PELVIC ORGAN PROLAPS.

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1 PELVIC ORGAN PROLAPS

2 Risk Factors Pregnancy Vaginal childbirth
Menopause ( Aging, Hypoestrogenism Chronically increased intra-abdominal pressure (COPD, Constipation, Obesity )

3 Risk Factors Pelvic floor trauma Genetic factors Race
  Connective tissue disorders Hysterectomy Spina bifida

4 Drawing displays the anatomic landmarks used during pelvic organ prolapse quantification (POP-Q).

5 Grid system used for charting in pelvic organ prolapse quantification (POP-Q).

6 The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support
Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at –3 cm and either point C or D is between –TVL (total vaginal length) cm and –(TVL–2) cm (i.e., the quantitation value for point C or D is –[TVL – 2] cm).

7 The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support
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).

8 The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support
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 < + [TVL–2] cm).

9 The Pelvic Organ Prolapse Quantification (POP-Q) Staging System of Pelvic Organ Support
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 (TVL–2) cm (i.e., its quantitation value is +[TVL–2] cm). In most instances, the leading edge of stage IV prolapse will be the cervix or vaginal cuff scar

10 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

11 Pathophysiology Pelvic organ support is maintained by complex interactions between the levator ani muscle, vagina, and pelvic floor connective tissue. However, these mechanisms have not been fully delineated.

12 Mechanism of Levator Ani Damage
Skeletal muscle is a dynamic tissue that is constantly remodeling and regenerating. A heterogeneous population of fibers with different functions allows skeletal muscle to adapt to different situations, such as stretch and mechanical load. Damage to the levator ani muscles follows direct muscle tissue injury or may result from damage to its nerve supply.

13 Mechanism of Levator Ani Damage
Labor and vaginal delivery has the potential to cause this type of damage. However, it is unclear what effect other pathologic conditions, such as chronically increased intra-abdominal pressure, may have on the levator ani muscle.

14 Levels of Vaginal Support
Level I support suspends the upper or proximal vagina. Level II support attaches the mid-vagina along its length to the arcus tendineus fascia pelvis. Level III support results from fusion of the distal vagina to adjacent structures. * Defects in each level of support result in identifiable vaginal wall prolapse: anterior, apical, and posterior.

15 Bulge Symptoms Sensation of vaginal bulging or protrusion
 Rectal prolapse   Seeing or feeling a vaginal or perineal bulge Vulvar or vaginal cyst/mass   Pelvic or vaginal pressure Pelvic mass   Heaviness in pelvis or vagina  Hernia (inguinal or femoral)

16 Urinary symptoms Urinary incontinence
 Urethral sphincter incompetence   Urinary frequency  Detrusor overactivity   Urinary urgency Hypoactive detrusor function   Weak or prolonged urinary stream Bladder outlet obstruction

17 Urinary symptoms Hesitancy Excessive fluid intake
  Feeling of incomplete emptying  Interstitial cystitis   Manual reduction of prolapse to start or complete voiding  Urinary tract infection   Position change to start or complete voiding

18 Bowel symptoms Incontinence of flatus or liquid/solid stool
 Anal sphincter disruption or neuropathy Feeling of incomplete emptying Diarrheal disorder Hard straining to defecate Rectal prolapse Urgency to defecate Irritable bowel syndrome

19 Bowel symptoms Digital evacuation to complete defecation
Rectal inertia Splinting vagina or perineum to start or complete defecation Pelvic floor dyssynergia  Feeling of blockage or obstruction during defecation Hemorrhoids  Anorectal neoplasm

20 Sexual symptoms Dyspareunia  Vaginal atrophy
Decreased lubrication  Levator ani syndrome  Decreased sensation Vulvodynia Decreased arousal or orgasm Other female sexual disorder

21 Pain Pain in vagina, bladder, or rectum  Interstitial cystitis
  Pelvic pain  Levator ani syndrome   Low back pain  Vulvodynia Lumbar disc disease  Musculoskeletal pain  Other causes of chronic pelvic pain

22 Physical Examination Physical examination begins with a full body systems evaluation to identify pathology outside the pelvis. Systemic conditions such as cardiovascular, pulmonary, renal, or endocrinologic disease may affect treatment choices and should be identified early.

