Pelvic Organ Prolapse

Question 1

What is a female pelvic organ prolapse?

Answer 1

The descent of the pelvic organs towards or through the vagina

Question 2

What is the incidence of female pelvic organ prolapse?

Answer 2

12-30% of multiparous women

2% of nulliparous women

Question 3

What are the borders of the utero-sacral or cardinal complex fascia and where does it commonly break?

Answer 3

Medial border- uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia
Lateral border- sacrum and fascia overlying piriformis
Breaks- Tend to break medially around the cervix

Question 4

What are the borders of the pubocervical fascia and where does it commonly break?

Answer 4

Central border- merge with base of cardinal ligaments and cervix
Lateral border- Arcus tendineus fascia pelvis
Distal border- Urogenital diaphragm
Breaks- Lateral attachments
Immediately in anterior to cervix

Question 5

What are the borders of the rectovaginal fascia and where does it commonly break?

Answer 5

Central border- merge with base of cardinal complex and peritoneum
Laterally - fuses with fascia over levator ani
Distally- firmly attached to perineal body
Breaks- Tends to break centrally
If upper defect- enterocele, lower defect- rectocele

Question 6

What are the risk factors for pelvic organ prolapse?

Answer 6

• Pregnancy and vaginal birth
• Forceps delivery
• Large baby (>4500g)
• Prolonged second stage of labour
• Age
• Obesity
• Previous pelvic floor surgery
• Hormonal factors
• Constipation
• Occupation with Heavy Lifting
• Exercise

Question 7

What is a urethrocele?

Answer 7

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 8

What is a cystocele?

Answer 8

Prolapse of the upper anterior vaginal wall involving the bladder

Question 9

What is a uterovaginal prolapse?

Answer 9

Prolapse of uterus, cervix and upper vagina

Question 10

What is an enterocele?

Answer 10

Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel

Question 11

What is a rectocele?

Answer 11

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

Question 12

What is the cause of an anterior wall prolapse?

Answer 12

Breakage of the pubocervical fascia between the bladder and the vagina

Question 13

What is the cause of a posterior wall prolapse?

Answer 13

Breakage of rectovaginal fascia

Question 14

What are the vaginal symptoms of pelvic organ prolapse?

Answer 14

• Sensation of a bulge or protrusion
• Seeing or feeling a bulge or protrusion
• Pressure
• Vaginal heaviness
• Difficulty in inserting tampons

Question 15

What urinary symptoms can present with pelvic organ prolapse?

Answer 15

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

Question 16

What gastrointestinal symptoms can present with pelvic organ prolapse?

Answer 16

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

Question 17

What steps are involved in assessment of pelvic organ prolapse?

Answer 17

• Examination to exclude pelvic mass
• Record the position of examination
• Quality of Life
• Objective assessment with POPQ score

Question 18

What investigations can be done to check for other problems such as pelvic masses or ureteric onbstruction?

Answer 18

• Ultrasound/MRI
• Urodynamics
• Intravaginal or renal ultrasound

Question 19

How can pelvic organ prolapses be prevented?

Answer 19

• Avoid constipation.
• Effective management chronic chest pathology (COPD & asthma).
• Smaller family size.
• Improvements in antenatal and intra-partum care (pelvic floor muscle training)

Question 20

What are the treatment options for pelvic organ prolapse?

Answer 20

Physiotherapy- pelvic floor muscle training
Pessaries
Surgery

Question 21

What are the aims of pelvic organ prolapse surgery?

Answer 21

• Relieve symptoms
• Restore/maintain bladder & bowel function
• Maintain vaginal capacity for sexual function

Question 22

What additional measures may be required with pelvic organ prolapse surgery?

Answer 22

• Prophylactic Antibiotics.
• Thrombo-embolic prophylaxis
• Postoperative urinary or supra-pubic catheter