**2. Anatomical considerations**

In 1555 Andreas Vesalius referred to the pelvic floor muscles as "Musculus sedem attollens". Von Behr later referred this as levator ani. The term pelvic diaphragm includes ischiococcygeus, ileococcygeus and pubococcygeus which all forms the levator ani. Puborectalis or "Sphincter Recti" is described as the fibers of pubococcygeus which loop around the rectum and this muscle is now included in the levator ani group. As the muscles of the pelvic diaphragm are intimately related to the urethra, vagina, rectum and anal canal, the term pubovisceralis for the muscles of pelvic floor was first coined by Lawson and was later supported by Delancey [1–3].

junction of the fascia of the obturator internus and levator ani muscle. This tissue provides

Recurrent Pelvic Organ Prolapse

61

http://dx.doi.org/10.5772/intechopen.76669

The initial evaluation of patients with vaginal vault prolapse requires a systematic approach

Physicians treating the recurrent prolapse patient should empathically ask them how the pro-

The physical examination of the patient with recurrent prolapse should focus on both the general medical conditions that may affect the pelvic organs as well as the problems related to prolapse [10, 11]. Such conditions include cardiovascular insufficiency, pulmonary disease, occult neurologic processes, (e.g. Multiple sclerosis, stroke, Parkinson's disease, and anomalies of the spine and lower back), abdominal masses and general activity of the patient [12, 13].

This should be performed by POP-Q system [12–14]. A special note should be made regarding pelvic organ prolapse and atrophy. Levator ani muscle symmetry should be noted during the ability to squeeze test. Anal sphincter function, presence of fissures and symmetry during

Recurrent prolapse assessment should include urodynamic studies to reach a correct diagnosis of the type of incontinence associated with recurrent prolapse. The indications of urody-

**1.** The diagnosis is uncertain (major discrepancies between the history, voiding diary and

**3.** Associated neurological conditions like multiple sclerosis leading to recurrent prolapse.

Gait assessment should be done and mobility status should be noted. A detailed neurological examination should incorporate measures of mental status, perineal sensation, perineal

lapse specially affects their life and to what degree the prolapse bothers them.

support to vagina vault laterally [2, 8, 9].

**3. Initial evaluation**

**3.2. Physical examination**

**3.3. Pelvic examination**

namic studies are:

symptom scale).

**5.** Coexisting rectal prolapse.

**3.4. Systemic examination**

squeezing should also be noted.

**2.** Elevated post void residual urine volume.

**4.** Previous surgery for incontinence correction.

**3.1. History**

to consider the probable causes.

The muscles in pelvis can be classified into two groups. The lateral wall muscles and the pelvic floor muscles. The lateral wall muscles include the obturator internus and piriformis and the pelvic floor muscles include the levator ani. The pelvic floor muscles form the pelvic diaphragm [4, 5]. The levator ani is a broad thin sheet of muscle arising from the inner aspect of the pelvic walls unites with its fellow from the opposite side to form the floor of pelvic cavity. It supports the pelvic viscera and some of its fibers get attached to the wall of the visceral structures passing through it. The levator ani has an extensive origin starting from the posterior surface of the superior ramus of pubic bone, obturator fascia to the inner aspect of the ischial spine. The fibers pass downward and backwards thus creating a shallow saucer like structure on which the pelvic viscera rests. The posterior most fibers from either side get attached to the sides of the terminal two pieces of coccyx. Fibers immediately anterior to this unite with the fellow fibers of opposite side to form a median anococcygeal raphe extending between the coccyx and the posterior margin of anus.

The term pubovisceralis is extensively used in gynecological texts but it is not commonly mentioned in anatomical texts. The portions of pubovisceralis that are inserted into the urethra, vagina, perineal body and anal canal were given names as pubourethralis, pubovaginalis and puboperinalis respectively by Lawson [4–6]. The action of these muscles is to provide support to the visceral organs. The ileococcygeous muscle provides support to the posterior compartment and fuses anterior to the coccyx with fibers of opposite side to form the anococcygeal raphe or the levator plate in the median plane. This thin muscular plate supports the viscera of the pelvis especially when there is rise in intraabdominal pressure. Sagging of levator plate is an important defect leading to loss of support of the pelvic organs [7, 8].

The perineal body, which lies posterior to the posterior vaginal wall and anterior to the wall of anal canal, is an important support of pelvic floor. The attachments and components of perineal body are still debated. Recent studies using 3D endovaginal ultrasonography have assessed the structure of the perineal body showed that it has mixed echogenicity and situated between rectum, anal canal and posterior wall of vagina [2, 5]. Perineal body is divided into two levels, i.e. a superficial level which is continuous with external anal sphincter, bulbospongiosus and the superficial transverse perineal muscles and a deeper part, which is in continuity with the pubovisceralis muscle of the pelvic floor [6, 7].

The endopelvic connective tissue in this area attaches to the perineal membrane and laterally it stretches over the levator ani and condenses to form the arcus tendineus fascia pelvis, which stretches from pubic bone till the ischial spine. This arcus tendineus fascia pelvis lies at the junction of the fascia of the obturator internus and levator ani muscle. This tissue provides support to vagina vault laterally [2, 8, 9].
