Pelvic Organ Prolapse

Question 1

POP overal ideas

Answer 1

• clinically relevant only if symptomatic (pressure, bulge, sexual dysfunction, abnormal lower urinary or bowel function)
• usually occurs if reaches 0.5cm above the hymen
• 13% lifetime risk of surgery
• 30% risk of repeat surgery

Question 2

POP staging

Answer 2

• Stage 0: no prolapse
• 1: higher than 1cm above hymen
• 2: at 1cm above to below hymen
• 3: more than 1cm below hymen
• 4: procidentia (complete prolapse or eversion)

Question 3

Risk factos POP

Answer 3

Parity
vaginal delivery
age
obesity
connective tissue disease
menopause
chronic constipation

Question 4

w/u POP

Answer 4

hx: symptoms, past medical, surgical hx
exam:
- vaginal epithelium looking for atrophy
- do pelvic exam in standing position
- POP-Q eval 
- assessment of muscle tone
labs: 
- UA
- PVR (if prolapsed stage 3 or 4)
- urodynamic testing is stage 2 or worse

Question 5

POP Treatment: non-surgical options

Answer 5

• high fiber diet
• osmotic laxatives
• local estrogen therapy
• vaginal pessary (change every 3-4 months, or more frequently if wall erosion occurs)

Question 6

POP surgical treatment options for upper vaginal prolapse

Answer 6

Abdominal sacral colpopexy (with mesh)

• for pt with short vagina, other intra-abdominal pathology ad risk for POP recurrence
• can be laparoscopically/robotic

USLS

Sacrospinus ligament fixation

Question 7

POP surgical management: anterior wall prolapse

Answer 7

Anterior colporrhaphy

Question 8

POP surgical management: posterior wall prolapse

Answer 8

posterior colporrhaphya

Question 9

POP surgical management: apical vaginal prolapse and/or anterior wall prolapse

Answer 9

repair with synthetic or biological graft

Question 10

POP surgical management: Uterine prolaps

Answer 10

Hysterectomy with USLS and sacrospinous ligament suspension

hysteropexy comprising attachment of the cervix to the sacrospinous ligaments (less invasive and reduced morbidity compared to hysterectomy)

Question 11

Mesh

Answer 11

Mesh with prolapse repair is associated with ~10% risk of erosion (with 10% of those patients needing re-operation)

Effective for anterior wall prolapse (not posterior wall), should only be considered in high risk pt such as those with recurrence or medical co-morbidities

Compared to natural tissue for anterior wall repair, polypropylene mesh provides better anatomic and subjective results, but higher morbidity

special surgical training required

Question 12

anterior repair or apical compartment prolapse surgery

Answer 12

should get a cystoscopy always

Question 13

Complications from mesh

Answer 13

• Bleeding, infections (especially UTI)
• Voiding dysfunction (typically transient)
• Structual anatomic breach (fistula, ureteral injury, diminished vaginal capacity which can cause dyspareunia)
• mesh erosion
• symptom recurrence with need for repeat surgery