Pelvic Organ Prolapse

Question 1

What is the definition of utero vagina prolapse?

Answer 1

Descent of the uterus and/or vaginal walls beyond normal anatomical confines

Type of herniation

Question 2

What is the epidemiology of uterovaginal prolapse?

Answer 2

40-60% of porous women have some degree of prolapse on examination (due to loss pelvic wall support)

6-8% report a bulging mass

Question 3

What makes up the pelvic floor?

Answer 3

• muscular and fascial structures
• transverse cervical (cardinal) ligaments
• uerosacral ligaments
• endopelvic fascia
• Levator ani/ perineal muscles

Question 4

What is the role of the pelvic floor?

Answer 4

Support pelvic organs and external openings

Question 5

What are the uterus and vagina suspended from the pelvic side walls by?

Answer 5

Endopelvic fascial attachments that support the vagina @ 3 levels

Question 6

What makes up the pelvic floor?

Answer 6

Question 7

What is level 1 of the pelvic floor?

Answer 7

• cervix and upper 1/3 vagina

Question 8

What is level 1 of the pelvic floor supported by?

Answer 8

Cardinal (transverse cervical) and uterosacral ligaments

Question 9

What is level 2 of the pelvic floor?

Answer 9

Mid-portion of the vagina

Question 10

What is the mid-portion of the vagina (level 2) attached by?

Answer 10

Endopelvic fascia laterally to pelvic side walls

Question 11

What is level 3 of the pelvic floor?

Answer 11

Lower 1/3 of the vagina

Question 12

What is the lower 1/3 of the vagina (level 3) supported by?

Answer 12

Levator ani muscles and perineal body

Question 13

What do Levator ani muscles form?

Answer 13

The floor of the pelvis form attachments on the bony pelvic walls and incorporate the perineal body

Leavator ani + associated fascia termed the pelvic diaphragm

Question 14

What are the 3 components of each Levator ani muscle?

Answer 14

ischiococcygeus, iliococcygeus, pubococcygeous

Question 15

What does the pelvic floor look like?

Answer 15

Question 16

How are the types of prolapse classified?

Answer 16

Anatomically acc. To site of defect and pelvic organs affected

Question 17

What are the different types of prolapse?

Answer 17

• uterine prolapse or vaginal vault prolapse
• anterior vaginal wall
• posterior vaginal wall

Question 18

What are the 3 types of anterior vaginal wall prolapses?

Answer 18

• urethrocele
• cystocoele
• cystourethrocoele

Question 19

What are the two types of posterior vaginal wall prolapses?

Answer 19

• enterocoele
• retocoele

Question 20

What is the normal pelvic anatomy?

Answer 20

Question 21

What are the different types of pelvic organ prolapse?

Answer 21

Question 22

What do you need to record when grading a prolapse?

Answer 22

• position of patient
• rest or straining
• use of traction

Question 23

What is one method of grading uterine prolapse?

Answer 23

Grade 1: Uterus dropped slightly, within vagina, many unaware of the prolapse, noticed during a routine pelvic examination

Grade 2: The cervix and uterus dropped further, felt or seen at the introitus

Grade 3: Cervix and uterus seen or felt outside the vagina. This is the most severe of uterine prolapse and also known as procidentia

Question 24

What is the Baden Walker / Quantative POP Classification for pelvic organ prolapse?

Answer 24

Stage 0: no descent of pelvic organs
Stage 1: Descent to any point in the vagina above the hymen
Stage 2: Descent to the level of the hymen
Stage 3: Descent beyond the hymen
Stage 4: the entire uterus outside the vagina
(procidentia)

Question 25

What does the Baden Walker Classification use as a landmark?

Answer 25

Question 26

What is this?

Answer 26

Procidentia

Question 27

What is this?

Answer 27

Cystocele

Question 28

What is a cystocele?

Answer 28

When there is a defect in the anterior wall supports and this allows the bladder to prolapse into the vaginal wall

Question 29

Does a cystocele always present with symptoms?

