5 - Pelvic Organ Prolapse (+ anatomy of pelvic floor)

Question 1

define prolapse?

Answer 1

Protrusion of an organ or structure beyond its normal anatomical confines

Question 2

define female POP?

Answer 2

the descent of the pelvic organs towards or through the vagina

Question 3

effect of prolapse on multiparous women? (%)

Answer 3

12-30%

Question 4

effect of prolapse on nulliparous women? (%)

Answer 4

2%

Question 5

% of parous women with degree of prolapse?

Answer 5

~50%

Question 6

what % of gynaecological waiting lists is accounted for by POPs?

Answer 6

20%

Question 7

what is indicated by prolapse at ~10%?

Answer 7

hysterectomies

Question 8

which viscera is contained in abdomino-pelvic cavity?

Answer 8

abdominal and pelvic

Question 9

why must the walls of the abdomino-pelvic be flexible?

Answer 9

to withstand changes in volumes of these organs & pressure changes

Question 10

name 3 layers of pelvic floor?

Answer 10

endo-pelvic fascia

pelvic diaphragm

urogenital diaphragm

Question 11

which layer of the pelvic floor is similar to a hammock structure?

Answer 11

endo-pelvic fascia

Question 12

what type of tissue is present in the endo-pelvic fascia?

Answer 12

fibro-muscular connective-type tissue

Question 13

which 3 structures are surrounded by the endo-pelvic fascia?

Answer 13

uterosacral ligaments

pubocervical fascia

rectovaginal fascia

Question 14

describe flexibility of endo-pelvic fascia and the effects of this?

Answer 14

Fibro-muscular component can stretch (Uteroscarals)

Connective tissue does not stretch, therefore it breaks

Question 15

describe the location of the utero-sacral complex MEDIALLY?

Answer 15

medially to uterus, cervix, lateral vaginal fornices and pubocervical & rectovaginal fascia

Question 16

describe the location of the utero-sacral complex LATERALLY?

Answer 16

sacrum & fascia overlying the Piriforms muscle

Question 17

where does utero-sacral complex tend to break?

Answer 17

medially - @ the cervix

Question 18

what is the utero-sacral complex AKA?

Answer 18

Cardinal complex?

Question 19

which tissue provides the main support of the anterior vaginal wall?

Answer 19

trapezoidal fibro-muscular tissue

Question 20

where does the pubocervical fascia tend to break?

Answer 20

@ lateral attachments OR immediately in front of cervix

Question 21

what does the pubocervical fascia merge with CENTRALLY?

Answer 21

base of cardinal ligaments and cervix

Question 22

what is the pubocervical fascia associated with LATERALLY?

Answer 22

archus tendineus fascia pelvis

Question 23

what is the pubocervical fascia associated with DISTALLY?

Answer 23

Urogenital diaphragm

Question 24

which type of tissue makes up the rectovaginal fascia?

Answer 24

fibro-musculo-elastic tissue

Question 25

what does the rectovaginal fascia merge with CENTRALLY?

Answer 25

base of cardinal ligaments and peritoneum

Question 26

what is the rectovaginal fascia associated with LATERALLY?

Answer 26

fascia over the levator ani

Question 27

what is the rectovaginal fascia associated with DISTALLY?

Answer 27

firmly stuck to the perineal body

Question 28

where does the rectovaginal fascia tend to break?

Answer 28

centrally

Question 29

where does the rectovaginal fascia tend to break if there is an upper defect?

Answer 29

enterocele

Question 30

where does the rectovaginal fascia tend to break if there is a lower defect?

Answer 30

perineal body descent and retrocele

Question 31

How many levels of endopelvic support are there?

Answer 31

3

Question 32

components of level 1 of endopelvic support?

Answer 32

utero-sacral ligaments cardinal ligaments

Question 33

components of level 2 of endopelvic support?

Answer 33

para-vaginal to arcus tendineus fascia pubocervical fascia

Question 34

components of level 3 of endopelvic support?

Answer 34

Urogenital Diaphragm Perineal body

Question 35

3 common risk factors of POP?

Answer 35

parity (increases as parity increases) advancing age obesity

Question 36

complication of Burch Colposuspension?

Answer 36

further surgery for prolapse

Question 37

what is the Burch Colposuspension procedure for?

Answer 37

to improve continence

Question 38

complication of hysterectomy?

Answer 38

vaginal vault prolapse

Question 39

5 other risk factors of POP?

Answer 39

Hormonal factors Quality’ of Connective Tissue Constipation Occupation with Heavy Lifting Exercise

Question 40

5 types of prolapse in traditional classification of prolapse?

Answer 40

urethrocele cystocele uterovaginal prolapse enterocele rectocele

Question 41

describe urethrocele?

Answer 41

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 42

describe cystocele?

Answer 42

Prolapse of the upper anterior vaginal wall involving the bladder (anterior wall prolapse)

Question 43

describe uterovaginal prolapse?

Answer 43

prolapse of the uterus, cervix and upper vagina

Question 44

describe enterocele?

Answer 44

Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel (apical prolapse)

Question 45

describe rectocele?

Answer 45

Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina (posterior wall prolapse)

Question 46

Typical symptoms of the vagina in women with pelvic organ prolapse?

Answer 46

Sensation of a bulge or protrusion Seeing or feeling a bulge or protrusion Pressure Heaviness Difficulty in inserting tampons

Question 47

Typical urinary symptoms in women with pelvic organ prolapse?

Answer 47

Urinary Incontinence Frequency/ Urgency Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying Manual reduction of prolapse to start or complete voiding

Question 48

Typical bowel symptoms in women with pelvic organ prolapse?

Answer 48

Incontinence of flatus, or liquid or solid stool Feeling of incomplete emptying/ Straining Urgency Digital evacuation to complete defecation Splinting, or pushing on or around the vagina or perineum, to start or complete defecation

Question 49

3 aspects of assessment of POP?

Answer 49

Examination to exclude pelvic mass Record the position of examination Quality of Life

Question 50

Grading for assessment of POP?

Answer 50

Baden-Walker-Halfawy

Question 51

What is gold standard for assessment of POP?

Answer 51

POPQ score

Question 52

4 investigations for POP?

Answer 52

USS/MRI (imaging) urodynamics IVU Renal USS

Question 53

4 methods of prevention of POP?

Answer 53

avoid constipation effective management chronic chest pathology smaller family size improvements in antenatal and intra-partum care

Question 54

3 possible treatments for POP?

Answer 54

physiotherapy pessaries surgery

Question 55

in terms of pessaries, which material is advantageous and give 3 reasons why?

Answer 55

silicone: long shelf-life inertness resistance to repeated cleaning