Uterovaginal Prolapse
/Today we sit down with Dr. Julia Shinnick, one of our co-residents at Brown University and future FPMRS specialist, to talk through prolapse!
The POP-Q tool from AUGS is a helpful web-based tool (also with iPhone/iPad apps!) that can help you understand prolapse, as well as illustrate prolapse to patients in your practice.
One common quiz question are the levels of support. These are:
Level I consists of the cardinal and uterosacral ligaments, and suspends the vaginal apex. Uterosacral/cardinal ligament complex, which suspends the uterus and upper vagina to the sacrum and lateral pelvic side wall. In a magnetic resonance imaging (MRI) study of asymptomatic women, the uterosacral ligaments were found to originate on the cervix in 33 percent, cervix and vagina in 63 percent, and vagina alone in 4 percent. Loss of level 1 support contributes to the prolapse of the uterus and/or vaginal apex.
Level II consists of the paravaginal attachments, are what create the H shape of the vagina. The anterior vaginal wall is suspended laterally to the arcus tendineus fascia pelvis (ATFP) or “white line,” which is a thickened condensation of fascia overlying the iliococcygeus muscle. The anterior Level II supports suspend the mid-portion of the anterior vaginal wall creating the anterior lateral vaginal sulci. Detachment of these lateral supports can lead to paravaginal defects and prolapse of the anterior vaginal wall. There are also more posterior lateral supports at Level II. The distal half of the posterior vaginal wall fuses with the aponeurosis of the levator ani muscle from the perineal body along a line referred to as the arcus tendineus rectovaginalis. It converges with the ATFP at a point approximately midway between the pubic symphysis and the ischial spine. Along the proximal half of the vagina, the anterior and posterior vaginal walls are both supported laterally to the ATFP.
Level III consists of the perineal body and includes interlacing muscle fibers of the bulbospongiosus, transverse perinei, and external anal sphincter. Loss of level 3 support can result in a distal rectocele or perineal descent.
Remember — the treatments are generally conservative with pelvic floor PT; devices, such as pessaries; or surgeries.