Connective tissue support of the vagina. Level 1 (suspensory support) includes the uterosacral/cardinal ligament. Level 2 support includes the lateral attachment to the levator ani muscles through the arcus tendineus fasciae pelvis and arcus tendineus rectovaginalis. Level 3 support anchors the distal support to the pelvic bone through the perineal membrane with a union of distal support at the perineal body.
At level 1, the support of the uterus and the apical portion of the anterior and posterior vaginal walls is provided primarily by the cardinal-uterosacral ligaments.[2, 3] This mesentery of support originates at the sacrum and the pelvic sidewalls and inserts onto the posterior cervix and upper vagina. With normal support, the vagina is directed dorsally to lie in a horizontal fashion over the levator ani muscles. With increases in abdominal pressure, the vaginal tube is closed and is primarily supported by the pelvic floor muscles (levator ani and coccygeus muscles) rather than connective tissue.
Level 2 includes the support for the midportion of the vagina. This support is provided by the endopelvic fascia attaching the lateral anterior and posterior vaginal walls to the aponeurosis of the levator ani. The proximal half of the anterior and posterior vagina is supported by endopelvic attachment to the arcus tendineus fasciae pelvis. The lateral attachment of the posterior wall diverges dorsally from the arcus tendineus fasciae pelvis in the distal vagina.
Level 3, or distal support of the posterior vaginal wall, is primarily provided by the perineal membrane, superficial and deep perineal muscles, and perineal body. The perineal body resists caudally directed abdominal pressure and provides a physical barrier between the vagina and rectum. The perineal membrane anchors this perineal body laterally and anteriorly to the bones of the pelvis to resist downward movement of the vagina during periods of increased abdominal pressure. Separation of the perineal body from the perineal membrane results in perineal body hypermobility and defecatory dysfunction (Figure 21-2). The perineal body extends cranially to the hymenal ring and is suspended by the levator ani muscles. On magnetic resonance imaging (MRI), the perineal body descends more caudally in women with posterior wall prolapse or with levator defects than controls.[4, 5]
The levator ani muscles provide a sling of support, enclosing the genital hiatus, through which the urethra, vagina, and anorectum pass. In a woman with an intact pelvic floor, the levator ani muscles are in a chronic state of contraction, and the anterior and posterior vaginal walls are in direct apposition. During defecation the increased pressure placed on the posterior vaginal wall is equilibrated by the opposing abdominal pressure on the anterior vaginal wall. There is no stress placed on the connective tissue attachments. In the presence of muscular or neurologic damage to the pelvic floor, the levator hiatus widens and the vaginal canal opens. The increased rectal pressure and distension associated with defecation now places strain on the connective tissue attachments and the fibromuscularis of the posterior vaginal wall.
Epidemiology of pelvic organ prolapse
Some degree of POP is described in 50% of women during a vaginal examination; however, only 3%–9% of women see or feel a bulge at the vaginal opening. The incidence of POP surgery ranges from 1.5 to 1.8 per 1,000 women years with a 12.6% lifetime risk of surgery.[6, 7] The anterior vaginal wall (supporting the urethra and bladder) is the most common site for primary and recurrent pelvic organ prolapse.[6] The risk of surgery peaks in the elderly population of women aged 60–79 years.[6–8]
The US baby boomer population is entering the “elderly” classification, and the number of American women 65 years and older will more than double by 2050. In 1997, 220,000 surgeries were performed for pelvic organ prolapse in the United States.[9] It has been estimated that the workload related to pelvic organ prolapse will increase by 46%–200% by the year 2050 due to the exponential growth in the elderly population.[10]
Risk factors for pelvic organ prolapse
A number of risk factors for the development of POP have been identified. Risks can be differentiated into those that are inheritable, related to trauma, or occur with time (Table 21-1). Birth defects that damage the pelvis (such as bladder exstrophy) and structural components (e.g., collagen) can increase the attributable risk of development of POP and lower the age in which it occurs.[11, 12] Genetic linkage studies have mapped predisposition for the development of POP to the chromosomes 10 and 17.[13] Although genetic linkage studies begin to unveil an important piece of the complexity of POP, age (promotional) and vaginal delivery (trauma) are currently the most important recognized determinants of POP.[8, 14]
| Inheritable | Trauma | Promotional |
|---|---|---|
| Genetics | Childbirth | Aging |
| Pelvic surgery | Obesity | |
| Smoking | ||
| Chronic cough or straining |
History
Women with POP may have symptoms related to the change in anatomy – vaginal pressure or bulging mass – or symptoms may be related to urinary, defecatory, or sexual dysfunction. The severity of prolapse does not necessarily correlate with severity of symptoms.
