GENITAL PROLAPSE

Question 1

What are the muscles of the pelvic floor?

Answer 1

Levator ani (pubococcygeus and iliococcygeus)
Internal obturator
Piriformis
Superficial and deep perineal muscle

Question 2

What is the gap in the pelvic floor through which the urethra and vagina pass?

Answer 2

Urogenital aperture formed by the medical border of the levator ani.

Question 3

What are the pelvic ligaments that act to support the uterus in the upper part of the vagina?

Answer 3

Transverse cervical or cardinal ligaments
Uterosacral ligaments
(Round ligaments)

Question 4

What are the types of genital prolapse?

Answer 4

Cystourethrocoele
Cystocoele
Rectocoele
Enterocoele
Uterine descent
Vault descent

Question 5

What is the most common type of genital prolapse?

Answer 5

1. Cystourethrocoele
2. Uterine descent
3. Rectocoele

Question 6

What is a cystocoele?

Answer 6

This is when the bladder prolapses. There is prolapse of the anterior wall of the vagina, attached to bladder by fascia.

Question 7

What is a cystourethrocoele?

Answer 7

This is when the bladder and urethra prolapse. It is basically a cystocoele that extends into the lower anterior vaginal wall, displacing the urethra downwards.

Question 8

What is a rectocoele?

Answer 8

This is when the rectum prolapses. Weakness in the levator ani muscles cause a bulge in the mid posterior vaginal wall which incorporates the rectum.

Question 9

What is an enterocoele?

Answer 9

This is a true hernia of the Pouch of Douglas. There is a prolapse of the upper third of the posterior vaginal wall and contains small bowel.

Question 10

What is uterine descent?

Answer 10

This is when the uterus descends with the vagina and may even lie outside it. Often associated with a cystocoele and/or rectocoele.

Question 11

How is uterine descent graded?

Answer 11

According to position of cervix on vaginal examination:

First degree - cervical descent within vagina

Second degree - Cervical descent to the opening of the vagina

Third degree - Cervical descent to outside the vagina

Question 12

What is procidentia?

Answer 12

This is when the uterus descends so far that it actually lies outside of the vagina.

Question 13

What is vaginal vault descent?

Answer 13

This is when the proximal end of the vagina prolapses within or outside the vagina, following hysterectomy.

Question 14

What are the congenital conditions associated with genital prolapse?

Answer 14

Spina bifida

Connective tissue disorders such as Ehlers Danlos

Question 15

What are the risk factors for genital prolapse?

Answer 15

Multiparity with normal vaginal deliveries
Giving birth to a large baby
High BMI
Increasing age - postmenopausal atrophy
Frequent heavy lifting
Chronic coughing
Prior pelvic surgery - eg colposuspension increases predisposition for rectocoele
Frequent straining during bowel movements
Hysterectomy (vaginal vault)
Being hispanic or white

Question 16

What are the classic features of genital prolapse?

Answer 16

Discomfort
Feeling of something coming down
Dragging sensation
Worse standing or straining (cough or defecation)
Relieved by lying down
Interferes with sexual function
Backache
Bloody purulent discharge 
Incontinence

Question 17

What are the urinary symptoms associated with genital prolapse?

Answer 17

Frequency
Incomplete emptying of the bladder
Frequent UTI
Overflow incontinence
Stress incontinence

Question 18

What are the bowel symptoms associated with rectocoele?

Answer 18

Tenesmus

Question 19

What are the preventative factors that should be taken into account to avoid genital prolapse?

Answer 19

Appropriate management of labour - avoiding prolonged first and second stages

Caesarian section if risk factors or history

Postnatal pelvic floor exercises

Question 20

What are the conservative/medical management options for someone suffering from genital prolapse?

Answer 20

Weight loss
Stop smoking to reduce cough
Treat constipation
Pelvic floor exercises
Hormone replacement therapy - increases skin collagen content
Vaginal pessaries

Question 21

What are the types of pessary used to treat genital prolapse?

Answer 21

Ring pessary

Shelf pessary

Question 22

What are the indications for using a vaginal pessary rather than surgery?

Answer 22

Patient has not completed her family
Patient choice
Medically unfit for surgery

Question 23

What are the main complications of a vaginal pessary?

Answer 23

Bleeding
Discharge
Discomfort if too large possibly leading to ulceration
Granulation tissue may develop, incarcerating the pessary if it is not changed regularly.

Question 24

How often should a pessary be replaced?

Answer 24

Cleaned every 6 months

Replaced every 2 years

Question 25

What are the main complications of surgical repair of genital prolapse?

Answer 25

Dyspareunia - vagina is narrowed and shortened