Answer 29

May be asymptomatic

Question 30

What are some of the symptoms of a cystocele? (5)

Answer 30

* incomplete emptying * hesitancy * slow stream * frequency * urinary incontinence (stress): can lessen with higher degrees of prolapse due to urethral kinking

Question 31

What is this?

Answer 31

Rectocele

Question 32

What is a rectocele?

Answer 32

Where the defect is in the posterior wall supports of the vagina and as a result the rectum bulges forward into the vagina

Question 33

What symptoms can a rectocele cause? (4)

Answer 33

difficulty emptying the bowel: * constipation * incomplete emptying * straining * post-void soiling

Question 34

What is this?

Answer 34

Enterocoele

Question 35

What is an enterocoele?

Answer 35

Where the small bowel prolapses into the top of the vagina between the uterus and rectum

Question 36

What is different about an enterocoele compared to the other pelvic organ prolapses?

Answer 36

It is a true hernia - protrusion of the peritoneum of the pouch of Douglas through upper posterior wall of vagina - resulting pouch usually contains loops of small bowel

Question 37

What are the risk factors/etiologies for pelvic organ prolapse? (5)

Answer 37

* pregnancy & delivery esp. bigger babies, longer 2nd stage, instrumental delivery * CT disorders (eg EDS) * menopause * anything that increases intraabdominal pressure (constipation, high BMI, chronic cough, heavy lifting, mass) * surgery

Question 38

What is seen in the history of a patient with pelvic organ prolapse?

Answer 38

* ‘Dragging sensation/something coming down’ -(suprapubic or vaginal discomfort. Occasionally backache) - Worse at end of day - Worse at straining/exercise - ? Lump at introitus or outside * Dysparuenia * Vaginal discharge/bleeding (if at intrutis then PCB) * Urinary/Bowel Symptoms (include splinting - applying digital pressure to aid emptying) * QOL * Pre-disposing factors Note: medical, surgical, medications, family and social history can be relevant to surgical risk

Question 39

What examination is done for pelvic organ prolapse?

Answer 39

* observation (eg with procidentia will find it difficult to walk) * abdomen (mass) * pelvic =. Mass, pelvic floor tone, ask them to bear down having moved your finger back a bit from the cervix and will feel it come down to it - Sims speculum in left lateral position * PR/DRE = to evaluate (P) wall prolapse

Question 40

What investigations are needed to diagnose a pelvic organ prolapse?

Answer 40

None - CLINICAL DIAGNOSIS

Question 41

What investigations may be considered to aid diagnosis of a pelvic organ prolapse? (4)

Answer 41

* urinalysis (if urinary symptoms - infection) * pelvic US (if mass suspected) * urodynamics (urge/mixed incontinence symptoms) * ultrasound assessment of pelvic floor

Question 42

Why might patients with a pelvic organ prolapse need investigations?

Answer 42

To assess fitness for surgery

Question 43

What are some ways to prevent pelvic organ prolapse? (5)

Answer 43

Vaginal delivery issues: * recognition and management of obstructed labour * avoidance of excessively long 2nd stage * ?? C-section Post-delivery: * pelvic floor exercises Others: * modifiable risk factors

Question 44

How are pelvic organ prolapses managed?

Answer 44

* if asymptomatic ?no treatment * alter modifiable predisposing factors * physio - PFE’s (helps mild to moderate prolapse) * pessaries (usually combined with oestrogen) * oestrogen replacement - topical usually (vagifen cream) * surgical * modifiable risk factors

Question 45

What pelvic floor exercises are recommended for mild prolapse?

