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Evaluation + Workup

Defining prolapse

• Anterior: bladder, urethra, or intestinal prolapse, most common type of prolapse
• Apical: intestinal, uterine, cervical, or vaginal cuff prolapse
• Posterior: rectum, intestine, or uterine prolapse
• Procidentia: total vaginal eversion

History

• Symptoms: palpable vaginal bulge noted by patient, pelvic pressure, discharge, need to splint (insert fingers and push) for urination/defecation, low back pain
• Urinary symptoms: frequency, urgency, nocturia, incontinence, incomplete emptying
• Poor correlation between symptoms and prolapse severity
• Risk factors: age, increased parity, obesity, prior hysterectomy, constipation

Imaging

• Ultrasound may be helpful to identify prior mesh usage/placement if unclear
• MR not necessary, but defecography may be helpful of symptoms unclear, helps to identify enterocele

POP-Q

Methods

• Measures prolapse based on defined points on vaginal wall midline in relation to vaginal ring
• Negative refers to within introitus, positive refers to prolapse past introitus
• Take Aa, Ba, C, Ap, Bp, D all during maximal prolapse, take gh, pb, tvl at rest
• Recommended to perform both while recumbent and while standing (put one foot on short stool)

Understanding the measurements

• Aa: 3cm proximal to hymen on anterior vaginal wall, approximate location of urethrovesical junction, can only range -3 to +3
• Ba: most distal point of prolapse between vaginal apex and Aa, -3 if no prolapse, equals C if complete prolapse
• C: most distal edge of cervix or vaginal cuff (if prior hysterectomy)
• Ap: 3cm proximal to hymen (parallels Aa)
• Bp: most distal point of prolapse between vaginal apex and Ap, -3 if no prolapse, equals C if complete prolapse
• D: posterior fornix (if cervix present), approximate location of uterosacral ligament attachment, omitted if no cervix present
• gh: genital hiatus, measure urethral meatus to posterior hymenal ring, larger gh (smaller pb) decreases pessary and apical repair efficacy
• pb: perineal body, measure posterior genital hiatus to midanal opening
• tvl: total vaginal length, measure from posterior fornix to hymen

Staging

• Stage 0: no prolapse, Aa, Ba, Ap, Bp all equal -3, C and D are between tvl and tvl-2cm
• Stage 1: most distal prolapse is > -1
• Stage 2: most distal prolpase is between -1 and +1
• Stage 3: most distal prolapse is between +1 and tvl-2cm
• Stage 4: complete prolapse within 2cm of tvl

Treatment

Considerations

• Questions for surgical planning: is vault suspended (apical prolapse), prior hysterectomy, willing to undergo hysterectomy, and okay with mesh?
• Wider

Apical (+/- anterior/posterior) repair algorithm

Obliterative?	Uterus present?	Desires hysterectomy?	Approach?	Surgery
Yes	No			Colpocleisis
	Yes			Lefort colpocleisis
No	No		Abdominal	Sacrocolpopexy (w/ mesh)
			Vaginal	Sacrospinous ligament fixation Iliococcygeus suspension
	Yes	No	Abdominal	Sacrohysteropexy (w/ mesh)
			Vaginal	Uterosacral hysteropexy Sacrospinous hysteropexy
		Yes	Abdominal	Supracervical hysterectomy + sacrocolpopexy (w/ mesh)
			Vaginal	Hysterectomy + uterosacral suspension

Anterior repair

• Anterior colporrhaphy: native tissue repair, imbricate fibromuscular layer in midline, failure rate 40%, needs to be combined with lateral repair for lateral defects
• Vaginal paravaginal repair: reattach pubocervical fascia to the ATFP, better for lateral anterior prolapse

Apical repair

• Uterosacral ligament suspension (USLS): intraperitoneal transvaginal or transabdominal hitching vaginal cuff to midline uterosacral ligament, best choice when performing hysterectomy but not using mesh (due to intraperitoneal access) side effects include ureteral obstruction (11%), nerve injury
• Sacrospinous ligament fixation (SSLF): extraperitoneal transvaginal suspension of apex to sacrospinous ligament, best choice when patient already had hysterectomy (no need to enter peritoneum), sutures usually placed on right side to avoid rectum, success 63-97%, side effects include gluteal pain (usually resolves after 6wks), dyspareunia, anterior wall prolapse, good option for older/sicker patients (faster surgery), good option if history of prior abdominal surgeries
• Iliococcygeus suspension: alternative to SSLF
• Abdominal sacrocolpopexy: transabdominal placed mesh attached to anterior/posterior vagina and sacral promontory or anterior longitudinal ligament, correctly placed mesh should also fix anterior/posterior prolapse, less risk for recurrence, SUI, or dyspareunia compared to vaginal repairs

Posterior repair

• Posterior colporrhaphy: repair of rectocele, may need to be performed with apical repair
• Perineorrhaphy: reconstructs perineal body to decrease apical prolapse recurrence, ensure vaginal opening not overly narrowed

Obliterative procedures (colpocleisis)

• Candidates: non-sexually active older patients, multiple medical comorbidities, or partner without functional erections
• Technique: close vaginal vault 2-3cm from urethral meatus
• Lefort: perform partial closure to provide uterine drainage if unable to perform hysterectomy
• Success: 80-90% satisfaction rate

Mesh

• Okay: abdominal placement for prolapse, vaginal placement for stress incontinence
• Not okay: vaginal placement for prolapse (higher erosion risk)

Conservative management

• Observation: if asymptomatic, can follow as needed or with serial exams
• Physical therapy if subjective symptoms are worse than objective prolapse, strengthens core and improves sensation

Pessary

• Benefits: treats SUI + POP, consider for short term (anticipating surgery) or for poor surgical candidates
• Management: remove 2-3x weekly or in office q1-3mo, use estrogen cream to decrease erosion risk
• Genital hiatus: wider GH more likely to fail pessary use
• Choice: ring for Stage II, Gelhorn for Stage III-IV, cube for complete prolapse