PELVIC ORGAN PROLAPSE

Dr Samuel

POP(Williams Gyn.)
Prolapse is the downward displacement of
one of the pelvic organs from its normal
location that results in vaginal wall protrusion
or bulge
The terms traditionally used to describe
location of protrusion are cystocele,
cystourethrocele, uterine prolapse, rectocele,
and enterocele .
a vaginal bulge due to herniation of the bladder,
bladder/urethra, uterus, rectum, or small bowel,
respectively
SAMUEL BEZABIH MESKEREM 2004 EC
GONDER

POP(Williams Gyn.)
However, these terms are imprecise and
misleading, as they focus on what is presumed
to be prolapsed rather than what is actually
seen.
More importantly, such assumptions can lead
to unforeseen problems.
For example, a posterior vaginal prolapse that is
presumed to be a rectocele may require an
alternative reconstructive repair if an undetected
enterocele is discovered at the time of surgery.
SAMUEL BEZABIH MESKEREM 2004 EC
GONDER

POP (Will Gyn

Gyn))
Although these terms are deeply entrenched in the
literature, it is more clinically useful to describe
prolapse in terms of what one actually sees:

anterior vaginal wall prolapse,

apical vaginal wall prolapse,
Cervical prolapse,
posterior vaginal wall prolapse,
Perineal prolapse, and
Rectal prolapse.

These descriptors do not presuppose what is behind

the vaginal wall, but rather describe the tissues that
are objectively noted to be prolapsed.
SAMUEL BEZABIH MESKEREM 2004 EC
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Involved V Compartments -Anna

Anterior Compartment
Midline defect-attenuation of pubocervical facsia
Lateral/paravaginal defect-detachment of PCF from
ATFP
Cystocele, cystourethrocele

Central/ Apical uterus , vaginal fornices, upper portion of posterior vaginal

wall
Involves USLs

Posterior Compartment
Lower part of posterior vaginal wall
rectocele
SAMUEL BEZABIH MESKEREM 2004 EC
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Anterior V Compartment- Telinde

The anterior vaginal compartment extends from the PS
anteriorly to the posterior aspect of the cervix
separates the bladder from the lumen of the vagina
Lateral boundaries are the white lines/ ATFP .
Pubocervical septum-a trapezoid-shaped fascia that
provides support for the anterior vagina under the
bladder , attached distally to pubic ramus, Superior- Pericervical ring, Lateral
ATFP)

EPF b/n anterior Vaginal epithelium and bladder

Anterior vaginal epithelium firmly adhered to PCS- Rugae
Laterally- linear attachment to the ATFP forms the
anterior lateral sulci of the vagina
Defects in the pubocervical septum are associated with
anterior vaginal compartment failure.
SAMUEL BEZABIH MESKEREM 2004 EC
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Anterior V Compartment Defects Telinde

Cystocelea defect within the central pubocervical septum that allows the floor of
the bladder to descend.
Cystoceles are normally caused by transverse apical defects in the PCS
Paravaginal defectA lateral defect at or near the attachment of the PCS to the ATFP
Paravaginal defects create a direct connection between the
vesicovaginal space and the paravesical space on the affected side of the
patient.

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Anterior V Compartment Defects Telinde

There are four clinically identifiable areas in which defects in this
support are likely to occur
1. Laterally, where the pubocervical
fascia attaches to arcus tendineus
fascia pelvis (paravaginal defect)
2. Transversely, in front of the cervix
where the pubocervical fascia
blends into the pericervical ring of
fibromuscular tissue, or in the case
of a woman who has had a
hysterectomy, at the vaginal cuff
(transverse defect)
3.Centrally, in the area immediately anterior to the vaginal mucosa
in between the lateral margins of the pubocervical fascia
(midline or central defect)
SAMUEL BEZABIH MESKEREM 2004 EC
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4.Distally, where the urethra perforates
the urogenital diaphragm

Pathophysiology
POP results from attenuation of the supportive
structures, whether by actual tears or breaks
or by neuromuscular dysfunction or both.(NOVAC)
Neuropathy of the pudendal nerve and
myopathy of the levator muscles are believed to
be significant contributing factors in the
development of pelvic organ prolapse (Telinde
Telinde))

SAMUEL BEZABIH MESKEREM 2004 EC

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Risk Factors Associated with POP

