205 © Springer International Publishing AG, part of Springer Nature 2019 D. E. Beck et al. (eds.), Fundamentals of Anorectal Surgery, https://doi.org/10.1007/978-3-319-65966-4_12 Pelvic Organ Prolapse and Perineal Hernias Dana R. Sands, Daniel S. Lavy, and Eric A. Hurtado Introduction As defned by the Joint Report on the Terminology for Female Pelvic Organ Prolapse (POP) by the International Urogynecological Association (IUGA)/International Continence Society (ICS), pelvic organ prolapse is defned as an anatomical change (i.e. downward dis- placement) of the pelvic organs which includes the uterus and/or the different vaginal compart- ments involving such organs as the bladder, rectum, or bowel [1]. Along with POP, urinary incontinence and bladder and bowel dysfunction comprise the category of pelvic foor disorders. Although rarely life threatening, these disor- ders can have a great impact upon one’s qual- ity of life. Not long ago these disorders were rarely discussed, and many women suffered in silence. As medical knowledge has expanded, growth in understanding these disorders has fol- lowed. Once thought to be uncommon, it is now known that the prevalence of one or more pel- vic foor disorders among US women was 25% among 8368 non-pregnant US women surveyed. Of those women, 2.9% reported prolapse by answering “yes” to the question, “Do you see or feel a bulge in the vaginal area?” [2]. In another study of 479 women presenting for their annual gynecologic exam, 48% of women were noted to have Stage 2 POP (1 cm within to 1 cm past the hymen), and 2.6% of women were noted to have Stage 3 POP (greater than 1 cm past the hymen) [3]. Once diagnosed, approximately 1 in 9 American women will undergo surgery for a vaginal prolapse or a related disorder in their lifetime [4]. POP is thought to begin by having an injury, such as childbirth that damages the levator ani muscles. With muscle damage and dropping of the pelvic foor, the intra-abdominal forces are placed upon the connective tissue attach- ments or “ligaments” that suspend the pelvic organs. Certain individuals with genetically- prone weakened connective tissue will then be more susceptible to POP. Promoting factors such as further vaginal deliveries, advancing age, and obesity, may also place individuals at risk for POP. Heavy lifting, straining from constipation, and previous hysterectomy may be other risk factors [5, 6]. POP may be graded by the Baden-Walker halfway system where grades are made in reference to halfway to the hymen or halfway past the hymen [7]. POP may also be graded by the POP quantifcation system or POP-Q. It is a system where differ- ent points along the anterior vaginal wall, pos- D. R. Sands (*) · D. S. Lavy Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA e-mail: sandsd@ccf.org E. A. Hurtado Department of Gynecology, Section of Urogynecology and Reconstructive Pelvic Surgery, Cleveland Clinic Florida, Weston, FL, USA 12