23 Perineal Examination Lithotomy position. The vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalities A neurologic examination of sacral reflexes is performed using a cotton swab (bulbocavernosus reflex , anal wink reflex.

24 Perineal Examination Pelvic organ prolapse examination begins by asking a woman to attempt Valsalva maneuver prior to placing a speculum in the vagina. Importantly, this assessment helps answer three questions: (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?

25 Vaginal Examination If the POP-Q examination is performed, the genital hiatus (gh) and perineal body (pb) are measured during Valsalva maneuver. The total vaginal length (TVL) is then measured by placing the marked ring forceps at the vaginal apex and noting the distance to the hymen.

26 Vaginal Examination A bivalve speculum is then inserted to the vaginal apex. It displaces the anterior and posterior vaginal walls C and D are then measured. The speculum is slowly withdrawn to assess descent of the apex. A split speculum is then used to displace the posterior vaginal wall and allow for visualization of the anterior wall and measurement of points Aa and Ba

27 Bimanual examination is performed to identify other pelvic pathology
. During evaluation, an index finger is placed 2 to 3 cm inside the hymen, at 4 and then 8 o'clock. Muscle resting tone and strength is assessed using the 0 through 5 Oxford grading scale. Five represents strong tone and strength (Laycock, 2002). Muscle symmetry is also evaluated. Asymmetric muscles, with palpable defects or scarring, may be associated with a prior obstetric forceps delivery or laceration.

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35 Treatment Nonsurgical Treatment  Pessary Use in Pelvic Organ Prolapse
Pelvic Floor Muscle Exercise  Pelvic floor muscle exercise has been suggested as a therapy that might limit progression and alleviate prolapse symptoms.

36 Surgical Treatment Obliterative Procedures Reconstructive Procedures

37 Anterior Compartment Anterior colporrhaphy .
. In a randomized trial of three anterior colporrhaphy techniques ( traditional midline plication, ultralateral repair, and traditional plication plus lateral reinforcement with synthetic mesh.

38 Vaginal Apex There is a growing appreciation that support of the vaginal apex provides the cornerstone for a successful prolapse repair. Some experts believe that isolated surgical repair of the anterior and posterior walls is doomed for failure if the apex is not adequately supported (Brubaker, 2005b).

39 Abdominal Sacrocolpopexy
This surgery suspends the vaginal vault to the sacrum using synthetic mesh. Sacrospinous Ligament Fixation (SSLF ) Uterosacral Ligament Vaginal Vault Suspension

40 Hysterectomy at the Time of Prolapse Repair
In the United States, hysterectomy is often performed concurrently with prolapse surgery

41 Posterior Compartment
Enterocele Repair Posterior vaginal wall prolapse may be due to enterocele or rectocele. Rectocele Repair Mesh Reinforcement Sacrocolpoperineopexy Perineorrhaphy

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48 Derajat Prolaps Uteri

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50 Diagram Posisi Normal genitalia dan Eversi komplit dari vagina

51 Diagram defek dinding anterior vagina dan posterior vagina

52 Cara Mudah Patokan Himen Di atas - 1cm Grade I 1 cm sp +1cm Grade II Di bawah + 1cm Grade III Eversi komplit Grade IV

53 PROSEDUR PEMERIKSAAN Hasil tergantung pengetahuan & pengalaman
Abnormal  Harus tahu normal Pemeriksaan : Inspeksi, Palpasi, Penilaian Apeks – Perineum Alat : Spekulum Graves Spekulum Sims Sonde

54 PROSEDUR PEMERIKSAAN Posisi : Berdiri Berbaring Posisi berdiri :
Penilaian lebih baik Posisi aktif normal Gejala timbul bila duduk/berdiri Saat Penilaian Istirahat Peregangan : Manuver Valsalva Tarikan dengan Tenakulum

55 PENATALAKSANAAN Pencegahan : Penanganan persalinan yang baik
Terapi hormon pengganti Latihan otot dasar panggul

56 PENATALAKSANAAN Konservatif Penggunaan pesarium vagina
Indikasi penggunaan: Kontra indikasi operasi Menunggu operasi (mengurangi simptom) Masih ingin hamil Trimester pertama kehamilan Pemeriksaan diagnostik memastikan koreksi sistouretrokel besar bukan penyebab stres inkontinensia urin