Will Gyn 2nd

SAMUEL BEZABIH MESKEREM 2004 EC
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Etiology/RFs
Vaginal deliverydelivery trauma(streching and laceration of DECT, LA, perineal
muscles)
pudendal Nerve neuropathy LA weakness (Myopathy)

Age
Age hypoestrogenism,
kyphosis due to osteoporesis pelvic inlet become more
horizontal weight of pelvic content act more directly over
the UGH and pelvic floor

Life stylestyle heavy lifting, straining at stool/urine, obesity, smoking

Connective tissue disease, DM ,chronic cough, Ascitis,

Constipation
Corticosterod therapy
SAMUEL BEZABIH MESKEREM 2004 EC
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RFs-Vaginal Delivery-Childbirth trauma

Vaginal Delivery-the most likely major contributing factor
Necessary but not sufficient cause

In the vast majority of women , the process of POP

development begins with their first vaginal delivery.
Each subsequent vaginal delivery contributes to the likelihood
that a clinically symptomatic prolapse will occur
The pelvis is contoured so that even in a normal labor and
delivery, substantial forces are applied to the endopelvic fascia,
muscular floor of the pelvis, and pudendal nerve.
The greatest forces generated are at the level of the
interspinous diameter.
This plane is the location of the singularly important
pericervical ring and its junction with every other septa and
ligament associated with normal vaginal support and
suspension
SAMUEL BEZABIH MESKEREM 2004 EC
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Vaginal Birth

SAMUEL BEZABIH MESKEREM 2004 EC

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Vaginal Birth Vs POP

No recommendation regarding optimum
length of 2nd stage of labor, vaginal operative
deliveries, Management of macrosomia etc in
the context of preventing POP risk

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Risk Factors Associated with POP Will Gyn

Pregnancy
Vaginal childbirth
Menopause
Aging
Hypoestrogenism
Chronically increased
intra-abdominal
pressure
COPD

Constipation
Obesity
Pelvic floor trauma
Genetic factors
Race
Connective tissue
disorders
Hysterectomy
Spina bifida

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POP- Protective Factors

Inflammatory reactions on the paracervical
and parametrial tissues with 20 fibrosis and
adhesion reduces the risk of POP
Eg PID, Puerperial/posstabortal metritis,
Endometriosis, Pelvic radiation

Cesarean Delivery ?????

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Clinical Evaluation-History
Clinical Presentations
Usually asymptomatic
Vaginal fullness/ pressure sensation
Back/sacral pain on standing
Spotting from ulceration
Lower abdominal discomfort
Urinary/coital/ defecatory difficulties

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Clinical Evaluation-History
Complaint and perception of the problem
Eg may consider it as life threatening that may rapture or malignant

A careful micturition, defecation, and sexual history

Stress, urge, and neurogenic urinary incontinence
number of trips to the toilet and the compensatory measures/
splinting necessary to complete evacuation,
continent or incontinent of gas, liquid, or solids.

The past surgical history helps the surgeon assess the status of
the patient in general and of the pelvis in particular. Specific
interest should be placed on previous attempts to correct pelvic
organ prolapse.
MED Hx
cardiac function, thromboembolic risks, entrenched tobacco
addiction, or limited mobility are not ideal candidates for this
type of surgery. A complete list of current medications, including
herbals and over-the-counter preparations, and treating
physicians is also helpful.
SAMUEL BEZABIH MESKEREM 2004 EC
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Clinical Evaluation-Pelvic Examination

Patient in lithotomy position
Separate labia, inspect interoitus
Prolapse could be internal ( prox to hymen) or
external

Inspect under straining/ valsalva

Straining causes pronounced difference in
prolapse in pts with healthy Pfloor muscles and
undecended levator plate

If no prolapse is apparent on exam

Switch to Standing position and valsalva man
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Clinical Evaluation-Pelvic Examination

Identify and Reduce dominant prolapse
The first hernia to descend / the most dependent part of a
descended prolapse
Anterior prolapse.( Eg Lateral paravaginal/apical transverse
defect) - easily replaced by placing a tongue blade or Ayre
spatula in each anterior lateral sulcus. If replacement is not
possible by this maneouver likely a central anterior
defect
A dominant posterior segment prolapse may be replaced
with the posterior blade of a disjoined Sims' speculum.
A dominant superior segment prolapse may be replaced
with a large cotton swab, a sponge stick, or, in advanced
cases, by attaching a tenaculum to the cervix.

