**5. Sacrospinous colpopexy**

reflexes and patellar reflexes. Cardiovascular examination should be done to rule out lower

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

The management options of recurrent pelvic organ prolapse is almost always surgical. It is to be realized that surgical options are the first choice as they provide a long-term relief. Surgical measures should always be accompanied by pelvic muscle strengthening exercises

The surgical procedure must be case based. If the initial repair was vaginal hysterectomy with pelvic floor repair the subsequent repair can be sacrospinous colpopexy or sacrospinous fixation. If the initial repair was sacrohysteropexy the recurrent prolapse can be managed by vaginal hysterectomy, anterior colporrhaphy and posterior colpoperineorrhaphy along with

extremities edema and feature of congestive heart failure [15–17].

common questionnaire used is the PFDI-20 questionnaire [18–20].

**3.5. Simple primary care tests**

62 Pelvic Floor Disorders

**4. Management options**

McCall's culdoplasty.

in the postoperative period for best outcome.

**Table 1.** Corrective surgery for vaginal vault prolapse.

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 or Capio (**Figure 3**).

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 anchored to the sacrospinous ligament.

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 vaginal wall.

**Figure 3.** (a) The anatomical identification of sacrospinous ligaments as viewed from above and laterally. (b) The vaginal vault is anchored to the sacrospinous ligaments with delayed absorbable or nonabsorbable sutures. (c) The vaginal mucosa is anchored and closed.

with anterior sacrospinous fixation to achieve the best outcome. Postoperative strengthening

**Figure 4.** Anterior v/s posterior sacrospinous vault fixation: Postoperative comparison based on pelvic organ prolapse . Solid line: Anterior sacrospinous vault fixation, dashed line: Posterior sacrospinous fixation. (a): Lateral view of Vaginal axis after anterior and posterior bilateral sacrospinous fixation. (b): Anterior posterior view of vaginal axis after anterior

Recurrent Pelvic Organ Prolapse

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

In vault prolapse the endopelvic fascia surrounding the vagina is broken at specific points. A site-specific repair and anchoring to the stumps of uterosacral ligaments will restore the suspension. Three principles are identification of the fascia defect, reducing the enterocele sac and closure of the fascia defect. Finally the vagina is anchored to the Level 1 support of uterosacral ligament making the procedure most anatomically close to physiologically correct vaginal axis. Vaginal apex is grabbed with two Allis clamps. The vaginal mucosa over the enterocele is incised. The enterocele sac is identified and dissected till the base or neck of the sac. The enterocele sac is opened carefully and contents are reduced taking care of adhesions. The excessive peritoneum is excised. A Deaver retractor is placed anteriorly and used to pack the abdominal

The uterosacral ligament stumps are identified; remnants are usually believed to be present at 5 0'clock and 7 0'clock position. The ureter position is confirmed by palpating the pelvic sidewall. The ureter is usually placed 2–3 cm lateral and ventral to the ischial spine. A nonabsorbable Prolene 1/0 suture is placed on the uterosacral remnant on left side passing the needle from lateral to medial side to avoid injuring the ureter. The rectum is then deflected away by the non-dominant hand. A second suture is placed further high and medially on the left uterosacral ligament for better anchoring. The peritoneum is included in the stich and now the stich is passed in the opposite uterosacral ligament taking the needle from lateral to medial side. Now these sutures are tied and this obliterates the cul-de-sac (**Figure 5**). Anterior

colporrhaphy or sling procedures if required are performed at this stage now.

of perineal muscles by structured pelvic exercises is effective.

**6. Uterosacral vaginal vault suspension**

and posterior bilateral sacrospinous fixation.

contents anteriorly.

The anterior approach was developed subsequently to overcome the shortcomings of posterior approach. In the anterior approach a vertical anterior vaginal incision is made for retro pubic entry and paravaginal and paravesical space is dissected. The sacrospinous ligament is identified and the anterior cuff of vagina is anchored with two polytetrafluoroethylene (00) sutures. The two sutures are placed 2 cm apart on sacrospinous ligament. The same procedure is performed on the contralateral sacrospinous ligament.

The anterior suspension technique positions the vaginal vault in a more capacious anatomic space, in comparison to the relatively narrow pararectal area occupied by the upper vagina after posterior sacrospinous vault suspension (**Figure 4(a)** and **(b)**). After anterior sacrospinous vaginal vault suspension, vaginal length and apical suspension are slightly increased. The axis of the suspended vagina appears more physiological. There are less chances of recurrent anterior compartment prolapse as compared with the posterior sacrospinous vaginal vault suspension procedure. The upper vaginal lumen caliber and sexual function are adequately preserved in both techniques [23]. The posterior vaginal wall laxity, on the contrary, is more common after anterior sacrospinous vault suspension.

However, these differences are likely to be influenced by differences in levator muscle tone and degree of perineal support. So a posterior colporrhaphy may be concurrently performed

**Figure 4.** Anterior v/s posterior sacrospinous vault fixation: Postoperative comparison based on pelvic organ prolapse . Solid line: Anterior sacrospinous vault fixation, dashed line: Posterior sacrospinous fixation. (a): Lateral view of Vaginal axis after anterior and posterior bilateral sacrospinous fixation. (b): Anterior posterior view of vaginal axis after anterior and posterior bilateral sacrospinous fixation.

with anterior sacrospinous fixation to achieve the best outcome. Postoperative strengthening of perineal muscles by structured pelvic exercises is effective.
