PELVIC ORGAN PROLAPS

1. PELVIC ORGAN PROLAPS

2. Risk Factors • Pregnancy • Vaginal childbirth • Menopause ( Aging, Hypoestrogenism • Chronically increased intra-abdominal pressure (COPD, Constipation, Obesity )

3. Risk Factors • Pelvic floor trauma • Genetic factors •   Race •   Connective tissue disorders • Hysterectomy • Spina bifida

4. Drawing displays the anatomic landmarks used during pelvic organ prolapse quantification (POP-Q).

5. Grid system used for charting in pelvic organ prolapse quantification (POP-Q).

6. The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support • Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at –3 cm and either point C or D is between –TVL (total vaginal length) cm and –(TVL–2) cm (i.e., the quantitation value for point C or D is –[TVL – 2] cm).

7. The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support • Stage I: The criteria for stage 0 are not met, but the most distal portion of the prolapse is >1 cm above the level of the hymen (i.e., its quantitation value is < – 1 cm). • Stage II: The most distal portion of the prolapse is 1 cm proximal to or distal to the plane of the hymen (i.e., its quantitation value is –1 cm but +1 cm).

8. The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support Stage III: • The most distal portion of the prolapse is >1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters (i.e., its quantitation value is > + 1 cm but < + [TVL–2] cm).

9. The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support • Stage IV: • Essentially, complete eversion of the total length of the lower genital tract is demonstrated. The distal portion of the prolapse protrudes to at least (TVL–2) cm (i.e., its quantitation value is +[TVL–2] cm). In most instances, the leading edge of stage IV prolapse will be the cervix or vaginal cuff scar

10. Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse on Physical Examinationa • Grade 0 Normal position for each respective site • Grade 1 Descent halfway to the hymen • Grade 2 Descent to the hymen • Grade 3 Descent halfway past the hymen • Grade 4 Maximum possible descent for each site

11. Pathophysiology Pelvic organ support is maintained by complex interactions between the levatorani muscle, vagina, and pelvic floor connective tissue. However, these mechanisms have not been fully delineated.

12. Mechanism of LevatorAni Damage Skeletal muscle is a dynamic tissue that is constantly remodeling and regenerating. A heterogeneous population of fibers with different functions allows skeletal muscle to adapt to different situations, such as stretch and mechanical load. Damage to the levatorani muscles follows direct muscle tissue injury or may result from damage to its nerve supply.

13. Mechanism of LevatorAni Damage Labor and vaginal delivery has the potential to cause this type of damage. However, it is unclear what effect other pathologic conditions, such as chronically increased intra-abdominal pressure, may have on the levatorani muscle.

14. Levels of Vaginal Support • Level I support suspends the upper or proximal vagina. • Level II support attaches the mid-vagina along its length to the arcustendineus fascia pelvis. • Level III support results from fusion of the distal vagina to adjacent structures. * Defects in each level of support result in identifiable vaginal wall prolapse: anterior, apical, and posterior.

15. Bulge Symptoms • Sensation of vaginal bulging or protrusion  Rectal prolapse •   Seeing or feeling a vaginal or perineal bulge Vulvar or vaginal cyst/mass •   Pelvic or vaginal pressure Pelvic mass •   Heaviness in pelvis or vagina  Hernia (inguinal or femoral)

16. Urinary symptoms • Urinary incontinence  Urethral sphincter incompetence •   Urinary frequency  Detrusoroveractivity •   Urinary urgency Hypoactive detrusor function •   Weak or prolonged urinary stream Bladder outlet obstruction

17. Urinary symptoms •  Hesitancy Excessive fluid intake •   Feeling of incomplete emptying  Interstitial cystitis •   Manual reduction of prolapse to start or complete voiding  Urinary tract infection •   Position change to start or complete voiding

18. Bowel symptoms • Incontinence of flatus or liquid/solid stool  Anal sphincter disruption or neuropathy • Feeling of incomplete emptying Diarrheal disorder • Hard straining to defecate Rectal prolapse • Urgency to defecate Irritable bowel syndrome

