4Drawing displays the anatomic landmarks used during pelvic organ prolapse quantification (POP-Q).
5Grid system used for charting in pelvic organ prolapse quantification (POP-Q).
6The 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).
7The 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).
8The 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).
9The 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
10Baden-Walker Halfway System for the Evaluation of Pelvic Organ Prolapse on Physical Examinationa Grade 0 Normal position for each respective siteGrade 1 Descent halfway to the hymenGrade 2 Descent to the hymenGrade 3 Descent halfway past the hymenGrade 4 Maximum possible descent for each site
11PathophysiologyPelvic 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.
12Mechanism 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.
13Mechanism 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.
14Levels 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.
15Bulge 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 pressurePelvic mass Heaviness in pelvis or vagina Hernia (inguinal or femoral)
17Urinary 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
18Bowel symptoms Incontinence of flatus or liquid/solid stool Anal sphincter disruption or neuropathyFeeling of incomplete emptyingDiarrheal disorderHard straining to defecateRectal prolapseUrgency to defecateIrritable bowel syndrome
19Bowel symptoms Digital evacuation to complete defecation Rectal inertiaSplinting vagina or perineum to start or complete defecationPelvic floor dyssynergia Feeling of blockage or obstruction during defecationHemorrhoids Anorectal neoplasm
20Sexual symptoms Dyspareunia Vaginal atrophy Decreased lubrication Levator ani syndrome Decreased sensation VulvodyniaDecreased arousal or orgasm Other female sexual disorder
21Pain Pain in vagina, bladder, or rectum Interstitial cystitis Pelvic pain Levator ani syndrome Low back pain VulvodyniaLumbar disc disease Musculoskeletal pain Other causes of chronic pelvic pain
22Physical ExaminationPhysical 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.
23Perineal ExaminationLithotomy position. The vulva and perineum are examined for signs of vulvar or vaginal atrophy, lesions, or other abnormalitiesA neurologic examination of sacral reflexes is performed using a cotton swab (bulbocavernosus reflex , anal wink reflex.
24Perineal ExaminationPelvic 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?
25Vaginal ExaminationIf 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.
26Vaginal ExaminationA bivalve speculum is then inserted to the vaginal apex. It displaces the anterior and posterior vaginal wallsC 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
27Bimanual 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.
35Treatment 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.
37Anterior 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.
38Vaginal ApexThere 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).
39Abdominal Sacrocolpopexy This surgery suspends the vaginal vault to the sacrum using synthetic mesh.Sacrospinous Ligament Fixation (SSLF )Uterosacral Ligament Vaginal Vault Suspension
40Hysterectomy at the Time of Prolapse Repair In the United States, hysterectomy is often performed concurrently with prolapse surgery
41Posterior Compartment Enterocele RepairPosterior vaginal wall prolapse may be due to enterocele or rectocele.Rectocele RepairMesh ReinforcementSacrocolpoperineopexyPerineorrhaphy
54PROSEDUR PEMERIKSAAN Posisi : Berdiri Berbaring Posisi berdiri : Penilaian lebih baik Posisi aktif normalGejala timbul bila duduk/berdiriSaat PenilaianIstirahatPeregangan : Manuver ValsalvaTarikan dengan Tenakulum
55PENATALAKSANAAN Pencegahan : Penanganan persalinan yang baik Terapi hormon penggantiLatihan otot dasar panggul
56PENATALAKSANAAN Konservatif Penggunaan pesarium vagina Indikasi penggunaan:Kontra indikasi operasiMenunggu operasi (mengurangi simptom)Masih ingin hamilTrimester pertama kehamilanPemeriksaan diagnostik memastikan koreksi sistouretrokel besar bukan penyebab stres inkontinensia urin
57Smith (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)
59PENATALAKSANAAN Pembedahan Kompartemen Melalaui Vagina Melalaui SuprapubikAnteriorVagina Anterior repair dgn atau tanpa meshKolposuspensionMiddleVaginal hysterektomy; vault repair ( fascia); sacrospinous fixation; bilateral iliococcygeal hitchSacrosphysteropexy ; sacrocolpopexyPosteriorLevator plication; fascia repair with or without mesh; transanal repairMesh interposition; sacrocolpopexy with mesh interposition
60MASALAH REKURENSIProlaps puncak vagina akan terjadi bila puncak vagina tidak dijahit pada ligamenta sakro uterinaPerbaikan bisa dikerjakan pervaginam atau suprapubikProsedur sederhana seperti kolpokleisis bisa dikerjakan (khususnya pada wanita yang tidak aktif seksual)
61Fiksasi 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%
62KESIMPULANMengerti tentang pato anatomi prolaps genitalia akan memberikan hasil yang lebih baik dalam tatalaksana prolapsus genitaliaAngka rekurensi sesudah pembedahan vagina perlu mendapat perhatian terutama dalam mengantisipasi berbagai defek yang mungkin terjadi
85Caramemegang Ring pesarium Langkah 2Jari tangan yang lain membuka labia minora sehingga liang vagina tampakPessarium dimasukkan kedalam liang vagina sejajar dengan lantai dan didorong sepanjang dinding posteriorCaramemegang Ring pesarium
86Pessarium dimasukkan ke vagina sejajar dinding posterior