Look for 20 prolapses after replacement of the

dominant prolapseSAMUEL BEZABIH MESKEREM 2004 EC
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Paravaginal Defect Dx-Telinde

Baden and Walker have recommended the use of a
curved ring forceps to elevate the lateral aspects of the
anterior vagina to their normal points of attachment
along the pelvic sidewall. The curved arms of the ring
forceps are directed laterally and posteriorly toward the
ischial spines as the patient bears down. When this
lateral elevation corrects the support defect, the
diagnosis of a paravaginal defect can be
If the patient continues to have a bulge of tissue
through the open arms of the forceps, she either has a
midline loss of support or a combined midline and
lateral loss of support.
Imaging studies such as magnetic resonance imaging
and ultrasound provide details not only about
connective tissue support in the pelvis but also about
muscle integrity. SAMUEL BEZABIH MESKEREM 2004 EC
GONDER

Clinical EvaluationEvaluation-Pelvic Examination

Inspect rugae presence or absence of underlying EPF,
Vaginal epithelium- atrophy??
Rcto-vaginal examination- posterior and superior segment
evaluation US ligaments medial to I spines
Enterocele Vs Rectocele
Push finger anteriorly towards posteror vaginal wall, patient
strains
Enterocele- bulging down the vaginal wall proximal to the rectal
finger
Rectocele- palpation of transverse detachment of the proximal RV
septum

Integrity of S3 - anal sphincter, LA muscle contraction ,

spread and dorsiflex the toes
Incotenience at any stage ( check for potential SI valsalva
wit prolapse reduced)SAMUEL BEZABIH MESKEREM 2004 EC
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POP Classification
POP-Q System
This system contains a series of site-specific measurements of
a woman's pelvic organ support.
Prolapse in each segment is measured relative to the HYMEN,
which is a fixed anatomic landmark that can be identified
consistently.
Six points are located with reference to the plane of the
hymen: two on each of the following
the anterior vaginal wall (points Aa and Ba),
the apical vagina (points C and D), and
the posterior vaginal wall (points Ap and Bp) .

All POP-Q points, except total vaginal length (tvl), are

measured during patient Valsalva and should reflect
maximum protrusion.
SAMUEL BEZABIH MESKEREM 2004 EC
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ANATOMIC LANDMARKS USED DURING POPPOP-Q.

Aa
Aa--3cm proximal to urethral meatus on anterior vaginal wall
Ap
Ap--3cm proximal to hymen on posterior vaginal wall
Ba and Bp maximum prolapse excursions on A and P Vaginal wall
SAMUEL BEZABIH MESKEREM 2004 EC
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The Pelvic Organ Prolapse Quantification (POP(POP-Q)

Staging System of Pelvic Organ Support (Williams)
Stage 0:
No prolapse is demonstrated.
Points Aa, Ap, Ba, and Bp are all at 3 cm
and either point C or D is b/n (TVL)cm and (TVL2) cm

(i.e., the quantitation value for point C or D is [TVL 2] cm

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).
SAMUEL BEZABIH MESKEREM 2004 EC
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POP (Williams)
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 < + [TVL2] cm).
Fig. 244A represents stage III Ba and Fig. 244B represents stage III
Bp prolapse.

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 (TVL2) cm (i.e., its
quantitation value is >/= +[TVL2] cm). In most instances,
the leading edge of stage IV prolapse will be the cervix or
vaginal cuff scar.
Fig. 243A represents stage IV C prolapse.
SAMUEL BEZABIH MESKEREM 2004 EC
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Mediscape
Most clinicians routinely use the ICS classification
(POP-Q) system, which is classified as follows:
Stage 0 - No prolapse
Stage I - Descent of the most distal portion of prolapse
is more than 1 cm above the level of the hymen.
Stage II - Maximal descent of prolapse is between 1
cm above and 1 cm below the hymen.
Stage III - Prolapse extends more than 1 cm beyond
the hymen, but no more than within 2 cm of the total
vaginal length.
Stage IV - Total or complete vaginal eversion
SAMUEL BEZABIH MESKEREM 2004 EC
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Baden--Walker Halfway System

Baden
Will Gyn.

