh. Fixation of the vaginal cuff to the sacrospinous ligament for instance is called a sacrospinous ligament fixation procedure. The use of vaginal mesh has been controversial recently, and its use is generally reserved for large defects with thorough informed consent. Using a synthetic material to fix the vaginal cuff to the sacral bone is called a sacrocolpopexy. Recently, the FDA has issued warnings that synthetic meshes in the vagina may lead to erosion and other complications.

Figure 33–2. Pessary devices.

CASE CORRELATION See also Case 35 (Urinary Incontinence).

COMPREHENSION QUESTIONS

33.1 A 48-year-old G3P3 woman has leakage of urine with coughing and sneezing. She denies dysuria or urinary urgency. Which of the following is likely to be present on physical examination?

A. Hypermobile urethra

B. Rectocele

C. Hypertrophic bladder

D. Paravaginal defect

33.2 A 62-year-old woman complains of constipation and difficulty having bowel movements. She states that she often needs to use her fingers to push her vagina backward to achieve a bowel movement. Her history is otherwise unremarkable. Which of the following is the best treatment for this patient?

A. Hysterectomy

B. Anterior colporrhaphy

C. Posterior colporrhaphy

D. Resection and repair of enterocele

33.3 A 35-year-old woman is undergoing a hysterectomy for uterine fibroids that have been symptomatic and failed medical therapy. The surgeon is attempting to ensure that the patient does not have subsequent vaginal vault prolapse. One step that is taken is to use suture to fix the vaginal vault to the uterosacral ligaments. The patient is also noted to have a spacious cul-de-sac area. Which of the following techniques may be used to further decrease the likelihood of vaginal vault prolapse?

A. Obliteration of the vaginal cavity

B. Fixation of the vagina to the anterior abdominal wall

C. Obliteration of the cul-de-sac

D. Prophylactic pessary

ANSWERS

33.1 A. This patient has symptoms consistent with pure stress urinary incontinence, typically due to the bladder falling out of its normal intra-abdominal position. When she bears down (Valsalva), the pressure to the bladder causes loss of urine. Another component of the urinary incontinence is loss of the vesicourethral angle and hypermobile urethra. The common denominator is probably childbirth, leading to damage of the pelvic support.

33.2 C. This woman has symptoms of a rectocele, which is a posterior vaginal defect. Because the support structure to the rectum is defective, the rectum is impinging into the vagina. When the patient bears down to have a bowel movement, the stool gathers in the pouch toward the vagina, instead of out the anal opening. When the patient splints against the rectum with her fingers, she acts as to alleviate the damaged muscular “endopelvic fascia,” and simultaneous with Valsalva, the stool can be directed toward the anal opening. The surgical repair in this instance is a posterior colporrhaphy consisting of incision of the vaginal mucosa posteriorly, identification of the edges of the endopelvic fascia, and surgical repair of these edges that have separated.

33.3 C. One important risk factor for subsequent vaginal vault prolapse is a very spacious and deep cul-de-sac. A surgical technique of obliterating the culde- sac region is called culdoplasty. For instance, a circumferential sequence of purse-string sutures can be used to suture the cul-de-sac area closed. This procedure reduces the opportunity for the small bowel to push into the vaginal vault and enterocele formation. Caution must be taken to avoid injury to the rectum and the ureter.

    CLINICAL PEARLS    

» Pelvic organ prolapse is very common and is associated with multiparous women over the age of 40 years. » Treatment of POP can entail pessary devices or surgical repair. » Anterior defects lead to cystoceles and possibly urinary incontinence. If conservative treatment fails, surgical treatment includes anterior colporrhaphy, often in conjunction with a midurethral sling for stress urinary incontinence. » Central defects lead to enteroceles and vaginal vault prolapse or uterine prolapse. The treatment is resection of the enterocele hernia sac and fixation of the vagina to secure ligamentous tissue. » Posterior defects may lead to rectoceles and constipation or difficulty having bowel movements. Treatment is surgical repair (posterior colporrhaphy). » Lateral defects lead to lack of lateral vaginal support. Repair is a paravaginal repair, reattachment of the levatorani muscle to its tendinous insertion site of the pelvic side wall.

REFERENCES

American College of Obstetricians and Gynecologists. Pelvic organ prolapse. ACOG Practice Bulletin 85. Washington, DC; 2007. (Reaffirmed 2013.) 

Lentz GM. Anatomical defects of the abdominal wall and pelvic floor. In: Katz VL, Lentz GM, Lobo RA, Gersenson DM, eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Mosby; 2012: 453-474. 

Tarnay CM. Urinary incontinence & pelvic floor disorders. In: DeCherney AH, Nathan L, Laufer N, Roman AS, eds. Current Diagnosis & Treatment: Obstetrics & Gynecology. 11th ed. New York, NY: McGraw-Hill; 2013, Chap. 42, 671-700. 

Tarnay CM, Bhatia NN. Genitourinary dysfunction, pelvic organ prolapse, urinary incontinence, and infections. In: H acker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009:276-289.

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