Pelvic organ prolapse in women (POP) is a common condition that can reach up to 40% in multiparous women. Their associated conditions, such as urinary and fecal incontinence are important problems to address when studying these patients.

Adequate knowledge of the anatomy and physiology of the pelvic floor, as well as an understanding of the pathophysiology of POP, are essential when planning treatment for these pathologies.

There are multiple treatment alternatives for POP, not all of them are surgical.

The diagnosis of each of the defects will allow planning the most appropriate surgical technique. The repair of each of the levels involved is essential to achieve a better result over time.

Pelvic organ prolapse (POP) is one of the most common indications in gynecological surgery. In the United States, it is estimated that 200,000 surgeries are performed annually for this reason. Between 7.5-14% of hysterectomies are caused by POP [1]. A Women's Health Initiative (WHI) study describes that 41% of non-hysterectomies women and 38% of hysterectomies women had some type of prolapse [2,3]. In this same study, anterior chamber prolapse was always the most common, both in women who did not give birth, multiparous women and in women who had a hysterectomy versus women without a uterus [4,5].      

The incidence of POP surgery increases with age. It is estimated that the risk of having an intervention for this reason at age 80 is 11.1% and that the risk of re-surgery is 30%. Given that the life expectancy of the US population has been increasing, it is estimated that by 2030 20% of the population will be over 65 years of age, the volume of POP surgeries will therefore increase dramatically (45%) (1). The same situation is expected to occur in Chile, were, according to data published by the National Institute of Statistics (INE), by 2025, 20.1% of the population will be over 60 years [6,7].

It is difficult to estimate the incidence and prevalence of POPs, as they only become symptomatic once they are removed from the entrance.

It is important to keep in mind that the prevalence of urinary incontinence in women in the major reproductive period is still 40% and rises to 50% in the postpartum period [8]. Anal enuresis  is  found  among 6-28% of the female population in the United States [10]. Finally, the relationship between urinary incontinence and anal incontinence is as high as 9% [9].

It is important to take these latter elements into account when confronting a patient with POP, as urinary and rectal diseases should not be overlooked due to the high percentage of association between them [11]. 

This prolapse may cause the vagina or uterus to protrude, or both. The development of pelvic organ prolapse can also be attributed to other factors such as age, obesity, hysterectomy, chronic stress and connective tissue abnormalities that lead to rupture or stretching or dysfunction of vaginal connective tissue appendices, which leads to pelvic organ prolapse [12].

There are different types of pelvic organ prolapse depending on which organ is affected. The most common types are:

• Cystocele, the most common type of pelvic prolapse that occurs when the bladder falls into or out of the vagina.

• A rectocele occurs when the rectum bulges into or out of the vagina for a variety of reasons.

Uterine prolapse occurs when the uterus swells inside or outside the vagina and this may sometimes be associated with a collapse of the small intestine called an enterocele, in which part of the small intestine swells and protrudes into the vagina. Pelvic prolapse can also occur after a hysterectomy, although infrequently, any part of the vaginal wall is lowered, resulting in swelling inside or outside the vagina [13].

Low to medium quality evidence suggests the benefit of using a permanent (prosthetic) transvaginal mesh over restoration using original tissue. These benefits include decreased prolapse sensation, re-progression and recurrence [of occurrence] of prolapse found on examination. Evidence suggests that while 19% of women will experience prolapse after recovering with the use of their tissue, 10% to 15% of women will experience prolapse after recovering with permanent mesh. If the frequency of recurrent prolapse detected during the examination, after reconstructive surgery using tissues, is 38%, then, after re-installation with a permanent transvaginal mesh, this risk will be between 11% and 20%. However, there are problems associated with the use of permanent vaginal nets. If the frequency of surgical operations due to prolapse, incontinence, or traces of mesh use - after restoration with special tissues is 5%, then this risk after restoration with permanent mesh will be from 7% to 18%. Eight percent of the women in the networked groups required a restart due to network effects. Then after recovering with a static network, this risk will range from 7% to 18%. Eight percent of the women in the networked groups required a restart due to network effects. Then after recovering with a static network, this risk will range from 7% to 18%. Eight percent of the women in the networked groups required a restart due to network effects [14-18].

The pelvic floor (SP) is a complex anatomical and functional unit located in the lower part of the pelvic cavity. In addition to maintaining a balance between standing, intra-abdominal pressure and support of the abdominal organ's pelvic organs, it has important functions, among which its contribution to sexual response and its great distension at the time of delivery [19]. Far from being a static phenomenon, pelvic floor dysfunction is an alteration of the adequate interaction of all the elements that form it.3 Therefore, the weakness of any of them especially predisposes women due to their characteristics anatomical to present affections at this level, which cause symptoms in multiple occasions by combining different problems such as incontinence urinary and fecal, genital prolapse, chronic pelvic pain and sexual dysfunction, among other [20-24].

