Pelvic organ prolapse

Question 1

What is Prolapse?

What is Femlae POP?

Answer 1

Prolapse - Protrusion of an organ or structure beyond its normal anatomical confines.

Female POP - refers to the descent of the pelvic organs towards or through the vagina, there are various different types. Such as:

• Cystocoele
• Rectocoele
• Uretocoele

Question 2

What is the incidence of Pelvic Organ Prolapse?

Answer 2

Estimated - 12-30% of multiparous women and 2% of nulliparous women.

Prevalence varies from 2% for symptomatic prolpase to 50% for asymptomatic prolpase.

Question 3

Outline the anatomy of the pelvic floor.

Answer 3

• Abdomino-pelvic cavity is an odd shaped box that contains all the abdominal & pelvic viscera.
• Walls must be sufficiently flexible to withstand changes in volumes of the organs, and pressure changes wihtin the cavity.
• Pelvic floor represents the bottom of this box and consists of all the soft tissue structures that close the space between the pelvic bones.
• If the pelvic floor is normal, all the pelvic viscera will be maintained in their position both at rest and in periods of increased intra-abdominal pressure.

Question 4

What daily increases in volume occur in the pelvic organs?

Answer 4

• Bladder inflates and deflates about 7 times a day.
• Rectum inflates and deflates about 1 time a day.

Question 5

What are the three distinct layers of the pelvic floor?

Answer 5

• Endo-pelvic Fascia
• Pelvic Diagphragm
• Urogenital Diaphragm

Question 6

What is the Endo-pelvic fascia?

Answer 6

• Network of fibro-muscular connective tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uterosacral ligaments/Pubocervical Fascia/Rectovaginal Fascia)
• Fibro-muscular componenet can stretch (uterosacrals)
• Connective tissue does not stretch or attenuate instead it breaks.

Question 7

What is the Pelvic Diagphragm?

Answer 7

• Layers of Striated Muscle with its fascial coverings (Levator ani & Coccygeus)

Question 8

What is the Urogenital Diaphragm?

Answer 8

• The superifical & deep transverse perineal muscles with their fascial coverings.

Question 9

What are the Medial and Lateral extent of the Uterosacral/Cardinal Complex?

Answer 9

• Medially to uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia.
• Laterally to the sacrum & fascia overlying the Piriformis muscle.

Question 10

How can the utero-sacral/cardinal complex be palpated?

Answer 10

Easily palpated by down traction on the Cervix and if intact allows limited side-side movement of the cervix.

Question 11

Where does the utero-sacral/cardinal complex tend to break?

Answer 11

Tends to break medially (around the cervix).

Question 12

What is the Pubocervical Fascia and what does it do?

Answer 12

• Trapezoid Fibro-muscular tissue.

Function:

• Provide the main support of the anterior vaginal wall.

Question 13

What are the central, lateral and distal extents of the Pubocervical Fascia?

Answer 13

• Centrally
  
  • ​Merge with the base of the Cardinal Ligaments & Cervix
• Laterally
  
  • Arcus Tendineus Fascia Pelvis
• Distally
  
  • ​Urogenital Diaphragm

Question 14

Where does the Pubocervical Fascia tend to break?

Answer 14

Tends to break at lateral attachemnets or immediately in front of the cervix.

Question 15

What is the Rectovaginal Fascia?

Answer 15

• Fibro-muscular - elastic tissue

Question 16

What are the central, lateral and distal extent of the Rectovaginal Fascia?

Answer 16

• Centrally
  
  • ​merge with the base of Cardinal/uterosacral ligaments & peritoneum.
• Laterally
  
  • ​fuses with fascia over the levator ani
• Distally
  
  • ​firmly to the Perineal Body.

Question 17

Where does the Rectovaginal Fascai tend to break?

Causing?

Answer 17

• If upper defect:
  
  • Enterocoele
• If lower defect:
  
  • Perineal body descent & Rectocoele

Question 18

What are the Risk Factors for POP?

