Rahadiansyah Ramadhani

Definition Assessment

Etiology Classification

Risk Factors Management

Pathophysiology

Symptoms
 Abnormal descent or herniation of pelvic organs from their normal attachment sites or

position in the pelvis into the vagina due to loss of supports

Pelvic organs:

Urethra

Bladder

Large intestine

Small intestine

Omentum

Rectum

Cervix

Uterus

Vagina
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 5th ed. ICUD-EAU; 2013.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
 Multifactorial

Weakening or damage of pelvic support connective tissue

and muscles as well as nerve

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 5th ed. ICUD-EAU; 2013.
Berek JS. Berek & Novaks Gynecology. 14th Ed. Amsterdam: Lippincott Williams & Wilkins; 2006.
 Predispose Incite Promote Decompensate

Genetic (congenital or Vaginal delivery Obesity Aging

hereditary)

Race: White & Hispanic > Surgery such as Smoking Menopause

African-American hysterectomy

Gender: Female > Male Myopathy Pulmonary disease (chronic Neuropathy

coughing)

Neuropathy Constipation (chronic straining) Myopathy

Recreational or occupational
(frequent or heavy lifting)

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Bent AE, Cundiff GW, Swift SE. Ostergards Urogynecology and Pelvic Floor Dysfunction. 6th Ed. New York: Wolters Kluwer; 2007.
 Connective Vaginal
Muscle
tissue Wall
Combination of these creates a system to support and maintain

normal physiologic function of the pelvic organ

Disruption in the supportive system may cause failure to support

combination of genetic predisposition & acquired dysfunction of

actual tears or breaks or by neuromuscular dysfunction or both
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 5th ed. ICUD-EAU; 2013.
Berek JS. Berek & Novaks Gynecology. 14th Ed. Amsterdam: Lippincott Williams & Wilkins; 2006.
 Levator ani muscle: pair striated muscles that elevates the

pelvic floor and compresses the vagina, urethra, and rectum

towards the pubic bone

3 regions of levator ani muscle:

Iliococcygeal muscle

Pubococcygeus muscle

Puborectalis muscle

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Forms flat horizontal
shelf from one pelvic
sidewall to the other

Suspending vaginal
wall to pelvis
 Connective tissues and ligaments surrounds the pelvic organs and attaches

them to the levator ani muscle and bony pelvis

Arcus tendineus fascia pelvis

Condensation of parietal fascia in medial aspects of levator ani muscle

Provides lateral and apical support for anterior and posterior vagina

Uterosacral ligaments

Provide apical support by suspending and stabilizing uterus, cervix, upper vagina

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
 Apical support

Lateral support
 Vaginal wall comprised of:

Mucosa (epithelium & lamina propria)

Fibroelastic muscularis layer

Adventitial layer
} fibromuscular layer

Fibromuscular layer attaches to arcus tendineus fascia pelvis

and superior fascia of levator ani muscle

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
 Level I: Cardinal and uterosacral ligaments attaches cervix and upper

vagina to bony sacrum

Level II: Arcus tendineus fascia pelvis and arcus tendineus rectovaginalis

attaches the middle part of vagina

Level III: Perineal body, muscles, and fibromuscular connective tissue

attaches the lower part of vagina

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Berek JS. Berek & Novaks Gynecology. 14th Ed. Amsterdam: Lippincott Williams & Wilkins; 2006.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 5th ed. ICUD-EAU; 2013.
 Differ in each individual

Can be asymptomatic

Hoffman BL, et al. Williams Gynecology. 2nd ed.

New York: McGraw-Hill; 2012.
 Two commonly used tools too assessed severity:

Pelvic floor distress inventory (PFDI) assess urinary, colorectal, and

prolapse symptoms

Pelvic floor impact questionnaire (PFIQ) assess the impact on quality

of life

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Hoffman BL, et al. Williams
Gynecology. 2nd ed. New
York: McGraw-Hill; 2012.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
 POP can be assessed by:

Visual descriptors
Describe prolapse by what actually sees e.g. anterior wall prolapse, apical vaginal
wall prolapse, cervical prolapse
Previously describes by the structures thought to be prolapse behind vaginal wall
e.g. cystocele, rectocele, enterocele

Pelvic organ prolpase quantification (POP-Q) ICS1996

A system to report findings in standardized, easily reproducible manner

Site specific measurement to anatomic landmark (hymen)

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
 Visual Descriptor

A. Normal pelvic
anatomy

B. Anterior wall
prolapse or
cystocele (bladder)

C. Distal posterior wall

prolapse or
rectocele (rectum)

D. Apical posterior wall

prolapse or
enterocele (small
bowel)
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Baessler K, Burgio Kl Norton PA. Clinical Evaluation of the Pelvic Floor Muscles. London: Springer;2008.
 Ba: midline of anterior vaginal wall
Bp: most distal of upper anterior vaginal wall

6 points as reference to the hymen:

2 on anterior vaginal wall (Aa and Ba)

2 on apical vagina (C and D) C: most distal edge of cervix

D: posterior fornix
2 on posterior vaginal wall (Ap and Bp)

3 length measurements: Ap: midline of posterior vaginal wall

Bp: most distal of upper posterior vaginal wall
Genital hiatus (Gh)

Perineal body (Pb)

Total vaginal length (TVL)

All points except TVL are measured during

valsalva to reflect maximum protrusion

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Berek JS. Berek & Novaks Gynecology. 14th Ed. Amsterdam: Lippincott Williams & Wilkins;
2006.
 Hymental plane = 0
Measured in centimeter
Above/proximal hymen = (-)
Below/distal hymen = (+)
Tamiselvi A, Rane A. Principles and practice of urogynaecologoy. India:Springer;2015.
Berek JS. Berek & Novaks Gynecology. 14th Ed. Amsterdam: Lippincott Williams & Wilkins; 2006.
Abrams P, Cardozo L, Khoury S, Wein A. Incontinence. 5th ed. ICUD-EAU; 2013.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Persu C, Chapple C, Cauni V, Gutue S, Geavlete P. Pelvic Organ Prolapse Quantification System (POPQ) a new era in pelvic prolapse staging .Journal of Medicine and Life. 2011;4(1):75-81.
 Treatment choice depends
on type and severity of Non Pessary
symptoms
Surgical Pelvic floor muscle
exercise (Kegel)
Not life threatening

Aim: symptom relief

Not all require treatment

Obliterative
Surgical Reconstructive

Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.
Hoffman BL, et al. Williams Gynecology. 2nd ed. New York: McGraw-Hill; 2012.