Pop lecture by hale

1. Mekelle University,
College of Health Sciences,
School of Medicine,
Department of Obstetrics and Gynecology
HALE TEKA, M.D,
OB/GYN RESIDENT,
MEKELLE UNIVERSITY
Wednesday, Augus 15, 2019 HALE TEKA, M.D., RESIDENT PHYSICIAN 1
Pelvic Organ Prolapse
(POP)
Hale
Digitally signed by
Hale
Date: 2019.09.07
23:54:58 +03'00'

2. •Contents
1. Introduction
2. Epidemilogy
3. Risk factors
4. Levels of Support
5. Grading
6. Management
HALE T., M.D., RESIDENT PHYSICIAN
Saturday, January 7, 2017 2

3. Epidemiology
•US
✓12% life time risk of undergoing surgery for POP
✓Third most common indication for hysterectomy
✓Based on patient symptoms: Prevalence 3 – 6%
✓POP Q stage 2: 30 – 65%
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 3

4. Risk Factors Associated with Pelvic Organ Prolapse
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 4

5. •Obstetrics related risks
✓ Pregnancy itself
✓ Vaginal delivery
✓ Other controversies
o Macrosomia,
o Prolonged second-stage labor,
o Episiotomy,
o Anal sphincter laceration,
o Epidural analgesia,
o Forceps use, and
o Oxytocin stimulation of labor
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 5

6. •Age
✓Doubles with each decade
✓Reasons
oHormonal deprivation
oPhysiologic aging and degenerative processes
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 6

7. •The following interventions to prevent POP are not recommended
✓Cesarean delivery
✓Forceps to shorten second stage of labor
✓Elective episiothomy
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 7

8. •Race
✓Collagen content
✓Pelvic type
✓Genetics
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 8

9. •Connective tissue disorders
✓Ehlers-Danlos syndrome
✓Marfan syndrome
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 9

10. •Increased Abdominal pressure
✓Obesity
✓Constipation
✓Cough
✓Repetitive heavy lifting
✓Smoking
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 10

11. Levels of Vaginal Support
✓Level I
o Suspends the upper or proximal vagina
o Ligaments
✓Level II
o Attaches the midvagina along its length to the arcus tendineus fascia pelvis
o Endopelvic fascia
✓Level III
o Results from fusion of the distal vagina to adjacent structures
o Perineal muscles
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 11

12. Grading
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 12

13. The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic
Organ Support
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 13

14. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 14
Stage 2. This
stage is defined
by the most distal
edge of the
prolapse lying
within 1 cm of the
hymenal ring.
Stage 3. This stage is
defined by the most distal
portion of the prolapse
being >1 cm below the
plane of the hymen, but
protruding no farther than 2
cm less than the total
vaginal length in
centimeters.
Stage 4. This stage is
defined as complete or
near complete eversion.

15. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 15
Measurement of the genital
hiatus (Gh). For POP-Q
evaluation, a sponge stick
is used that is marked at 1-,
2-, 3-, 4-, 5-, 7.5-, and 10-
cm increments.
Measurement is obtained
with a woman performing
maximum Valsalva
maneuver.
Measurement of the
perineal body
Measurement of points Aa
and Ba. Aa is a discrete point
lying 3 cm proximal to the
urethral meatus and is
measured in relation to the
hymen. During measurement,
a split speculum displaces the
posterior vaginal wall, but
downward traction is avoided,
as this causes artificial descent
of the anterior vaginal wall.

16. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 16
Normal lateral support as shown by
normal positioning of the vaginal sulci
Complete loss of lateral support, shown as
absent lateral sulci.

17. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 17
transverse vaginal wall defect. Note
detachment of the anterior vaginal wall
from the apex and the presence of
rugae, which suggests that this is not a
midline or central defect.
Enterocele. During evaluation, small bowel
peristalsis may be noted behind the vaginal
wall. Enterocele is most commonly noted at
the vaginal apex, although anterior and
posterior vaginal wall enteroceles may occur.

18. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 18
Split speculum displacing the anterior
vaginal wall. This allows for measurement
of points Ap and Bp. Ap is always defined
as a discrete point lying 3 cm proximal to
the hymen
Pelvic floor muscle assessment. The
index finger is placed 2 to 3 cm
inside the hymen at 4 and 8 o’clock.
Both resting and contraction tone
and strength are evaluated.

19. Baden-Walker Halfway System for the Evaluation of Pelvic
Organ Prolapse During Physical Examination
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 19

20. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 20

21. •Neurologic exams
✓Bulbocavernosus reflex
✓Anal wink reflex
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 21

22. •Treatment
✓Nonsurgical
✓Surgical
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 22

23. •Nonsurgical
✓Pessary
✓Pelvic floor muscle exercise
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 23

24. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 24
Types of Milex pessaries.
A. Cube pessary.
B. Gehrung pessary
C. Hodge with knob
pessary.
D. Regula pessary.
E. Gellhorn pessary.
F. Shaatz pessary.
G. Incontinence dish
pessary.
H. Ring pessary
I. Donut pessary.

25. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 25
Technique for placement and removal of a Gellhorn pessary.
Figures A, B, and C show placement. D. To remove a Gellhorn pessary, an
index finger is placed behind the disk and suction is broken prior to
removal

26. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 26
Guidelines for Pessary
Care

27. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 27
Granulation tissue resulting from pessary trauma.

28. •Surgical
✓Obliterative Procedures
oLefort colpocleisis and
oComplete colpocleisis
✓Reconstructive procedures
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 28

29. •Surgical repair for anterior vaginal wall prolapse
✓Anterior colporrhaphy
oTraditional midline plication,
➢https://www.youtube.com/watch?v=M08ztEcAovM&has_verified=1
oUltralateral repair, and
oTraditional plication plus lateral reinforcement with synthetic mesh
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 29

30. •Surgical repair for apical prolapse
✓Abdominal Sacrocolpopexy
oAnterior longitudinal ligament and vaginal apex fixation
➢https://www.youtube.com/watch?v=fm4kquetbmo
✓Sacrospinous Ligament Fixation
➢https://www.youtube.com/watch?v=FXv588o1vfU
✓Uterosacral Ligament Vaginal Vault Suspension
➢https://www.youtube.com/watch?v=8QPy37RmflE
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 30

31. •Surgical repair for posterior prolapse
✓Enterocele Repair
✓Rectocele Repair
✓Site-Specific Posterior Repair
✓Mesh Reinforcement
✓Sacrocolpoperineopexy
ohttps://www.youtube.com/watch?v=OAnD4C0x2D0
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 31

32. Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 32
Types of Surgical Mesh

33. •Surgical Success
✓Absence of buldge symptoms
✓Anatomic restoration
Saturday, January 7, 2017 HALE T., M.D., RESIDENT PHYSICIAN 33

34. REFERENCES
HALE TEKA, M.D., RESIDENT PHYSICIAN 34
1. F. Gary Cunningham, 2016. Williams Gynecology, 3rd edition, The McGraw-
Hill Companies, Inc.
2. James R. Scott, 2008. Danforth’s Obstetrics and Gynecology, 9th edition
Wednesday, Augus 15, 2019

35. Wednesday, Augus 15, 2019 Hale Teka, M.D., Resident Physician 35
“No man should escape our
universities without knowing
how little he knows!”
J. Robert Oppenheimer