pelvic organ prolapse

Question 1

what is a prolapse

Answer 1

protrusion of an organ/structure beyond its normal anatomical confines

Question 2

what is female POP

Answer 2

female pelvic organ prolapse

the descent of the pelvic organs towards or through the vagina

Question 3

incidence of prolapse

Answer 3

difficult to determine
estimated to affect 12-30% of multiparous and 2% of nulliparous women

estimates vary from 2% for symptomatic prolapse to 50% for asympomatic prolapse

Question 4

prevalence of prolapse

Answer 4

estimates vary from 2% for symptomatic prolapse to 50% for asympomatic prolapse

~50% of parous women will have some degree and only 10-20% of these seek medical help

POP accounts for 20% of women on the waiting list for major gynae surgery

Question 5

what % of hysterectomies are indicated due to prolapse

Answer 5

7-14%

Question 6

why must the pelvic cavity wall be flexible

Answer 6

to withstand changes in volume of these organs and also pressure changes within the cavity

Question 7

what does the pelvic floor contain

Answer 7

all of the soft tissue structures that close the space between the pelvic bones

if the pelvic floor is normal, all the viscera will be maintained in their position at rest and during increased intra-abdo pressure

Question 8

what are the 3 layers of the pelvic floor

Answer 8

endo-pelvic fascia
pelvic diaphragm
urogenital diaphragm

3 layers do not parallel each other and vary in strength and thickness from place to place

Question 9

what does the pelvic floor act as

Answer 9

1 functional unit made from 3 layers

Question 10

what is the endo-pelvic fascia

Answer 10

network of fibro-muscular connective type tissue that has a hammock like configuration and surrounds the various visceral structures

uterosacral ligaments/pubocervical fascia/rectovaginal fascia

Question 11

what is the pelvic diaphragm

Answer 11

layer of striated muscles with its fascial coverings

levator ani and coccygeus

Question 12

what is the urogenital diaphragm

Answer 12

superficial and deep transverse perineal muscles with their fascial coverings

Question 13

how stretchy is the endo-pelvic fascia

Answer 13

fibro-muscular component can stretch

connective tissues doesn’t stretch or attenuate, instead it breaks

Question 14

location of the uterosacral/cardinal complex

Answer 14

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

laterally to the sacrum and fascia overlying the piriformis muscle

Question 15

how can the uterosacral complex be palpated

Answer 15

down traction on the cervix and if intact allows limited side-side movement of the cervix

Question 16

how does the utero-sacral complex tend to break

Answer 16

medially - around the cervix

Question 17

what is the pubocervical fascia and what is its role

Answer 17

trapezoidal fibro-muscular tissue

provides the main support of the anterior vaginal wall

Question 18

location of the pubocervical fascia

Answer 18

centrally - merge with the base of the cardinal ligaments and cervix
laterally - arcus tendineus fascia pelvis (white line)
distally - urogenital diaphragm (under SP)

Question 19

how does the pubocervical fascia tend to break

Answer 19

3 supports = 3 defects

tends to break at lateral attachments of immediately in front of the cervix

Question 20

what is the rectovaginal fascia and where is it located

Answer 20

fibro-musculo-elastic tissue

centrally - merge with the base of cardinal/uterosacral ligaments and peritoneum

laterally - fuses with fascia over levator ani

distally - firmly to the perineal body

Question 21

where does the rectovaginal fascia tend to break

Answer 21

centrally

if upper defect = enterocele

Question 22

describe the 3 levels of endopelvic support

Answer 22

I - uterosacral ligaments, cardinal ligaments

II - para-vagina to arcus tendineus fascia: pubocervical/rectovaginal fascia

III - urogenital diaphragm and perineal body

Question 23

what levels of support do we aim for when repairing different types of prolapse

Answer 23

I - apical prolaps
II - vaginal prolapse
III - perineoplasty, perineorraphy

Question 24

risk factors of POPP

Answer 24

PREGNANCY AND VAGINAL BIRTH
advancing age 
obesity
previous pelvic surgery
other - hormonal factors quality of connective tissue, constipation, occupation with heavy lifting, exercise

