Pelvic Floor Surgery
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Direct answer
Pelvic floor surgery covers the operative treatment of pelvic organ prolapse and stress urinary incontinence, and its language is the POP-Q system, which measures defined vaginal points against the hymen — Aa and Ba anteriorly, Ap and Bp posteriorly, C for the cervix or cuff, plus genital hiatus, perineal body and total vaginal length — staging prolapse from 0 to IV. Standard operations include vaginal hysterectomy with colporrhaphy and vault suspension for uterovaginal prolapse, the Manchester-Fothergill operation for cervical elongation with descent in a woman conserving her uterus, abdominal sacrocolpopexy as the gold standard for vault prolapse, and mid-urethral slings (TVT or TOT) for stress incontinence.
What you must remember
- POP-Q numbers — Aa and Ba (anterior wall) and Ap and Bp (posterior wall) range from minus 3 cm to plus 3 cm; point C is the most distal cervix or cuff; D marks the posterior fornix (omitted post-hysterectomy); genital hiatus, perineal body and total vaginal length complete the nine measurements.
- Stages — 0: no prolapse; I: most distal point above minus 1 cm; II: within 1 cm of the hymen (minus 1 to plus 1); III: beyond plus 1 cm but short of complete eversion; IV: complete eversion.
- Conservative-first rule — pelvic floor muscle training and vaginal ring pessaries suit many women, including those unfit for surgery; surgery is offered for symptomatic prolapse, not anatomy alone.
- Anterior compartment — anterior colporrhaphy plicates the pubocervical fascia for a cystocele; native tissue remains standard, since transvaginal mesh for anterior repair is restricted in most countries.
- Apical support is the keystone — options are uterosacral ligament suspension (including McCall culdoplasty), sacrospinous ligament fixation (buttock pain a known complication) and abdominal sacrocolpopexy (mesh to the sacral promontory, gold standard for vault prolapse).
- Uterine preservation — Manchester-Fothergill operation (cervical amputation with cardinal ligament plication plus colporrhaphy) for cervical elongation with descent; obliterative Le Fort colpocleisis for elderly women not sexually active.
- Stress incontinence surgery — mid-urethral tension-free slings are first line: retropubic TVT or transobturator TOT (similar efficacy; retropubic, more bladder injury and voiding difficulty; transobturator, more groin pain); Burch colposuspension remains durable; bulking injections suit frail women.
- Work-up — stress testing with the prolapse reduced to unmask occult incontinence, topical oestrogen for atrophic vaginitis, and bowel assessment.
- Complications to counsel — recurrence, dyspareunia, voiding dysfunction after sling, bleeding, and de novo urgency.
Staging a prolapse and choosing the operation
A 62-year-old para 4 reports a bulge worse by evening, incomplete emptying, and leakage when she coughs. On straining, the anterior wall descends 2 cm beyond the hymen, the cervix is 4 cm beyond, and total vaginal length is 9 cm: her POP-Q reads Aa plus 2, Ba plus 2, C plus 4, Ap minus 3, Bp minus 3, gh 4, pb 3, TVL 9 — stage III uterovaginal prolapse.
Because a ring pessary has failed, surgery is planned addressing all three compartments: vaginal hysterectomy, anterior colporrhaphy, a sacrospinous ligament fixation for apical support (the step that determines whether the repair holds), and a posterior repair. Her cough-leakage, confirmed with the prolapse reduced, is treated in the same sitting with a transobturator sling — decided beforehand, because repairing prolapse alone can unmask stress incontinence that urethral kinking had hidden.
Contrast two other plans. A 72-year-old widow with stage IV vault eversion and cardiac failure chooses a Le Fort colpocleisis — short, effective, low-risk obliteration. A 45-year-old with cervical elongation wanting to keep her uterus is offered the Manchester-Fothergill operation, with the caveat of higher recurrence; isolated vault prolapse after hysterectomy answers to sacrocolpopexy, or sacrospinous fixation if laparotomy is unsuitable.
Where students slip
Numbers first: students mislabel the POP-Q range (minus 3 to plus 3) or forget that stage III requires protrusion beyond plus 1 cm short of eversion. Second, the apical principle is missed — repairing walls without suspending the apex invites recurrence, hence sacrospinous fixation or sacrocolpopexy in every good plan. Third, the sling answers are swapped: TVT and TOT are both mid-urethral slings for stress incontinence, while Burch colposuspension is the older abdominal option — and none of these treat urgency, which is detrusor overactivity treated medically. Finally, native tissue is the default for vaginal prolapse repair today, with mesh reserved for sacrocolpopexy-type procedures.
Frequently asked questions
What are the nine POP-Q measurements?
Aa and Ba for the anterior wall, Ap and Bp for the posterior wall, C (cervix or cuff) and D (posterior fornix), plus genital hiatus, perineal body and total vaginal length.
What is the Manchester-Fothergill operation?
Cervical amputation with plication of the cardinal ligaments onto the anterior cervical stump plus colporrhaphy — uterine-preserving surgery for descent with cervical elongation.
Which operation is the gold standard for vault prolapse?
Abdominal sacrocolpopexy, suspending the vault to the sacral promontory with mesh; sacrospinous fixation is the leading vaginal alternative.
What are the first-line surgeries for stress urinary incontinence?
Mid-urethral tension-free slings — retropubic TVT or transobturator TOT — with Burch colposuspension as a durable alternative and bulking agents for frail women.