Diagnosis of pelvic organ prolapse

Surgical correction: plastic repair and fixation

The choice of surgical treatment for prolapse directly depends on the need to preserve the patient's sexual function. One of the baseline operations is colpoperineolevatoroplasty. The procedure begins with careful dissection of the posterior vaginal wall mucosa. Afterward, the surgeon isolates the levator ani muscle (m. levator ani) and places strengthening sutures on it. The procedure concludes with the meticulous closure of the perineal skin.

For women leading an active sex life, the optimal choice is colpopexy, which is the surgical fixation of the vaginal vault. The surgical technique varies depending on the access approach:

• Vaginal approach: the vaginal vault is sutured to the sacrospinous ligament (most commonly on the right side).
• Laparoscopic or abdominal approach: the operation is called sacral colpopexy (or sacrocolpopexy). The vault is fixed to the anterior longitudinal ligament of the sacrum with the mandatory use of a synthetic mesh.

This technique is universal: it is successfully used both after total hysterectomy (fixing the vault itself) and after supracervical amputation of the uterus (in this case, the cervical stump is fixed).

There are also vaginal obliteration procedures—the Le Fort and Labhardt operations. These are non-physiological interventions that completely and irreversibly preclude any future sexual activity.

Vaginal Hysterectomy

Vaginal hysterectomy (Hysterectomia vaginalis) is a radical multi-step procedure aimed at removing the organ and strengthening the pelvic floor.

1. Vaginal approach. A precise circular incision of the vaginal wall is made around the cervix (cervix uteri). The essence of this step is to dissect the mucosa to expose the fascia and create safe access to the ligamentous apparatus.
2. Uterine mobilization. The surgeon sequentially applies clamps, cuts, and ligates the cardinal ligaments (ligamenta cardinalia). Next, clamping, transection, and secure ligation of the vascular bundles (primarily the uterine arteries and veins, vasa uterina) are performed. The uterus is completely severed from its supporting and feeding structures, leaving only the ligated stumps in the wound.
3. Peritonealization. The pelvic peritoneum (peritoneum pelvicum) is carefully closed using a purse-string suture. This ensures the sealing of the abdominal cavity and extraperitonealization of the remaining ligament and vascular stumps, which is a crucial measure for preventing postoperative peritonitis and adhesion formation.
4. Pelvic floor strengthening. To prevent prolapse recurrence, the stumps of the cardinal ligaments and uterine adnexa (adnexa uteri) are sutured together strictly along the midline. This forms a strong connective tissue framework (arch) over the vaginal stump, preventing wall prolapse and the development of an enterocele.

Mesh repair for prolapse

In cases of severe pelvic floor defects, surgical correction using synthetic prostheses (meshes) is performed. The implantation scheme requires precise positioning of the graft:

• The anterior part of the prosthesis is placed directly beneath the urinary bladder, providing reliable support for it.
• The vaginal vault (or the posterior part of the prosthesis) is positioned over the rectal wall.
• For secure fixation of the entire structure, special mesh arms are brought out through the obturator foramen, as well as in the gluteal region.

Associated pathology: urinary incontinence

Pelvic organ prolapse is very frequently accompanied by urinary incontinence, a condition characterized by the complete loss of voluntary control over urination. This is a serious social, medical, and hygienic problem that can occur at any age. According to statistics, in Europe and the USA, symptoms are reported by about 45% of women aged 40–60 years, while in Russia this figure reaches 38.6%.

Normal bladder functioning requires intact innervation and coordinated action of the pelvic floor muscles:

• Filling phase: resistance at the internal urethral meatus increases, while the detrusor muscle (the urine-expelling muscle) remains relaxed.
• Emptying phase: the urine volume reaches a threshold value, and impulses from stretch receptors are transmitted to the brain. A reflex is triggered that causes the detrusor to contract.

Neurophysiological control is carried out by the micturition center in the brain, which has close connections with the cerebellum. It is the cerebellum that coordinates the relaxation of the pelvic floor muscles and strictly controls the amplitude and frequency of detrusor contractions during urination. Subsequently, the signal is transmitted via descending pathways to lower centers.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Topographic anatomy of the levator ani muscle (m. levator ani).
• Technique of placing a purse-string suture on the pelvic peritoneum (peritoneum pelvicum).
• Specifics of routing synthetic graft strips through the obturator foramen.
• Descending neural pathways from the cerebral micturition center.
• Prevention of enterocele following vaginal hysterectomy.

Other topics in the "Gynecology" section

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