Most cases of POP are insidious in progression, however prolapse may be acutely identified when the prolapse is perceived to “suddenly” protrude through the vaginal opening. Women with POP frequently describe a bulging sensation that is worsened with prolonged activity in the standing position. This discomfort often improves or resolves with lying down. The protrusion of the vagina beyond the vaginal opening may lead to irritation, dryness, or ulceration of the vaginal skin or cervix.
Bladder symptoms may be related to prolapse of all segments of the vagina. Loss of support at the urethra may result in alteration of the stream or urine (such as spraying) or leakage of urine with cough, sneeze, and activity; this is stress urinary incontinence. As the anterior vaginal wall loses support a mechanical kinking of the urethra may occur. This is more predominant in a setting of a combination of apical and anterior wall prolapse. This mechanical urethral kinking may hinder complete emptying of the bladder resulting in voiding dysfunction (hesitancy, straining, change of position to void), urinary retention, urinary tract infections, and overactive bladder. Digital reduction of the prolapse may be necessary to facilitate complete emptying of the bladder. The mechanical kinking of the urethra may mask symptoms of stress urinary incontinence, which may be unmasked with treatment (pessary or surgery). Posterior vaginal wall bulging (rectocele or enterocele) may additionally compress the urethra and contribute to urinary retention.
Loss of support over the rectum may lead to defecatory dysfunction. Sung et al. reported in a prospective evaluation of 160 women undergoing rectocele repair that 87% had bowel symptoms. The most common symptom was incomplete evacuation (85%) followed by straining (74%), sensation of obstructed defecation (66%) and anal incontinence (63%), and manual splinting (56%).[15] Stool may be trapped in the rectocele and increase the likelihood of fecal incontinence. Many of the defecatory symptoms may be improved with increasing fiber or water intake. Infrequent bowel movements are unlikely to be related to POP and may require a transit study to evaluate for slow colonic transit.
Sexual function is multifaceted in women. This may occur in the setting of POP through an alteration of body image, loss of sensation, discomfort, or fear of urinary of fecal incontinence. Postmenopausal women may have decreased arousal due to vaginal atrophy, and heterosexual women may have partners with erectile dysfunction. A thorough understanding a woman’s goals with treatment of her prolapse with regard to sexual function is important in design of treatment and specific surgical planning (i.e., if the partner has erectile dysfunction, constriction of the vaginal opening should be avoided).
Physical examination
A complete physical examination should be performed in women with POP, including evaluation of skeletal, mental, cardiovascular, abdominal and pelvic systems and organs.
Skeletal/gait
Limitations in mobility can impair a woman’s ability to void or defecate on time. Kyphosis and/or loss of lumbar lordosis will increases the pressure placed on the pelvic floor and may increase the risk for development of prolapse.
Mental status
Mental status includes the degree of consciousness, orientation, comprehension, memory, and speech. Disorders impacting a woman’s mental status include dementia, brain tumors, stroke, and Parkinson’s disease. Mental status may have a significant impact on the ability to obtain an accurate history and limit treatment options.