This descriptive tool is also used to classify

prolapse on physical examination and is in
widespread clinical use.
Although not as informative as the POP-Q, it
is adequate for clinical use if each
compartment (anterior, apical, and posterior)
is evaluated

SAMUEL BEZABIH MESKEREM 2004 EC

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Baden--Walker Halfway System -Telinde

Baden
Two anatomic points to be assesed for prolapse
(Grade 0-4) on each compartment (total 6)
Urethral and vesical - anterior
Uterine and Culdesac- superior
Rectal and perineal- posterior
+Levator strength graded subjectively out of 4

Example: 12/44/32.
A dominant complete apical prolapse is with
enterocele,
significant cystocele and rectocele, and
perineal attenuation to the level of the external anal
sphincter

2/4 levator strength is present.

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Primary and Secondary Symptoms at Each Site Used in

the BadenBaden-Walker Halfway System-Telinde
Anatomic site
Urethral

Primary symptoms
Urinary incontinence

Secondary symptoms
Falling out

Vesical

Voiding difficulties

Falling out

Uterine

Falling out

Heaviness and so forth

Cul-de-sac

Falling out

Rectal

Pelvic pressure
(standing)
True bowel pocket

Perineal

Anal incontinence

Too loose (gas/feces)

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Falling out

Table 24-3 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
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B-W Halfway System

Telinde
SAMUEL
BEZABIH MESKEREM 2004 EC
GONDER

POP (Telinde)
LUMBOSCRAL LORDOSIS

partially vertical pelvic inlet posterior aspect

is ~60 higher than the anterior downard
pressure deflected from pelvic outlet and UGH
onto superior symphysis Pubis partial
shielding of the PO & UGH from downward
stress

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SAMUEL BEZABIH MESKEREM 2004 EC

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Pelvic Diaphragm (Telinde)

Muscles-collectively named Levator ani/ sling
These muscles form a basin or covering of the pelvic outlet and
are often grouped together as the levator ani or levator sling

Puborectalis
Pubococcygeous
Iliococcygeous
Coccygeous
Piriformis

The levator ani muscles are fused posteriorly to the rectum and
attach to the coccyx
Lavator Plate/Sacrococcygeal Raphae - strong band of fibrous
CT due to midline confluence of lavator muscles b/n coccyx
and anus
Vagina and anus are suspended by EP fascia directly over
lavator plate
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Telinde
This plate is oriented horizontally in the standing
patient.
The vagina and the rectum are suspended by the
endopelvic fascia directly over the levator plate.
Myopathies or neuropathies cause weakness of the
pubococcygeus and iliococcygeus muscles and may
allow the levator plate to sag and descend
permanently.
This descent causes the genital hiatus to remain open
as it does during defecation.
This increased opening changes the normal horizontal
axis of the proximal vagina to a vertical orientation and
predisposes the central pelvic organs to prolapse.
SAMUEL BEZABIH MESKEREM 2004 EC
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SAMUEL BEZABIH MESKEREM 2004 EC

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Pelvic Diaphragm WILL GYN.

The muscles that span the pelvic floor are collectively
known as the pelvic diaphragm (Fig. 38-8). This diaphragm
consists of the levator ani and coccygeus muscles along
with their superior and inferior investing layers of fasciae.
Levator Ani-a critical component of pelvic organ support .
Physiologically, normal levator ani muscles maintain a constant
state of contraction. (Basal Tonicity)
They provide a solid floor that supports the weight of the
abdominopelvic contents against intra-abdominal forces.

Inferior to the pelvic diaphragm, the perineal membrane

and perineal body also contribute to the pelvic floor
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Pelvic Diaphragm WILL GYN.

The levator plate is the region between the anus
and the coccyx formed primarily by the insertion
of the iliococcygeus muscles (see Figs. 38-7 and 38-9).
This portion of the levator muscles forms a
supportive shelf on which the rectum, upper
vagina, and uterus rest.
In a woman with normal support, the levator
plate lies almost parallel to the horizontal plane
in the standing position (Berglas, 1953).
One theory suggests that levator plate support
prevents excessive tension or stretching of the
connective tissue pelvic ligaments and faciae
(Paramore, 1908)

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Pelvic Diaphragm WILL GYN.

