Genital prolapse -Its etilogy and classification

 

Some knowledge of normal vaginal support is needed to understand the pathophysiology of pelvic organ prolapse. Delancey’s three levels of support are now accepted worldwide

I Three Levels of Support:

* Level I (upper level):

Cardinal/Uterosacral ligaments ,

 Level II (middle level):

Pubocervical fascia anteriorly

Rectovaginal fascia posteriorly

Levator ani muscles (through the arcus tendineus fasciae pelvis)

Level III (lower level):

Perineum

Urogenital Diaphragm

.

Q.1:-What is the relevance of Pelvic Floor / Levator Ani Muscle in supporting the uterus soas to prevent genital prolapse.

Ans: It offers indirect support to the uterus as true ligaments merge with its apponeurosis. All these  support lower 1/ 3"' of the vagina. They are attached to the Perineal body which may be torn during labour causing laxity of the perineum. It is formed from three muscle components: the puborectalis, the pubococcygeus muscle (of which the puborectalis is part of) and the iliococcygeus muscle.

Q.2: what are the FALSE LIGAMENTS of genital organs?? :

The Round and the Broad Ligament don’t offer any direct support to the Uterus. They may be utilized in the anteversion of the uterus during the operations for prolapse. One can do shortening of the round ligament during advancement of the U-V fold of the peritoneum

Q.3: RISK FACTORS FOR PROLAPSE UTERUS

Confirmed Risk Factors -

Increased Age

Race

Family History

Obesity and Increased BMI

Increased Parity

 Vaginal Delivery

 Chronic Constipation

Possible Risk Factors —

Intrapartum variables (macrosomia, long second stage of labour, episiotomy, epidural analgesia)

Increased Abdominal Pressure

Menopause

Q,4: What is the globally accepted classification of genital prolapse?

There are several classifications of genital prolapse. All make use of the basic following 5 stages of prolapse.

Stage 0: No prolapse

Stage I: The most distal portion of the prolapse is > 1 cm above the level of the hymen

Stage II: The most distal portion of the prolapse is d”l cm proximal or distal to the hymen

Stage III: The most distal portion of the prolapse is >1 cm below the hymen but protrudes no further than 2 cm less than the total length of the vagina

Stage IV: Complete eversion of the vagina

TYPES OF CLASSIFICATION OF GENITAL PROLAPSE

Types : Older classification

Newer Classification

Q,6: How are the  Pelvic Organ Prolapse Quantified??

In order to create an encoding tool useful to both the clinician and researcher, the Standardization Subcomitee of the International Continence Society created the Pelvic Organ Prolapse Quantification (POP—Q) system in 2002.

The system relies on specific measurements of defined points in the midline of the vaginal wall. The reference point used for measurement remains the hymeneal ring. In this system, small increases in prolapse are recorded as small increases in measurement. Because specific measurements at nine sites are recorded in a tic— tac—toe grid, which improves interobserver agreement and reliability of the diagnosis.

There are 3 reference points anteriorly Aa, Ba and C and 3 reference points posteriorly Ap, Bp and D

Points Aa and Ap are 3 cm proximal to or above the hymeneal ring anteriorly and posteriorly, respectively.

Points Ba and Bp are defined as the lowest points of the prolapse between Aa anteriorly or Ap posteriorly and the vaginal apex.

Anteriorly, the apex is point C (cervix), and posteriorly is point D (pouch of Douglas).

In women after hysterectomy, point C is the vaginal cuff and point D is omitted

the vaginal length at rest, the genital hiatus (gh) from the middle of the urethral meatus to the posterior hymenal ring, and the perineal body (pb) from the posterior aspect of the genital hiatus to the midanal opening.

Amongst all the above mentioned classification the POPQ classification is much superior compared to the older classifications like  ( 1) Jeffcoate’s classification

2) Shaw’s classification 3)Baden walker and beecham classification, 4) Malpaz’s Classification ). POP-Q classification is relevant in the sense that it offers

    giving detailed information, that too with accurate measurement, in centimeters which can be used in statistical tests & research studies.