Suggested Surgical Methods

Several methods of surgical treatment of prolapse of the pelvic organs (uterus, bladder, rectum) have been proposed. Each of them, besides some advantages, has disadvantages, which are expressed mainly in relapses of the disease, pain syndrome, sexual disorders, disorders of the function of the pelvic organs. Therefore, the isolated use of vaginal healing with an omission of 3-4 degrees, leads to relapses in more than 40-50% of cases, which, of course, is unacceptable in modern conditions. The popular belief that if "everything is cut" (meaning the womb), "there will be nothing to fall" is also an illusion. The uterus itself does not affect prolapse, like other organs of the small pelvis. For some reason, no one suggests removing the latter, removing a healthy uterus using modern technologies is completely optional and has no reasons (including oncology). At the same time, need to understand that the removal of this organ can damage the nerve endings that regulate urination, disrupt the blood supply to all pelvic organs, and, eventually, lead to prolapse of the vaginal dome (when the uterus has already been removed) with a probability ranging from 7 to 25%.

Normal pelvic floor support relies on passive structures (bones and connective tissues) and active structures (muscles and nerves). The connective tissue that supports the pelvic organs is organized in the form of dense collagen (ligaments and tendons) and a less well-defined structure of collagen, smooth muscle, elastin and vascular tissue known as the intima fascia [17,18,25].

The upper part of the vagina and uterus are suspended towards the bony pelvis by the complex of the Sacro-uterine ligaments and the primary ligaments. These form around the cervix, which is known as the ring around the cervix.

Toward the lateral walls of the pelvis, the fascia within the pelvis thickens into a structure called the aortic arch of the pelvic fascia (white line), where the pubic fascia and the rectovaginal septum, the structures that separate the vagina from the bladder and the vagina from the rectum respectively, anchor laterally toward the pelvic walls.

The diaphragm is closed by the elevator anal muscle. This consists of various muscle bundles (the pubic bundle, pubic, rectum and iliac bundle) that extend from the bony pelvis and surround the pelvic organs. This striated, muscular structure has an anterior opening called the genitourinary hiatus, through which the urethra, vagina and rectum pass outward [20].

All pelvic organs are located on the levator in any muscle (horizontal position) and only the lower third of the urethra, vagina and rectum have a vertical position so that they can pass through the urogenital gap to the outside. When there is an increase in intra-abdominal pressure, it moves to the pelvis, making the organs located on the levator muscle horizontal. It also contracts, reducing the area of ​​\u200b\u200bthe urogenital gap. In this way, pressure is placed on the muscles and not the hiatus of the urogenital tract, avoiding injury to the passive supportive structures and thus producing genital prolapse [23].

Patients and Methods

Data were collected from Shatra Hospital, Thi-Qar and the necessary examinations were conducted for the infected patients' Different types of pelvic prolapse the data for 150 women and the average age of the women were 50 ± 5.4 Pelvic organ prolapse occurs when the muscles or connective tissues in the pelvis do not function as they should. There are several risk factors Pelvic floor disorders occur only in women and become more common as they age and about 1 in 11 women will need surgery to treat a pelvic floor disorder during their lifetime.

It is detected during the examination with the introduction of a single paper speculum along the posterior wall of the vagina in the position of lithotripsy. Stressing the patient on demand makes the cystocele or urethral hydrocele clearly and perceptibly visible as reducible tumor-like formations that spread into the anterior vaginal wall, which include the bladder, uterus and intestines - are often held in place by muscles and connective tissue in the pelvic floor. Anterior prolapse occurs when the pelvic floor becomes weak or if the pelvic floor is pushed too hard. This can happen over time, during vaginal delivery, or with chronic constipation, violent coughing, or weight lifting.

Anterior prolapse is treatable. Nonsurgical treatment is usually effective for mild or moderate prolapse. In more severe cases, surgery may be necessary to keep the vagina and other pelvic organs in their correct positions.

Analyzing the etiological factors and pathogenesis of genital prolapse, some authors put forward the concept that without a congenital (hereditary) disease or systemic connective tissue disease, the development of genital prolapse is generally impossible. Some "outside" signs that indicate the presence of systemic connective tissue disease are also given. These signs include: hernias in first-degree relatives, physique, flat feet, scoliosis, increased mobility of joints, decreased muscle tone, as well as changes in childbearing age on the part of the organs of the cardiovascular system - vascular dystonia, vascular spasms, lack of Cardiac arrhythmia, varicose veins.

Regardless of the etiological cause of the disease, genital prolapse began, progressing unabated, with a gradual increase in functional changes and then anatomical and morphological changes in the tissues and organs that were subjected to prolapse. At the same time, disturbances in one hundred aspects of the functions of the bladder or rectum are usually especially painful for patients.

Figure 1: Explain It shows standard deviations for Type of pelvic organ prolapse

Figure 2: Indicators of uroflowmetry and ultrasound of the bladder before surgical treatment

Figure 3: Indicators of uroflowmetry and ultrasound of the bladder after surgical treatment

At the same time, traumatic injuries of the pelvic floor - during childbirth or as a result of gynecological operations - according to our data, are the main cause of genital prolapse in at least 35-40% of cases. With age, the role of this factor increases and reaches 67 - 75% in the category of women over 50 who suffer from genital prolapse, according to some authors.

At the same time, as studies show, the syndrome of increased intra-abdominal pressure, as the only influencing factor, in most cases is insufficient to trigger the mechanisms of disease development. As a rule, this requires one or another degree of insufficiency or weakness of the fascial and ligamentous muscular structures of the pelvic cavity.

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