Accordingly, neuromuscular injury to the levator
muscles may lead to eventual sagging or vertical
inclination of the levator plate and of the urogenital
hiatus.
Consequently, the vaginal axis becomes more vertical,
and the cervix is oriented over the opened hiatus.
The mechanical effect of this change is to increase
strain on connective tissues that support the pelvic
viscera.
Increased urogenital hiatus size has been shown to
correlate with increased severity of pelvic organ
prolapse (DeLancey, 1998).
SAMUEL BEZABIH MESKEREM 2004 EC
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View of lateral pelvic sidewall-Will Fig 38-7

SAMUEL BEZABIH MESKEREM 2004 EC

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Pelvic Diaphragm Vs Floor-Telinde

The term pelvic diaphragm refers to the
levator ani muscle and its covering fasciae,
both the superior fascia and the inferior
fascia.
The term pelvic floor refers to all of the
supportive structures that are involved with
pelvic organ support.
Sometimes the term pelvic floor and pelvic
diaphragm can be used interchangeably,
especially in the British literature
SAMUEL BEZABIH MESKEREM 2004 EC
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Inferior view of pelvic floor muscles.

Will Fig 38-8

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SAMUEL
BEZABIH MESKEREM
2004 above
EC
The pelvic diaphragm
viewed
from
GONDER

(Telinde)

Archus Tendinus Levator ani ( Muscular Arches)/ATLA

Superior insertions of iliococcygeous- =>pelvic side wall
parietal fascia thickenings from ischial spines to pubic
tubercle

ATLA -a condensation of fascia covering the medial

surface of the obturator internus muscle, serves as the
point of origin for parts of the very important levator ani
muscles.( WILL GYN)
Arcus tendineus fasciae pelvis (fascial arches) white lines
/ATFP:
thickenings of the parietal fascia of the bellies of the

ileococcygeus muscles immediately inferior to the muscular

arches

ATFP-a condensation of fascia covering the medial aspect

of the obturator internus and levator ani muscles. It
represents the lateral point of attachment of the anterior
MESKEREM 2004 EC
vaginal wall. ( WILL SAMUEL
GYN)BEZABIHGONDER

The lateral attachments of the pubocervical fascia (PCF) and the

rectovaginal fascia (RVF) to the pelvic sidewall. Also shown are
the arcus tendineus fascia pelvis (ATFP), arcus tendineus fasciae
SAMUEL
BEZABIH MESKEREM
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EC
rectovaginalis (ATFRV), and
ischial
spine
(IS).
GONDER

(Telinde)

In the standing patient, the white line is nearly

horizontal; in the lithotomy position, it is nearly
vertical
The ATFP are the lateral attachment points for the
pubocervical fascia and proximal rectovaginal
septum.
The white line serves the function of midvaginal
lateral support.
Paravaginal and proximal pararectal defects are
located immediately medial to the white line
SAMUEL BEZABIH MESKEREM 2004 EC
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Pelvic CTs (Telinde)

The connective tissues of the pelvis are
collectively known as the endopelvic fascia.
This fibroelastic CT matrix contains varying
amounts of smooth muscle.
It supports and invests all the midline organs
and structures of the pelvis.
Only the ovaries and fallopian tubes lie outside
this investment.
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Pelvic CTs (Telinde)

In the central pelvis, the visceral peritoneum
drapes over the midline structures, dipping
into recesses but not descending into direct
contact with the muscular pelvic floor.
The irregular space between the pelvic
diaphragm, the muscular pelvic sidewall, and
the visceral peritoneum is the location of the
endopelvic fascia (Tables

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Pelvic CTs (Telinde)

At various locations, the endopelvic fascia manifests
different characteristics.
These forms include
loose areolar tissue capable of distention,
neurovascular sheaths,
septa and ligaments that support, suspend, and
separate organs, and
dense skeletal muscle investments

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Telinde))
PELVIC CTS (Telinde

The endopelvic fascia may be divided into

three parts:
I. parietal fasciae,- invest straited muscles
II. visceral fasciae, and
III. deep endopelvic connective tissue

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Parietal Faciae (Telinde)

Obturator facia
Levator ani facia( superio pelvic diaphragm facia)
Coccygeous faciae (sacrospinous ligament)
Piriformis
P
facia
Pelvic parietal fascia provides muscle
attachment to the bony pelvis and serves as
anchoring points for visceral fascia,
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Visceral Faciae (Telinde

Telinde))

Organs invested by VF
Vagina
Uterus
Bladder
Rectum

Not invested by VF
Fallopian tubes
ovaries
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DEEP ENDOPELVIC CONNECTIVE TISSUE

(Telinde)

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Deep Endopelvic Connective Tissue (Telinde)

