**3. Initial evaluation**

The initial evaluation of patients with vaginal vault prolapse requires a systematic approach to consider the probable causes.

#### **3.1. History**

**2. Anatomical considerations**

60 Pelvic Floor Disorders

between the coccyx and the posterior margin of anus.

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]. 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

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 leva-

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

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

tor plate is an important defect leading to loss of support of the pelvic organs [7, 8].

continuity with the pubovisceralis muscle of the pelvic floor [6, 7].

Physicians treating the recurrent prolapse patient should empathically ask them how the prolapse specially affects their life and to what degree the prolapse bothers them.

#### **3.2. Physical examination**

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].

#### **3.3. Pelvic examination**

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 squeezing should also be noted.

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


#### **3.4. Systemic examination**

Gait assessment should be done and mobility status should be noted. A detailed neurological examination should incorporate measures of mental status, perineal sensation, perineal reflexes and patellar reflexes. Cardiovascular examination should be done to rule out lower extremities edema and feature of congestive heart failure [15–17].

The reconstructive surgical procedures for the anterior and posterior vaginal vault prolapse are listed in **Table 1**. The anterior vaginal Wall repairs include anterior colporrhaphy and site-specific repair. The posterior vaginal wall repair procedures include posterior colporrhaphy, site-specific repair, perineorrhaphy, McCall's culdoplasty and Moskowitz procedure. The procedures for vault prolapse following hysterectomy include sacrospinous colpopexy, uterosacral ligament (USLS) suspension via abdominal or vaginal route, ileococcygeal fascia

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

Access to sacrospinous ligament is obtained through the Para rectal space in posterior approach and through the paravesical space in the anterior approach. The right ischial spine is localized digitally and after retractor positioning the ligament is made visible through blunt dissection. Two permanent sutures (Prolene 1.0, Ethicon, Somerville, NJ, USA) are placed through the right sacrospinous ligament at least 2 cm from the ischial spine. Pulley sutures are used to anchor the undersurface of the anterior vaginal cuff (anterior sacrospinous suspension) or posterior cuff (posterior sacrospinous suspension) along the sacrospinous ligament medially and laterally. During both techniques, the medial and lateral fixation sutures are placed at least 2 cm apart along the ligament. Hereafter an additional anterior and/or posterior colporrhaphy or incontinence surgery can be performed. The procedure is acceptable with few complications [22]. Sacrospinous Fixation can be done using Miya hook

There are two ways to access the sacrospinous ligament: the anterior approach and the posterior approach. In the anterior approach the sacrospinous ligament is accessed after dissecting the paravaginal and paravesical spaces and the anterior vaginal cuff is anchored to the sacrospinous ligament. In the posterior approach the pararectal fossa is opened after dissected the posterior vaginal wall from the rectovaginal fascia. And the posterior cuff of vagina is

In the posterior approach the vaginal mucosa is incised transversely at the posterior fourchette and the posterior vaginal mucosal flap is raised above from rectovaginal fascia. The assistant deflects the rectum medially while the surgeon palpates the ischial spine and identifies the sacrospinous ligament. A Miya hook passed through the sacrospinous ligament. The Miya hook is threaded with the suture and the sutures are carried and anchored to the vaginal vault. The permanent sutures are placed through the posterior side of the vagina in the posterior approach. The lower two thirds of posterior vaginal wall is closed with absorbable sutures (Vicryl 2, Eticon Somerville, NJ, USA). The permanent sutures are now tightened and the remaining one third of the vaginal wall is also closed (**Figures 3(a)**–**(c)**). The same principal is applied for sacrospinous hysteropexy in an intact uterus. The posterior sacrospinous approach is less invasive but the vaginal axis is slightly downwards as compared to the physiological axis of vagina. This predisposes to anterior compartment defects as the raised intraabdominal pressures are now directly transmitted to the anterior

suspension and abdominal sacrocolpopexy [21].

**5. Sacrospinous colpopexy**

or Capio (**Figure 3**).

vaginal wall.

anchored to the sacrospinous ligament.

#### **3.5. Simple primary care tests**

Simple primary care clinical tests are an integral part of initial evaluation. Pelvic Floor Distress Inventory-Short Form 20 (PFDI-20), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and the ICIQ-VS score can be used to evaluate the quality of life and severity of symptoms. The most common questionnaire used is the PFDI-20 questionnaire [18–20].
