Pelvic Organ Prolapse in a 63-Year-Old Patient: A Case Report

1. Case Report Katrina Marie D. Soto

2. General Data • G.S. • 63 year old • G3P3 (3003) • Married • Roman Catholic • Housewife

3. Introital mass Chief Complaint

4. Past Medical History • No comorbids (hypertension, DM, Asthma, COPD) • No previous surgeries • No allergies

5. Personal and Social History • Non-smoker • Non-alcoholic beverage drinker

6. Family History • (+) Bronchial Asthma- maternal side • (-) Hypertension, Diabetes mellitus, asthma

7. Menstrual History • Menarche: 17 years old • Regular intervals (28-30 days) • Duration: 3 days • 2 pads per day • (+) occassionaldysmenorrhea • Menopause for the past 19 years (1981)

8. Gynecologic History • Coitarche: 18 years old • Sexual Partners: 2 • Denied sexual activity • (+) occassional vaginal bleeding • No foul smelling vaginal discharge • Denied OCP or IUD use • Pap Smear 2009: normal

9. OB History • G3P3 (3003) • 1970 –full term- female- ~7lbs- NSD- Isabela hospital- no fetomaternal complications • 1971 –full term- female- ~8lbs- NSD- Isabela hospital- no fetomaternal complications • 1981 –full term- female- ~7lbs- NSD- Isabela hospital- no fetomaternal complications

10. History of Present Illness

11. HPI

12. HPI

13. Review of Systems • Unremarkeable

14. Physical Examination • Conscious, coherent, not in cardio-respiratory distress, • BP: 110/70mmHg CR: 68/min, regular RR: 20/min, regular T: 36.8oC Wt 58 kg Ht 168cm BMI 22.7 • Skin: warm with good skin turgor • Head: skull normocephalic, atraumatic • Eyes: pink palpebral conjunctivae, anictericsclerae • Neck: supple neck, with no palpable neck mass, no neck vein engorgement

15. Physical Examination • Lungs: symmetrical chest expansion, no rib retractions, clear and equal breath sounds • Heart: adynamicprecordium, normal rate, regular rhythm, no murmurs • Abdomen: Symmetrical, flabby , NABS, soft, no direct/indirect tenderness, no masses palpated • Full and equal pulses, no cyanosis • External exam: (+) introital mass, smooth mucosa, no ulcerations or bleeding noted.

16. Salient Features Subjective Objective • (+) 63 year old G3P3 (3003) • (+) 3 year history of gradually enlarging introital mass • (+) 1 year history of frequency, incontinence, feeling of incomplete voiding, occ vaginal bleeding TVS: normal • No comorbids or previous surgeries • Menopause for 19 years • G3P3 (3003) NSD, 7-8 lb babies • Conscious, coherent not in cardiorespiratory distress • BP: 110/70mmHg CR: 68/min, regular RR: 20/min, regular T: 36.8oC Wt 58 kg Ht 168cm BMI 22.7 • Abdomen: Symmetrical, flabby , NABS, soft, no direct/indirect tenderness, no masses palpated • External exam: (+) introital mass, smooth mucosa, no ulcerations or bleeding noted.

17. Initial Assessment • 63 year old G3P3 (3003) • Pelvic Organ Prolapse Stage III

18. Differential Diagnosis • Pedunculatedmyoma • Cervical Polyp • Bartholin’s Duct Cyst • Soft tissue tumors (lipoma, leimyomas, sarcomas)

19. Pelvic Organ Prolapse

20. Epidemiology • 3rd most common indication for hysterectomy • estimated lifetime risk of 11% to undergo surgery for prolapse or incontinence (Olsen, 1997) • Prevalence increases with age (Olsen, 1997) • there was a 100-percent increased risk of prolapse for each decade of life (POSST) • physiologic aging, degenerative processes and hypoestrogenism

21. Risk Factors • Multiparity • Vaginal birth – most frequently cited risk factor (Swift, 2005) risk of POP increased 1.2 times with each vaginal delivery • Menopause (aging, hypoestrogenism) • Chronically increased intra abdominal pressure (COPD, obesity, constipation) • Pelvic floor trauma • Race • Connective Tissue disorders

22. Definition • Prolapse is the downward displacement of one of the pelvic organs from its normal location that results in vaginal wall protrusion or bulge • cystocele, cystourethrocele, uterine prolapse, rectocele, and enterocele have traditionally been used to describe the protrusion location

24. POP-Q

25. POP-Q Staging Stage 0 No prolapse; anterior and posterior points are all -3 and C (cervix) or D (posterior fornix) is between - TVL (total Vaginal length) and - (TVL - 2) cm. Stage I The criteria for stage 0 are not met, and the most distal prolapse is >1 cm above the level of the hymen (< -1 cm). Stage II The most distal prolapse is between 1 cm above and 1 cm below the hymeneal ring (at least one point is - 1, 0, or +1). Stage III The most distal prolapse is between >1 cm below the hymeneal ring, but no further than 2 cm less than TVL. Stage IV Represents complete vault eversion; the most distal prolapse protrudes to at least (TVL - 2 ) cm. International Continence Society Stages of Pelvic Organ Prolapse Determined by Pelvic Organ Prolapse Quantification System Measurements

26. Baden-Walker Halfway System • 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

27. Pathophysiology • Pelvic organ support is maintained by complex interactions between the levatorani muscle, vagina, and pelvic floor connective tissue • the upper vagina lies nearly horizontal in the standing female • upper vagina is compressed against the levator plate during periods of increased intra-abdominal pressure (flap valve effect)

