Pelvic Organ prolapse

Question 1

Describe the anatomy of the pelvic floor

Answer 1

3 layers working as one unit:

• Endopelvic fascia (connective tissue)
  
  • Uterosacral/cardinal ligaments
  • Pubocervical fascia
  • Rectovaginal fascia
• Pelvic diaphragm (striated muscle)
  
  • ​Levator ani
  • Coccygeus
• Urogenital diaphragm
  
  • ​Superficial transverse perineal muscle
  • Deep transverse perineal muscle

Question 2

What is the defintion of prolapse?

Answer 2

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

Question 3

What is the defintion of female pelvic organ prolapse?

Answer 3

Refers to the descent of the pelvic organs towards or through the vagina.

Occurs due to progressive weakness of pelvic floor muscles followed by breakdown in fascial support.

• Muscle trauma
• Neuropathic injury
• Disruption
• Stretching

Question 4

What is a urethrocele?

Answer 4

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 5

What is a cystocele?

Answer 5

Prolapse of the upper anterior vaginal wall involving the bladder

Question 6

What is a rectocele?

Answer 6

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

Question 7

What is an enterocele?

Answer 7

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

Question 8

What is a uterovaginal prolapse?

Answer 8

This term is used to describe prolapse of the uterus, cervix and upper vagina

Question 9

What are risk factors for the development of pelvic organ prolapse?

Answer 9

• Pregnancy and labour related issues -
  
  • Large baby (>4500 gms),
  • Prolonged Second stage,
  • Forceps delivery,
  • Parity
  • Vaginal delivery
• Advanced Age
• Obesity
• Previous Pelvic Procedures
  
  • Continence procedures - Burch culposuspension,
  • Hysterectomy
• Hormonal Factors
• Quality of Connective Tissue
• Increased IAP - Constipation, chronic coughing
• Occupation with Heavy Lifting
• Exercise - Weight Lifting, High Impact
• Persistant cough, increased BMI

Question 10

What are general symptoms of pelvic organ prolapse?

Answer 10

• Dragging sensation/Something coming down
• Depending on site of prolapse
  
  • Cystitis
  • Frequency
  • Stress incontinence
  • Difficulty defecating

Question 11

What are symptoms of vaginal prolapse?

Answer 11

• Sensation of a bulge or protrusion
• Seeing or feeling a bulge or protrusion
• Pressure
• Heaviness
• Difficulty in inserting tampons
• Dysparuenia

Question 12

What are symptoms of a rectocele/Enterocele?

Answer 12

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

Question 13

What are symptoms of a cystocele/urethrocele

Answer 13

• Incontinence
• LUTS - storing/voiding symptoms: frequenct, urgency, poor stream, hesitancy, incomplete emptying
• To reduce the prolapse manually before voiding

Question 14

How would you examine someone with symptoms of a prolapse?

Answer 14

Left lateral side with Sim’s speculum - ask the patient to bear down

Question 15

What investigations would you consider doing in a woman with pelvic organ prolapse?

Answer 15

• Bedside - Dipstick
• Bloods - none
• Imaging - Bladder scan, IVU/renal USS (exclude pelvic mass/ureteric obstruction)
• Other - urodynamics (if incontinence present), urinalysis if urinary symtpoms

Question 16

What is the POPQ scoring system?

Answer 16

Pelvic organs prolapse quantification (POP-Q) is a standardised tool for documenting the examination findings

Question 17

What is stage 0 POPQ prolapse?

Answer 17

No prolapse

Question 18

What is stage 1 POPQ prolapse?

Answer 18

Most distal portion of the prolapse is >1cm proximal to the level of the hymen

Question 19

What is stage 2 POPQ prolapse?

Answer 19

Most distal portion of the prolapse is < 1cm proximal or distal to the level of the hymen

Question 20

What is stage III POPQ prolapse?

Answer 20

Most distal portion of the prolapse is > 1cm beyond the hymen but protrudes no further than total length of the vagina

Question 21

What is stage IV POPQ prolapse?

Answer 21

Complete vaginal eversion

Question 22

What measures can be taken to prevent pelvic organ prolapse?

Answer 22

• Avoid constipation
• Manage chronic chest pathology more effectively eg COPD, asthma
• Lower parity
• Improved intrapartum/antenatal care
• Pelvic floor exercises

Question 23

Why might you do Renal USS scan in someone with a POP?

Answer 23

Look for signs of ureteric obstructions

Question 24

What conservative measures could you use to manage POP?

Answer 24

• Preventative measures - alter exercise, reduce weight etc.
• Physiotherapy - Pelvic floor muscle training
  
  • ​Inclydes pushing knees together, stopping peeing halfway through etc

Question 25

What medical interventions can be used to manage pelvic organ prolapse?

Answer 25

* **Ring Pessaries -** as effective as surgery * **Oestrogen cream**

Question 26

What is the main purpose of surgical intervention in someone with POP?

Answer 26

* **Relieve symptoms** * **Restore bladder/Bowel function** * **Maintian vaginal capacity for sexual function**

Question 27

Surgical procedures used in pelvic organ prolapse

Answer 27

* **Colporrhaphy** * Anterior and posterior vaginal wall repair * **Hysterectomy**

Question 28

How is marked uterine prolapse managed surgically?

Answer 28

Hysterectomy

Question 29

How does a pessarie work?

Answer 29

Reduce prolapsed tissue inside the vagina, provide support to related pelvic structures, and relieve pressure on the bladder and bowel in order to avert or delay the need for surgery

Question 30

Complications of POP

Answer 30

* **Ulceration of prolapsed organ** * **Infection of prolapsed organ** * **Urinary tract complications** * **Bowel dyysfunction with rectocele**