Answer 18

• Forceps Delivery
• Large Baby (>4500gm)
• Prolonged Second Stage of Labour
• Parity (having babies) - more babies, more risk
• Advancing Age - muscles and ligaments are weaker
• Obesity - increased pressure on the pelvic floor.
• Previous pelvic surgery

Other risk factors

• Hormonal factors
• Quality of Connective Tissue
• Constipation
• Occupation Heavy Lifting
• Exercise - weights, high impact aerobics and long distance running.

Question 19

What is a Urethrocoele?

Answer 19

• Prolapse of the lower anterior vaginal wall involving the urethra only.

Question 20

What is a Cystocoele?

Answer 20

• Prolapse of the upper anterior vaginal wall involving the bladder.

Question 21

What is a uterovaginal prolapse?

Answer 21

Prolapse of the uterus, cervix and upper vagina.

Question 22

What is an enterocoele?

Answer 22

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

Question 23

What is a Rectocoele?

Answer 23

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

Question 24

What are the typical vaginal symptoms of women with a POP?

Answer 24

• Sensation of a bulge or protrusion
• Seeing or feeling a bulge or protrusion
• Pressure
• Heaviness
• Difficulty inserting tampons - seen in younger women.

Question 25

What urinary symptoms do women with POP present with?

Answer 25

* Urinary incontinence * Frequency/Uregency * Weak or prolonged urinary stream/Hesistancy/ Feeling of incomplete emptying * Manual reduction of prolapse to start or complete voiding.

Question 26

What bowel symptoms do women with POP present with?

Answer 26

* Incontinence of flaus, or liquid, or solid stool * Feeling of incomplete emptying/ Straining * Urgency * Digital evacuation to complete defacation * Splinting - pushing in or around teh vagina or perineum, to start or complete defecation.

Question 27

How is POP assesed?

Answer 27

* Examination to exclude pelvic mass. * Record the position of examination * Left lateral * Lithotomy * Standing * Quality of Life Impact **Objective Assessments:** * Baden-Walker-Halfway Grading * POPQ Score - **GOld Standard**

Question 28

What investigations are used in POP?

Answer 28

* Clinical Examination only. There are no other investigations needed to diagnose a prolapse. However, other investigations can be used to look for complications. * USS/MRI - Allow idenification of fascial defects/measurement of Levator ani thickness (research only). * Urodynamics - concurrent UI or to exclude Occult stress incontinence. * IVU or Renal USS - if suspicion of ureteric Obstruction.

Question 29

What methods can be used to prevent POP?

Answer 29

* Avoid constipation. * Effective management of chronic chest pathology (COPD & Asthma). * Smaller family size. * Improvements in antenatal and intra-partum care: * Antenatal and post natal pelvic floor muscel training - thought to be protective.

Question 30

What is the role of pelvic floor muscle training in physiotherapy?

Answer 30

**Physiotherapy** * **Pelvic floor muscle training (PFMT)** * **​**Increase the pelvic floor strength & bulk -\> relieve the tension * Used in mild prolapse * WIth younger women who want more children * Not used in advanced cases. * Cannot treat fascial defects. * Education about pelvic floor exercises may be supplemented with the use of **perineometer, biofeedback, vaginal cones and electrical stimulation.**

Question 31

What material are pessariies made of? What are the advantages of this?

Answer 31

Silicone Advantages * Long shelf life * Resistance to autoclaving and repeated cleaning * Non absorbent to secretions and odours * Inertness * Hypoallergenic

Question 32

What is the differences in using a vaginal pessary and having surgery?

Answer 32

No significant differences in median parity, HRT, pre-operative bowel, urinary and sexual symptoms. Pessaries cant be used: * Previous POP surgery * Unable to retain pessary for 2 weeks **At 1 year successful pessary treatment is as effective as surgery.**

Question 33

What is the aim of surgical treatment in POP? What propylaxis needs to be remebered?

Answer 33

**Aim** * Relieve symptoms * Restore/maintain bladder & bowel function * Maintain vaginal capacity for sexual function **Propylaxis** * Antibiotics * Thrombo-embolic