Pelvic organ prolapse

Question 1

What is a female POP?

Answer 1

Descent of pelvic organs towards or through the vagina

Question 2

Who is more at risk of POP?

Answer 2

Parous women

Question 3

What are the 3 layers of the pelvic floor?

Answer 3

Endo-pelvic fascia
Pelvic diaphragm
Urogenital diaphragm

Question 4

What is the endo-pelvic fascia?

Answer 4

Network of fibre-muscular connective-type tissue that has ‘hammock-like’ configuration and surrounds various visceral structures

Question 5

What is the pelvic diaphragm?

Answer 5

Layer of striated muscles with its facial coverings (Levator ani & coccygeus)

Question 6

What makes up the endo-pelvic fascia?

Answer 6

Uterosacral ligaments
Pubocervical fascia
Rectovaginal fascia

Question 7

What makes up the pelvic diaphragm?

Answer 7

Levator ani

Coccygeus

Question 8

What is the urogenital diaphragm?

Answer 8

Superficial and deep transverse perineal muscles with their fascial coverings

Question 9

Where does the uterosacral-cardinal complex tend to break?

Answer 9

Medially (around the cervix)

Question 10

What does the uterosacral-cardinal complex attach to medially?

Answer 10

Uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia

Question 11

What does the uterosacral-cardinal complex attach to laterally?

Answer 11

Sacrum a& fascia overlying piriformis

Question 12

How is the uterosacral-cardinal complex palpated?

Answer 12

Down traction on acerbic and, if intact, allows limited side-side movement of the cervix

Question 13

What does the pubocervical fascia do?

Answer 13

Provides the main support of anterior vaginal wall

Question 14

Where does the pubocervical fascia tend to break?

Answer 14

At lateral attachments of immediately in front of cervix

Question 15

Where does the pubocervical fascia attach centrally?

Answer 15

Merge with base of cardinal ligaments & cervix

Question 16

Where does the pubocervical fascia attach laterally?

Answer 16

Arcus tendinous fascia pelvis

Question 17

Where does the pubocervical fascia attach distally?

Answer 17

Urogenital diaphragm

Question 18

What type of tissue is the rectovaginal fascia tissue?

Answer 18

Fibro-musculo-elastic tissue

Question 19

Where does the rectovaginal fascia attach centrally?

Answer 19

Merge with base of cardinal/uterosacral ligaments & peritoneum

Question 20

Where does the rectovaginal fascia attach laterally?

Answer 20

Fuses with fascia over levator ani

Question 21

Where does the rectovaginal fascia attach distally?

Answer 21

Firmly to perineal body

Question 22

Where does the rectovaginal fascia tend to break?

Answer 22

Centrally - if upper defect e.g. enterocele

Question 23

What are the 3 levels of endopelvic support?

Answer 23

Level I: utero-sacral ligaments and cardinal ligaments
Level II: para-vagina to Marcus tendineus fascia: pubocervical/rectovaginal fascia
Level III: urogenital diaphragm and perineal body

Question 24

What are the main risk factors of POP?

Answer 24

Pregnancy and vaginal birth: forceps delivery, large baby, prolonged second stage
Advancing age
Obesity
Previous pelvic surgery (continence procedures)
Hormonal factors
Quality of connective tissue
Constipation
Occupation with heavy lifting
Exercise: weight lifting, high-impact aerobics, long-distance running

Question 25

What is a urethrocele?

Answer 25

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 26

What is a cystocele?

Answer 26

Prolapse of the upper anterior vaginal wall involving the bladder

Question 27

What is a uterovaginal prolapse?

Answer 27

Prolapse of uterus, cervix and upper vagina

Question 28

What is an enterocele?

Answer 28

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

Question 29

What is a rectocele?

Answer 29

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

Question 30

What is an apical prolapse the same as?

Answer 30

Enterocele

Question 31

What are typical vaginal symptoms in women with POP?

Answer 31

``` Sensation of bulge/ protrusion Seeing or feeling bulge/protrusion Pressure Heaviness Difficulty inserting tampons ```

Question 32

What are typical urinary symptoms in women with POP?

Answer 32

``` UI Frequency/urgency Weak or prolonged urinary stream Hesitancy Feeling of incomplete emptying Manual reduction of prolapse to start or complete voiding ```

Question 33

What are typical bowel symptoms in women with POP?

Answer 33

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

Question 34

What is the assessment for POP?

Answer 34

Examination - exclude pelvic mass Record position of exam QoL effect Objective assessments

Question 35

What are the objective assessments used in POP?

Answer 35

Bade-Walking-Halfawy Grading | POPQ score

Question 36

What is the gold standard objective assessment used in POP?

Answer 36

POPQ score

Question 37

What is the POPQ score?

Answer 37

Stage 0-VI | Measures 9 points in vagina

Question 38

What investigations can be done in POP?

Answer 38

USS/MRI Urodynamics IVU or renal USS

Question 39

What are preventions to avoid POP?

Answer 39

Avoid constipation Effective management chronic chest pathology (COPD/asthma) Smaller family - less parity! Antenatal pelvic floor training

Question 40

What are the treatment options for POP?

Answer 40

Physio: PFMT Pessaries Surgery

Question 41

How does PFMT help POP?

Answer 41

Increase pelvic floor strength/bulk = relieve tension of ligaments

Question 42

How does prolapse occur?

Answer 42

Progressive weakness of the pelvic floor muscles followed by breakdown in fascial support