28. Relevant Anatomy

29. The axes of pelvic support • Three support axes • Upper vertical axis (cardinal-uterosacral ligament complex) • Horizontal axis leads to lateral and paravaginalsupports two platforms pubocervical fascia and rectovaginalseptum • Lower vertical axis supports the lower third of the vagina, urethra and anal canal

30. DeLancey’s three levels of vaginal support • Apical suspension • Upper paracolpium suspends apex to pelvic walls and sacrum • Damage results in prolapse of vaginal apex • Midvaginal lateral attachment • Vaginal attachment to arcus tendineus fascia and levator ani muscle fascia • Pubocervical and rectovaginal fasciae support bladder and anterior rectum • Avulsion results in cystocele or rectocele • Distal perineal fusion • Fusion of vagina to perineal membrane, body and levators • Damage results in deficient perineal body or urethrocele

31. Clinical Evaluation • Bulge Symptoms • Urinary Symptoms - stress urinary incontinence (SUI), urge urinary incontinence, frequency, urgency, urinary retention, recurrent urinary tract infection, or voiding dysfunction • GI symptoms- constipation • Sexual dysfunction • Pelvic and back pain

32. Physical Examination • full body systems evaluation to identify pathology outside the pelvis • Initial pelvic exam  dorsal lithotomy position • vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalities • neurologic examination of sacral reflexes is performed using a cotton swab (bulbocavernosus reflex and anal wink) • Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina  true anatomy

33. Physical Examination • Speculum exam • (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? • Pop Q examination • Bimanual examination is performed to identify other pelvic pathology • Assessment of pelvic floor musculature

34. Anterior compartment defects • Urethral hypermobility • Distal 4 cm of anterior vaginal wall • Cotton swab test • If describes an arc greater than 30 degrees from horizontal with valsalva • Results in genuine stress incontinence • Cystocele

35. Evaluation of a cystourethrocele

36. Cystocele • Main support of urethra and bladder is the pubo-vesical-cervical fascia • Essentially a hernia in the anterior vaginal wall due to weakness or defect in this fascia • Symptoms include pelvic pressure and bulge or mass in the vagina • Surgical repair is the treatment of choice

37. Posterior compartment defects • Rectocele • Perineal deficiency • Bulbocavernous and superficial transverse muscle heads retracted • Perineal descent • Sagging and funneling of the levator ani around the perineum such that anus becomes most dependent • Difficulty with defecation

38. Rectocele • Chiefly a hernia in the posterior vaginal wall secondary to weakness or defect in the rectovaginal septum • Symptoms include difficulty evacuating stool, a vaginal mass, and fullness sensation • Rectovaginal exam confirms diagnosis

39. Evaluation of a rectocele

40. Rectocele • Damage generally due to excessive pushing in childbirth or chronic constipation • Surgical treatment if symptomatic • Posterior Colporrhaphy • Laxatives and stool softeners • Temporary relief

41. Apical defects • Uterine prolapse • Normal cervix located in upper third of vagina • Degree of prolapse measured by position of cervix at maximum intraabdominal pressure, without traction • Complete uterovaginal prolapse is called procidentia • Vault prolapse • Enterocele

42. Uterine prolapse • Weakness of endopelvic fascia and detachment of cardinal and uterosacral ligaments • Complains of severe pelvic or abdominal pressure, bulge or mass, and low back pain • Surgical management includes hysterectomy and vaginal cuff or apex suspension • Estrogen replacement important

43. Enterocele • A true hernia of the rectouterine or cul-de-sac pouch (pouch of Douglas) into the rectovaginal septum • Descent of bowel in a peritoneum-lined sac between posterior vaginal apex and anterior rectum • Can occur anteriorly as well • Symptoms of fullness and vaginal pressure or palpable mass • Bowel peristalsis confirms diagnosis

44. Enterocele • Commonly found in association with other defects • Surgical approach • Vaginal • Abdominal • Laparoscopic • Ligation of hernia sac and obliteration of the pouch of Douglas

45. Approach to Treatment • asymptomatic or mildly symptomatic, expectant management is appropriate • for women with significant prolapse or for those with bothersome symptoms, nonsurgical or surgical therapy may be selected.

46. Conservative treatments • Obstetric care to protect pelvic floor • Decreased pushing times • Avoid forceps, major lacerations • Permit passive descent • General lifestyle changes • Smoking cessation and cough cessation • Routine use of Kegel pelvic floor exercises • Regular physical activity • Proper nutrition • Weight loss • Avoid constipation and repetitive heavy lifting • Hormone replacement therapy

47. Non Surgical • Pessaries are the standard nonsurgical treatment for POP. • reserved for women either unfit or unwilling to undergo surgery • 2 types • Support • Space filling

48. Non Surgical • Pelvic floor muscle exercise  limit progression and alleviate prolapse symptoms (Kegel Exercises) • women learn to consciously contract muscles before and during increases in abdominal pressure, which prevents organ descent • regular muscle strength training builds permanent muscle volume and structural support

49. Principles of reconstructive pelvic surgery • Site-specific repair • Rebuild weakened endopelvic fascia, repair fascial tears, and reattach prolapsed tissues to stronger sites • Goal is a vagina of normal depth, width and axis • Denervation or muscle trauma cannot be corrected surgically

50. Surgical • Obliterative • Lefortcolpocleisis and complete colpocleisis • removing extensive vaginal epithelium, suturing anterior and posterior vaginal walls together, obliterating the vaginal vault, and effectively closing the vagina. • technically easier, require less operative time, and offer superior success rates (91-100%) • Reconstructive • restore normal pelvic anatomy and are more commonly performed than obliterative procedures for POP.