Answer 45

* PFMT: physio led x3/12 8 contractions 3 times/day (One to one training for 4-6months has lead to improvement in prolapse symptoms and staging in single centre trails for grade 1-3 prolapse) * weights: 2/day, when can do for 15 mins then increase the weight (eg vaginal cones)

Question 46

What were the traditional indications for pessaries? (5)

Answer 46

* wishing to delay surgery until childbearing complete * during pregnancy * whilst awaiting surgical correction of prolapse * serious chronic health problems, such as lung or heart disease where surgery is a considerable risk * surgery is not desirable - age -> major factor

Question 47

What do the NICE guidelines of 2019 suggest as management of pelvic organ prolapse?

Answer 47

* discuss management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and surgical options, taking into account: * the woman’s preference * site of prolapse * lifestyle factors * comorbidities including cognitive or physical impairments * age * desire for childbearing * previous abdominal or pelvic floor surgery * benefits and risks of individual procedures

Question 48

What are the two main types of pessaries?

Answer 48

Question 49

What are the different types of pessaries?

Answer 49

Support & space occupying pessaries

Question 50

What are the complications of pessaries? (9)

Answer 50

* discomfort * need to be changed every 6-9 months * expulsion * difficulty removing (fibrosis) * discharge/infections * vaginal bleeding: erosions/ulceration - fistulas (consider vagifem) * urinary retention * problems with intercourse (esp. shelf pessary)

Question 51

What are the aims of surgical treatment in pelvic organ prolapse?

Answer 51

* the restoration of normal vaginal anatomy * the resoration or maintenance of normal bladder function * the restoration or maintenance of normal bowel function * the restoration or maintenance of normal sexual function

Question 52

What concomitant surgery should be considered when doing surgery for prolapse?

Answer 52

Surgery for stress incontinence

Question 53

What surgeries are there for uterine prolapse? (3)

Answer 53

* vaginal hysterectomy * vaginal sacro-spinous hysteropexy with sutures * Manchester repair [* *Sacro-hysteropexy with mesh - to preserve uterus* ]

Question 54

What is the issue with vaginal hysterectomy for the surgical treatment of uterine prolapse?

Answer 54

Doesn’t address underlying poor pelvic support - up to 40% of women subsequently present with vault prolapse

Question 55

How is the no longer done sacro-hysteropexy with mesh done?

Answer 55

Uterus and cervix are attached to sacrum using a bifurcated non-absorbable mesh Open or laparoscopic

Question 56

What are the surgical options for vaginal vault prolapse? (2)

Answer 56

* [ *sacrocloprpexy - open or laparoscopic fixes vault to sacrum using a mesh*] * sacrospinous fixation - vaginally, suspends vault to sacrospinous ligament

Question 57

What are the surgical options for vaginal wall prolapse?

Answer 57

* anterior and posterior repairs - often combined: 90% of all prolapse procedures (also called colporrhapy) - no MESH

Question 58

What are some considerations for vaginal hysterectomy?

Answer 58

* anaesthetic: GA vs Spinal * catheter and vaginal pack initially * hospital x3-4 days * minimal exertion 1st week, no heavy lifting or driving for several weeks

Question 59

What were the concerns surrounding Mesh?

Answer 59

* 2008: FDA: public health safety notification regarding adverse events related to urogynaecological use of surgical mesh e.g. increased risk of repeat surgery, mesh erosion (anterior vaginal wall repair), dyspareunia * 2011: FDA: synthetic and metallic mesh associated with increased risk of adverse events e.g. mesh erosion which can require multiple surgeries and may result in consequences like pain after removal In 20191the US FDA ordered manufactures of synthetic mesh for VAGINAL repairs of Pelvic Organ Prolapse, to discontinue sale and distribution in US. This order does not apply to abdominally placed mesh for POP or that used for Stress Urinary Incontinence. In 2016 the Lancet published the Scottish Cohort Study of mesh use between 1997-2016 and concluded, “Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair.”

Question 60

What is the current situation surrounding the use of Mesh in Ireland?

Answer 60

July 2018: HSE placed a pause on the use of mesh procedures for: -Stress Incontinence -Pelvic Organ prolapse procedures Until recommendations surrounding -Informed Consent -Accreditation System -National Mesh Register Are in place.