19. Bowel symptoms • Digital evacuation to complete defecation Rectal inertia • Splinting vagina or perineum to start or complete defecation Pelvic floor dyssynergia •  Feeling of blockage or obstruction during defecation Hemorrhoids • Anorectal neoplasm

20. Sexual symptoms • Dyspareunia Vaginal atrophy • Decreased lubrication  Levatorani syndrome •  Decreased sensation Vulvodynia • Decreased arousal or orgasm Other female sexual disorder

21. Pain •  Pain in vagina, bladder, or rectum  Interstitial cystitis •   Pelvic pain  Levatorani syndrome •   Low back pain  Vulvodynia Lumbar disc disease  Musculoskeletal pain  Other causes of chronic pelvic pain

22. Physical Examination • Physical examination begins with a full body systems evaluation to identify pathology outside the pelvis. Systemic conditions such as cardiovascular, pulmonary, renal, or endocrinologic disease may affect treatment choices and should be identified early.

23. Perineal Examination • Lithotomy position. The vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalities • A neurologic examination of sacral reflexes is performed using a cotton swab (bulbocavernosus reflex , anal wink reflex.

24. Perineal Examination • Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina. • Importantly, this assessment helps answer three questions: (1) Does the protrusion come beyond the hymen?; (2) What is the presenting part of the prolapse (anterior, posterior, or apical)?; (3) Does the genital hiatus significantly widen with increased intra-abdominal pressure?

25. Vaginal Examination • If the POP-Q examination is performed, the genital hiatus (gh) and perineal body (pb) are measured during Valsalva maneuver. • The total vaginal length (TVL) is then measured by placing the marked ring forceps at the vaginal apex and noting the distance to the hymen.

26. Vaginal Examination • A bivalve speculum is then inserted to the vaginal apex. It displaces the anterior and posterior vaginal walls • C and D are then measured. The speculum is slowly withdrawn to assess descent of the apex. A split speculum is then used to displace the posterior vaginal wall and allow for visualization of the anterior wall and measurement of points Aa and Ba

27. Bimanual examination is performed to identify other pelvic pathology • . During evaluation, an index finger is placed 2 to 3 cm inside the hymen, at 4 and then 8 o'clock. Muscle resting tone and strength is assessed using the 0 through 5 Oxford grading scale. Five represents strong tone and strength (Laycock, 2002). • Muscle symmetry is also evaluated. Asymmetric muscles, with palpable defects or scarring, may be associated with a prior obstetric forceps delivery or laceration.

35. Treatment • Nonsurgical Treatment  Pessary Use in Pelvic Organ Prolapse • Pelvic Floor Muscle Exercise  Pelvic floor muscle exercise has been suggested as a therapy that might limit progression and alleviate prolapse symptoms.

36. Surgical Treatment • Obliterative Procedures • Reconstructive Procedures

37. Anterior Compartment • Anterior colporrhaphy . • . In a randomized trial of three anterior colporrhaphy techniques ( traditional midline plication, ultralateral repair, and traditional plication plus lateral reinforcement with synthetic mesh.

38. Vaginal Apex • There is a growing appreciation that support of the vaginal apex provides the cornerstone for a successful prolapse repair. Some experts believe that isolated surgical repair of the anterior and posterior walls is doomed for failure if the apex is not adequately supported (Brubaker, 2005b).

39. Abdominal Sacrocolpopexy • This surgery suspends the vaginal vault to the sacrum using synthetic mesh. • Sacrospinous Ligament Fixation (SSLF ) • Uterosacral Ligament Vaginal Vault Suspension

40. Hysterectomy at the Time of Prolapse Repair • In the United States, hysterectomy is often performed concurrently with prolapse surgery

41. Posterior Compartment • Enterocele Repair • Posterior vaginal wall prolapse may be due to enterocele or rectocele. • Rectocele Repair • Mesh Reinforcement • Sacrocolpoperineopexy • Perineorrhaphy

48. Derajat Prolaps Uteri

50. Diagram Posisi Normal genitalia dan Eversi komplit dari vagina