1.UTEROSACRLA LIGAMENTS (RECTAL PILLARS)
Origin-S2,S3,S4 pereostium
Insertion- 5 &7 oclock position of the supravaginal
cervix posteriorly and laterally
Contents: US autonomic N plexus, Rectouterine
muscles
Function: proximal suspension of the uterovaginal
complex
They hold the cervix behind the urogenital hiatus in
the posterior pelvis at the ischial spines level with the
uterus in anteflexion and the vagina suspended over
the levator plate
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2.Cardinal ligaments (Mackenrodt's ligament /lateral cervical

ligament/proper cervical ligament)
Origin
The hypogastric root with fibrous connections to the lateral
abdominal and pelvic walls
Insertion
on the lateral supravaginal cervix at the 3-o'clock and 9-o'clock
positions,continuous with and forms part of the pericervical ring.
Cntents
Portions of the uterosacral plexus.
Uterine artery and veins,Minimal smooth muscle content with no
named component.
The distal ureter passes under the uterine artery within the
superior portion of the cardinal ligament
Function
the primary vascular conduits of the uterus and vagina, providing
lateral stabilization to the cervix at the level of the ischial spines.
They are similar in structure, content, and function to the
mesenteries of the abdomen
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3. Pubocervical Ligaments
(Bladder pillar)
Origin
Inferior surface of the superior pubic ramus medially
and the arcus tendineus fascia pelvis laterally
Insertion
The points of insertion are on the anterior and lateral
supravaginal cervix at the 11-o'clock and 1-o'clock
positions. This insertion is continuous with and forms
part of the pericervical ring.
Vascular component
Artery and veins of the bladder pillar
Function
These ligaments are the least well developed of the
pericervical ligaments, serving as a vascular conduit
SAMUEL BEZABIH MESKEREM 2004 EC
and for a minimal degree of
cervical stabilization
GONDER

4: Pubocervical Septum or Fascia (Vesicovaginal septum /fascia,

pubovesicocervical septum/ fascia)

Shape:Trapezoidal with the narrow end located distally

Contents:Fibroelastic connective tissue and smooth
muscle
Function:Anterior vaginal support, including support of
the bladder
Boundaries
Distal: Pubic tubercles laterally and the pubic arch
centrally fusing with the urogenital diaphragm
Lateral: Arcus tendineus fascia pelvis or white line.
Proximal: Pericervical ring centrally and both
pubocervical and cardinal ligaments laterally
Superior: Visceral fascia of the bladder
Inferior: Epithelium
ofBEZABIH
theMESKEREM
vagina
SAMUEL
2004 EC
GONDER

Pubocervical fascia-TELINDE
A trapezoid-shaped fascia that provides
support for the anterior vagina under the
bladder.
It is attached
superiorly to the pericervical ring,
distally to the pubic ramus, and
laterally to the arcus tendineus fascia pelvis (white
line).
SAMUEL BEZABIH MESKEREM 2004 EC
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SAMUEL BEZABIH MESKEREM 2004 EC

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5: Rectovaginal Septum or Fascia

(Denonvilliers' fascia)

Shape:Trapezoidal with the narrow end located distally

Contents:Fibroelastic connective tissue and smooth
muscle
Function
Posterior vaginal support and suspension,
stabilization of the rectum, and perineal suspension.
The vaginal suspensory axis consists of the perineum,
rectovaginal septum, pericervical ring, uterosacral
ligaments, and presacral periosteum.
The RVS also guides the leading edge of a descending
bowel movement into the anus.
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Rectovaginal Septum or Fascia-Boundaries

(Denonvilliers' fascia)

Distal: Fusion with the proximal perineal body at

the central tendon of the perineum.
Lateral:
In the distal half of the vagina- the arcus tendineus
fasciae rectovaginalis;
in the proximal half of the vagina- the arcus tendineus
fascia pelvis

Proximal: Uterosacral ligaments laterally and the

pericervical ring centrally.
Superior: Epithelium of the vagina
Inferior: Visceral fascia of the rectum
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6-Pericervical Ring (Supravaginal septum)

