Definitions of Prolapse ANTERIOR Anterior Wall Defect AKA

Definitions of Prolapse ANTERIOR Anterior Wall Defect AKA Cystocele POSTERIOR Posterior Wall Defect AKA Rectocele Small Bowel Herniation AKA Enterocele LATERAL WALLS Paravaginal Defect APICAL Uterine Prolapse Vaginal Vault Prolapse

ETIOLOGY Childbirth Increased Intra-abd Pressure Lifting Coughing Obesity Constipation/Straining Neurologic Injury Genetic Predisposition Connective Tissue Abnormalities Estrogen Deficiency

Pelvic Organ Prolapse Repair

Symptoms of Prolapse Pressure Bulging Vaginal irritation/Ulcers PAIN IS NOT A PRESENTING SYMPTOM

Compartment-Specific Prolapse Symptoms ANTERIOR Stress urinary incontinence Incomplete bladder emptying Possible increased frequency of UTIs POSTERIOR Incomplete stool evacuation Splinting to assist defecation

Consequence of Prolapse

Diagnosis: POP-Q

THERAPY Conservative Therapy Pelvic Floor Muscle Exercises Pessary Surgical Therapy

Pelvic Organ Prolapse Repair Anterior Compartment Vesico-vaginal supportive tissue

Pelvic Organ Prolapse Repair Anterior Colporrhaphy Reinforcement and repair of vesicovaginal supportive tissue Non-permanent plication sutures

Pelvic Organ Prolapse Repair Posterior Compartment Rectovaginal septum Denonvillier’s “fascia”

Pelvic Organ Prolapse Repair Posterior Colporrhaphy Reinforcement and repair of rectovaginal septum Non-permanent plication sutures

Pelvic Organ Prolapse Repair Lateral Compartments Arcus Tendinius Fascia Pelvis (“White line”)

Pelvic Organ Prolapse Repair Lateral Compartments Reattachment of vaginal supportive tissue to white line

Pelvic Organ Prolapse Repair Apical Compartment Uterosacral ligaments to Uterus/cervix Vaginal cuff Cervical Os

Pelvic Organ Prolapse Repair Apical Compartment Attachment of uterosacral ligaments to vaginal cuff

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Sacrospinous ligament fixation

Suspension with uterine preservation

Pelvic Organ Prolapse Repair Apical Compartment Attachment of vaginal cuff to anterior longitudinal sacral ligament using a graft Sacrum Vagina

Robotic Sacrocolpopexy Apical Compartment Robotically-Assisted Laparoscopy da Vinci® surgical system Approved in 2005 Hysterectomy Myomectomy Sacrocolpopexy

SUMMARY Prolapse is associated with pressure, but not pain Site-specific exam is aided by Q-tip and half of speculum Site-specific approach to repair Treatment focused on symptom improvement, not anatomical correction