57 Smith (silicone, folding)
Hodge without support (silicone. folding) Hodge with support (silicone, folding) Gehrung with support (silicone, folding) Risser (silicone, folding) Ring with support (slllcone, folding) Ring without support (slllcone, folding) Cube (silicone, flexible) Tandem-Cube (silicone, flexible) Rigid Gellhom (acrylic, multiple drain) 95% Rigid Gellhom (silicone, multiple drain) Flexible Gellhom (silicone, multiple drain) Ring incontinence (silicone) Shaatz (silicone. folding) Incontinence dish (silicone, folding) Inflate Ball (latex) Donut (silicone)

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59 PENATALAKSANAAN Pembedahan Kompartemen Melalaui Vagina
Melalaui Suprapubik Anterior Vagina Anterior repair dgn atau tanpa mesh Kolposuspension Middle Vaginal hysterektomy; vault repair ( fascia); sacrospinous fixation; bilateral iliococcygeal hitch Sacrosphysteropexy ; sacrocolpopexy Posterior Levator plication; fascia repair with or without mesh; transanal repair Mesh interposition; sacrocolpopexy with mesh interposition

60 MASALAH REKURENSI Prolaps puncak vagina akan terjadi bila puncak vagina tidak dijahit pada ligamenta sakro uterina Perbaikan bisa dikerjakan pervaginam atau suprapubik Prosedur sederhana seperti kolpokleisis bisa dikerjakan (khususnya pada wanita yang tidak aktif seksual)

61 Fiksasi sakrospinosus dapat dikerjakan dengan menjahit puncak vagina pada ligamentum sakrospinosus tanpa mengurangi kapasitas vagina dengan angka penyembuhan selama 1tahun sebesar 90% Tindakan sakrokolpopeksi melalui abdomen, puncak vagina dijahit dengan proline mesh pada promotorium dengan angka penyembuhan 1-10 tahun sebesar 88-97%

62 KESIMPULAN Mengerti tentang pato anatomi prolaps genitalia akan memberikan hasil yang lebih baik dalam tatalaksana prolapsus genitalia Angka rekurensi sesudah pembedahan vagina perlu mendapat perhatian terutama dalam mengantisipasi berbagai defek yang mungkin terjadi

63 Vagina Normal

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65 Perubahan dinding anterior vagina paska persalinan

66 Prolaps Uteri Grade III Dengan Penonjolan Dinding Depan Vagina Yang Dominan

67 Prolaps Uteri Grade IV Dengan Kehilangan Penunjang Dinding Anterior Vagina Komplit

68 Dinding Vagina Posterior Wanita Yang Pernah Melahirkan

69 Rektokel Grade III

70 Rektokel Grade IV

71 Dinding Vagina Posterior Wanita Yang Pernah Melahirkan

72 Prolaps Puncak Vagina

73 Prolaps Genitalia Dan Prolaps Rekti

74 Fistula Urogenital Terdapat hubungan banormal anatara traktus urinarius ( uretra, vesica, ureter dan uterus, cervik vagina

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77 Fistula Vesikovaginalis

78 Etiologi Kelainan kongenital
Didapat ( Trauma Obstetri dan Pembedahan Panggul ) Penyebab lain ( Radiasi, keganasan, trauma, benda asing, infeksi )

79 Diagnosa Anamnesa Pemeriksaan Fisik Metilen Blu test Cystoskopi
Cystouretrogram

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81 Penatalaksanaan Konservatif Operatif ( Cure rate dan Timing )
Pervaginam Perabdominam

82 Penutupan perabdominam

83 Thank You

84 Persiapan insersi ring pessarium

85 Caramemegang Ring pesarium
Langkah 2 Jari tangan yang lain membuka labia minora sehingga liang vagina tampak Pessarium dimasukkan kedalam liang vagina sejajar dengan lantai dan didorong sepanjang dinding posterior Caramemegang Ring pesarium

86 Pessarium dimasukkan ke vagina sejajar dinding posterior

87 Pessarium terpasang dalam vagina

88 Memeriksa posisi pessarium

89 Mengait dan memutar pessarium dengan 1 jari

90 Memegang pessarium agar dalam posisi tertekuk