Shape Collar of connective tissue encircling the supravaginal cervix
Contents Fibroelastic connective tissue
Function
Cervical stabilization within the interspinous diameter by
connecting with all other named components of the deep
endopelvic connective tissue
Connections
Anterior: The PC ring is located between the base of the bladder and
the anterior cervix, where it connects with the pubocervical
ligaments at the 11-o'clock and 1-o'clock positions and the
proximal pubocervical septum centrally.
Lateral: Cardinal ligaments at the 3-o'clock and 9-o'clock positions
Posterior: The pericervical ring is located between the rectum and
the posterior cervix, where it connects with the uterosacral
ligaments at the 5-o'clock and 7-o'clock positions and the proximal
rectovaginal septum centrally.
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Avascular Spaces
Outside the confines of the named condensations of
endopelvic fascia are avascular potential spaces.
When properly used, these spaces give the surgeon access to
important support structures deep within the pelvis.
-Prevesical
-Paravesical
-Vesicovaginal
-Vesicocervical
-Rectovaginal
-Pararectal
-Retrorectal
These spaces are not only available to the vaginal
reconstructive surgeon, but they are also critical in
identification of pelvic support landmarks.
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The avascular spaces of the female pelvis.

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Delanceys Division of vaginal support levels

(Telinde)
LEVEL I (Proximal vaginal support)
Due to suspension by paracolpic
ligaments(Involves mainly USL and to a lesser
extent cardinal ligaments )
Defect of support at or above IS resulting in
UVP, Post hysterectomy vaginal prolapse,
enterocele

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Delanceys Division of vaginal support levels (Telinde)

Level II support (midvaginal)-lateral

support
Due to lateral attachment of the facial septa
(pubocervical and rectovaginal septa to the pelvic
side walls
the septa attach to the ATFP(anteriorly) and
ATFRV(posteriorly)
Damage results in paravaginal and pararectal
defects
Cystocel and rectocele - central defects in
pubocervical and rectovaginal septa
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Delanceys Division of vaginal support levels

(Telinde)
Level III support (distal fusion)
Due to fusion to urogenital diaphragm
anteriorly and proximal perineum posteriorly
Damage results in urinary incontenience
anteriorly and perineal body deficits
posteriorly(.. Damage to level III support contributes
to anterior and posterior vaginal wall prolapse, gaping
introitus, and perineal descent-Williams)
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Three-dimensional view of the endopelvic fascia. Notice the location of

the cervix in the proximalanterior vaginal segment. (From DeLancey
JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J
Obstet Gynecol 1992;166:1717.)
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DeLancey's biomechanical levels of The endopelvic fascia of a

posthysterectomy patient
level Iproximal suspension;
level II lateral attachment;
SAMUEL BEZABIH MESKEREM 2004 EC
level III distal fusion. (From DeLancey
JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol
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1992;166:1717.)

UPTODATE
Level 1 Uterosacral/cardinal ligament complex, which
suspends the uterus and upper vagina to the sacrum and
lateral pelvic side wall. Loss of level 1 support contributes
to the prolapse of the uterus and/or vaginal apex.
Level 2 Paravaginal attachments along the length of the
vagina to the superior fascia of the levator ani muscle and
the arcus tendineus fascia pelvis (also referred to as the
white line). Loss of level 2 support contributes to anterior
vaginal wall prolapse (cystocele).
Level 3 Perineal body, perineal membrane, and superficial
and deep perineal muscles, which support the distal one
third of the vagina.
Anteriorly, loss of level 3 support can result in urethral
hypermobility.
Posteriorly, loss of level 3 support can result in a distal
rectocele or perineal descent.
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Will. Gyn.
LEVEL I SUPPORT
consists of the cardinal and uterosacral ligaments
attachment to the cervix and upper vagina.
The CLs fan out laterally and attach to the parietal fascia
of the obturator internus and piriformis muscles, the
anterior border of the greater sciatic foramen, and the
ischial spines.
TheUSLs are posterior fibers that attach to the presacral
region at the level of S2 through S4.
Together, this dense visceral CT complex maintains
vaginal length and horizontal axis. It allows the vagina to
be supported by the levator plate and positions the
cervix just superior to the level of the ischial spines.
Defects in this support complex may lead to apical
prolapse. This is frequently associated with small bowel
herniation into theSAMUEL
vaginal
wall, that is, enterocele.
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Will. Gyn.
LEVEL II SUPPORT
consists of the paravaginal attachments that are contiguous with
the cardinal/uterosacral complex at the ischial spine.
These are the CT attachments of the lateral vagina anteriorly to the
ATFP and posteriorly to the ATRV. Detachment of this connective
tissue from the ATFP leads to lateral or paravaginal anterior vaginal
wall prolapse.
LEVEL III SUPPORT
The perineal body, superficial and deep perineal muscles, and
fibromuscular CT comprise level III. Collectively, these support the
distal1/3rd of the vagina and introitus.
The perineal body is essential for distal vaginal support as well as
proper function of the anal canal.
Damage to level III support contributes to anterior and posterior
vaginal wall prolapse, gaping introitus, and perineal descent
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Will Gyn.
The parametria continues down the vagina as the
paracolpium (see Fig. 38-11). This tissue attaches
the upper vagina to the pelvic wall, suspending it
over the pelvic floor. These attachments are also
known as level I support or the suspensory axis.
They provide connective tissue support to the
vaginal apex after hysterectomy. In the standing
position, level I support fibers are vertically
oriented. Clinical manifestations of level I support
defects include posthysterectomy vaginal vault
prolapse
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Level II Will Gyn.