Question 25

risk factors with pregnancy and vaginal birth for POP

Answer 25

``` forceps delivery large baby (>4500g) prolonged 2nd stage ``` parity was the strongest risk factor for the development of prolapse risk increases with increasing parity, rate of increase slows after 2 deliveries

Question 26

previous pelvic surgery as a risk factor for POP

Answer 26

continence procedures Burch colposuspension hysterectomy

Question 27

continence procedures and POP

Answer 27

while elevating the bladder neck, may lead to defects in other pelvic components

Question 28

Burch colposuspension and POP

Answer 28

fixing the lateral vaginal fornices to the ipsilateral iliopectineal ligaments leaves a potential defect in the posterior vaginal wall presidposes to rectocele and enterocele formation --> 25% of women following Burch colposuspension required further surgery for prolapse

Question 29

hysterectomy and POP

Answer 29

vaginal vault prolapse 9-13yrs after hysterectomy, in 11.6% of women who had the hysterectomy for prolapse and in 1.8% of women who had the hysterectomy for their benign disease

Question 30

excercise and POP

Answer 30

weight lifting high impact aerobics long distance running increased risk of urogenital prolapse

Question 31

traditional classification of prolapse

Answer 31

depends on the site of the defect and the presumed pelvic viscera that are involved ``` urethrocele cystocele uterovaginal prolapse enterocele rectocele ``` implies a unrealistic certainty as to the structures on the other side of the vaginal bulge this is often a false assumption, esp in women w/ prev prolapse surgery

Question 32

what is a urethrocele

Answer 32

prolape of the lower anterior vaginal wall involving the urethra only

Question 33

what is a cystocele

Answer 33

prolapse of the upper anterior vaginal wall involving the bladder

Question 34

what is a uterovaginal prolapse

Answer 34

prolapse of the uterus, cervix and upper vagina aka apical prolapse

Question 35

what is an enterocele

Answer 35

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

Question 36

what is a rectocele

Answer 36

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

Question 37

what can be seen on this imaging

Answer 37

cystocele | anterior wall prolapse

Question 38

what can be seen on this imaging

Answer 38

rectocele | posterior wall prolapse

Question 39

what can be seen on this imaging

Answer 39

enterocele | apical prolapse

Question 40

typical symptoms in women w/ POP - vaginal

Answer 40

``` sensation of a bulge/protrusion e.g. feels like sitting on a tennis ball etc seeing/feeling a bulge protrusion pressure heaviness difficulty in inserting tampons ```

Question 41

typical symptoms in women w/ POP - urinary

Answer 41

urinary incontinence frequency/urgency weak/prolonger urinary stream, hesitancy, feeling of incomplete emptying manual reduction of prolapse to start or complete voiding

Question 42

typical symptoms in women w/ POP - bowel

Answer 42

incontinence of flatus or liquid/solid stool feeling of incomplete emptying, straining urgency digital evacuation to complete defecation splinting or pushing on/around the vagina/perineum to start/complete defecation

Question 43

assessment of POP

Answer 43

mainly a clinical assessment: examination to exclude pelvic mass record the position of the examination e.g. L lateral vs lithotomy vs standing QOL objective assessment

Question 44

objective assessment of POP

Answer 44

Baden- Walker-Halfawy Grading POPQ score - gold standard others

Question 45

pelvic floor evaluation

Answer 45

Question 46

investigations for POP

Answer 46

none as standard = clinical diagnosis USS/MRI - allow identification of fascial defects/measurement of levator ani thickness (research only) urodynamics - concurrent UI or exclude occult SI IVU/renal USS - if suspicion of ureteric obstruction

Question 47

prevention of POP

Answer 47

avoid constipation effective management of chronic chest pathology - COAD, asthma (prevent coughing to prevent increase in intra-abdo pressure) improvements in antenatal and intra-partum care

Question 48

muscle training for prevention of POP

Answer 48

antenatal and post-natal pelvic floor muscle training has not yet been shown to conclusively reduce the incidence of prolapse, although there are logical reasons to think that it may be protective

Question 49

treatment of POP

Answer 49

conservative | physiotherappy

Question 50

physiotherapy for POP

Answer 50

pelvic floor muscle training (PFMT) - increase pelvic floor strength and bulk - relieve tension on the ligaments education re. pelvic floor exercises may be supplemented with the use of a perineometer and biofeedback, vaginal cones and electrical stimulation

Question 51

when can physiotherapy be used for POP

Answer 51

mild prolapse younger women who haven't yet completed their family no role in advanced cases cannot treat fascial defects

Question 52

pessaries for POP

Answer 52

silicone/rubber/plastic/ lucite based device type of device depends on type of prolapse helps place prolapse back into the vagina patient can insert and remove them by themself to continue having sex - not for all pessaries

Question 53

advantages of silicone for pessaries

Answer 53

long shelf life resistance to autoclaving and repeated cleaning non-absorbant towards secretions and odours inertness hypoallergenic

Question 54

vaginal pessaries vs surgery

Answer 54

prospective observational study: woman's decision: surgery vs pessary no sig difference in median parity, HRT, pre-op bowel, urinary, sexual symptoms exclusions: prev POP surgery, unable to retain pessary for 2wks results: no pessary related complications and no sig post-op morbidity 12 mths: no sig difference in bowel, urinary, sexual symptoms at 1yr, follow-up successful pessary treatment is as effective as surgery §

Question 55

general principles of surgical treatment

Answer 55

patient choice and informed decision depends on age, sexual activity and patient expectations usually indicated due to impact on QOL +/- exteriorised prolapse (stages 3/4)

Question 56

aim of surgical treatment for POP

Answer 56

relieve symptoms restore/maintain bladder and bowel function maintain vaginal capacity for sexual function

Question 57

what is surgical treatment of POP directed towards

Answer 57

the projecting compartments anterior wall prolapse = anterior wall repair posterior wall prolapse = posterior vaginal wall repair apical prolapse = vaginal hysterectomy/hysteropexy, sacrospinous fixation, abdominal sacro-colpo-pexy/hysteropexy usually combinations of the above colpocleisis - vaginal closure, no penetrative intercourse

Question 58

what is important to remember for surgical treatment of POP

Answer 58

prophylactic abx thrombo-embolic prophylaxis post-op urinary vs SPC