Cardiovascular/lungs
Congestive heart failure may increase lower extremity edema resulting in nocturia (frequent nighttime voiding) as a woman mobilizes the fluid with her legs up in bed. A chronic cough will increase pressure on the prolapse and may increase the frequency and bother of stress urinary incontinence.
Abdominal
Prior incisions should be noted. POP is thought to be a hernia; therefore, evaluation of the abdomen should include an evaluation for umbilical, ventral, inguinal, and femoral hernias.
Pelvic
The patient is typically examined in the dorsal lithotomy or semirecumbent position. The pelvic examination should start with a thorough examination of the groin for adenopathy and skin lesions. Vulvar dermatoses, such as lichen sclerosis or lichen planus, may impact treatment choice and outcomes (whether pessary or surgical therapy is selected).
Women with neurologic disorders should undergo a focused neurologic examination of sacral nerves 2–4. The patient can be asked to discriminate between sharp and dull sensation on the perineum. Reflex testing includes the bulbocavernosus reflex and anal wink. The bulbocavernosus reflex is contraction of the bulbocavernosus muscles in response to pressure on the clitoris. The anal wink is produced with light touch of the perianal skin eliciting contraction of the external anal sphincter. These reflexes are more useful if present than reflective of neurological damage if absent. They may be difficult to evaluate and are not consistently present even in neurologically intact women.
The vaginal examination includes evaluation of the urethra, uterus, adnexa, and support and health of the vaginal tissue. Abnormal or postmenopausal vaginal bleeding may be related to the uterus (in which case an endometrial sampling may be indicated) or due to ulceration of the vaginal skin. The urethra should be palpated for the presence of a urethral mass (diverticulum, abscess, or carcinoma). Initial evaluation of stress incontinence includes observation of the urethral meatus during a cough to evaluate for leakage of urine during the pelvic examination and an observation for leakage of urine from the urethra. Size, shape, mobility of the uterus and presence of adnexal masses may be determined with a bimanual examination; this may be inaccurate, however, in overweight or obese women.
In many postmenopausal women, vaginal atrophy is present and symptomatic. Atrophy alters the function and appearance of the vaginal skin. Upon speculum examination, the vaginal tissue may appear pale, thin, friable, and display a loss of rugation. Women with symptomatic vaginal atrophy who elect to proceed with treatment of POP (pessary or surgery) should be treated with vaginal estrogen unless a contraindication is present.
Support of each segment of the vagina (urethra, bladder, uterus or apex, rectum, perineal body, genital hiatus, and total vaginal length) can be evaluated through the pelvic organ prolapse quantification system (POPQ) or the Baden-Walker classification (Tables 21-2 and 21-3) (Figure 21-3).[16, 17] The POPQ system is a series of nine site-specific measurements. This system of measurement is easy to learn and has been validated and adopted internationally as a common language to convey support before and after treatment. When women perform a maximal Valsalva maneuver, there is an excellent correlation between the supine and standing positions.[16] Some women lose their ability to bear down effectively during the examination. If the patient is contracting the pelvic floor rather than pushing out, she should be directed to cough vigorously. If the examiner does not visualize the extent of prolapse that a woman describes, examining her in the standing position may allow for a more accurate determination of her prolapse (however, evaluation in this position is much more difficult to accomplish).
| Stage of prolapse | Extent of prolapse (in relationship to the hymen: prolapse above the hymen, negative numbers; prolapse beyond the hymen, positive numbers) |
|---|---|
| Stage 0 | No prolapse (apex can descend as far as 2 cm relative to the total vaginal length) |
| Stage 1 | The most distal portion of prolapse descends to a point less more than 1 cm above the hymen |
| Stage 2 | Maximum descent is within 1 cm of the hymen |
| Stage 3 | Prolapse extends more than 1 cm beyond the hymen but no more than 2 cm of the total vaginal length |
| Stage 4 | Complete eversion of the vagina or descent within 2 cm of the total vaginal length |
* Each compartment is staged, and the total stage is the most related to the highest staged compartment.
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