Midvaginal Support -The lateral walls of the
midportion of the vagina are attached to the
pelvic walls on each side by visceral connective
tissue known as endopelvic fascia. These lateral
attachments of the vaginal walls blend into the
arcus tendineus fascia pelvis and the medial
aspect of the levator ani muscles. In doing so,
these lateral attachments create the anterior and
posterior lateral vaginal sulci. These sulci run
along the vaginal sidewalls and give the vagina
an H shape when viewed in cross section
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Level II- Will Gyn.

Attachment of the anterior vaginal wall to the
levator ani muscles is responsible for the bladder
neck elevation noted with cough or Valsalva (see
Fig. 38-8). Therefore, these attachments may
have significance for stress urinary continence.
The midvaginal attachments are referred to as
level II support or the attachment axis. Clinical
manifestations of level II support defects include
anterior and posterior vaginal wall prolapse and
stress urinary incontinence.
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Level III- Will Gyn.

Distal Vaginal Support -The distal third of the vagina is
attached directly to its surrounding structures
Anteriorly, the vagina is fused with the urethra,
laterally it attaches to the pubovaginalis muscle and
perineal membrane, and
posteriorly it attaches to the perineal body.
These vaginal attachments are referred to as level III
support or the fusion axis. They are considered the
strongest of the vaginal support components. Failure of this
level of support can result in distal rectoceles or perineal
descent. Anal incontinence also may result if the perineal
body is absent, as may follow obstetric trauma.
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UPTODATE

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Preventive measures/ Conservative Mgt

(Telinde)

considerations in the conservative treatment of

pelvic organ prolapse are:
Pelvic floor exercises,
weight loss,
treatment of chronic disease(cough)
physical therapy,
cessation of smoking,
estrogen therapy
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Kegels Exercise- Telinde

Pelvic floor strengthening by voluntary contraction of the
muscles innervated by the pudendal nerve was popularized
by Arnold Kegel.
Pelvic diaphragm (10 ly Puborectalis) and anal sphincte
Several different strategies help to remind patients to do
their Kegel exercises. One of the most effective techniques
is briefly outlined below.
The Kegel contraction should be confirmed during a pelvic
examination to ensure that the patient understands the
correct muscles to contract
Frequently, patients will either perform a Valsalva
maneuver or tighten the gluteus maximus muscle instead
of the external anal sphincter and levator ani muscles
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Kegles Exercise- Telinde

The proper time to Kegel is after micturition.
After the bladder is emptied, the patient is instructed to lean as far
forward as her stability allows.
While leaning forward, she performs three or more isometric Kegel
exercises by tightening the muscles until they voluntarily relax on
their own.
The dependent portion of a cystocele is below the level of the
internal urethral orifice.
The forward tilt physically elevates the bladder floor and allows for
more complete emptying. The muscular action of the Kegel
contractions also aids the process of emptying
Coupling this activity with voiding habituates the patient to perform
the exercises several times a day.
The result is the combination of more complete emptying and a
strengthened pelvic floor, both of which are advantageous for the
patient. The patient may then be able to use the Kegel contraction
during physical stress to prevent incontinence or to protect against
the pelvic floor impact of sudden increases in abdominal pressure
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Surgical management (Telinde)

Regardless of the degree of prolapse, no
surgery should be done unless the patient
experiences a sufficient degree of morbidity.
Most symptoms relate to quality-of-life issues
The management of advanced and
symptomatic prolapse is primarily surgical

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Surgical management
1 obliterative procedures-colpocleisis- removing
vaginal epithelium

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Surgical management
Apical descent
Abdominal sacropoplexy
Sacrospinal ligament suspension
Uterosacral
U
ligament vaginal cuff suspension
Paravaginal defect
Reattachment of vagianl connective tissue to ATFP

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