Prolapse and Pelvic Support Defects

Question 1

What is Delancey Level 1 of pelvic support?

Answer 1

Level I: cardinal-uterosacral ligament complex - support of upper vagina, cervix

Question 2

What is Delancey Level 2 of pelvic support?

Answer 2

Endopelvic fascia - lateral paravaginal support of bladder, middle 2 quarters of vagina and rectum

Question 3

What is Delancey Level 3 of pelvic support?

Answer 3

fusion of lower vagina to perineal membrane (anteriorly) and perineal body (posteriorly): support for lower quarter of vagina, urethra and anal canal.

Question 4

RFx for pelvic organ prolapse?

Answer 4

• Genetic
• Multiparity
• Menopause
• Advancing age
• Pelvic surgery
• Congenital (CT, collagen, spina bifida)
• Elevated IAP
• Lifestyle (high impact activities, heavy lifting)
• Smoking
• Diabetes

Question 5

What is the cause of POP?

Answer 5

Complex combination of muscles (levators), fasciae (urogential diaphragm, endopelvic) and ligaments (cardinal, USL) support pelvic organs. Any may lose ability to provide support (birth trauma, IAP, atrophic changes etc)

Question 6

What are the types of POP?

Answer 6

• Uterus: prolapse. Cervix extends beyond vulva = procidentia. Apical descent.
• Urethra: urethrocele. Anterior vaginal wall descent
• Bladder: cystocele. Anterior vaginal wall descent
• Rectum: rectocele. Posterior wall descent.
• Enterocele: true hernia at top of vagina allowing herniation of small bowel. Apical descent.

Question 7

Signs and symptoms of POP?

Answer 7

• Urinary/faecal retention or incontinence
• Vaginal pressure / heaviness
• Mass sensation
• Abdo, back, vaginal or perineal pain
• mass sensation
• Protruding bulge
• Difficulty with intercourse

Question 8

Hx structure in POP evaluation?

Answer 8

• Evaluate for signs and symptoms
• Exclude other causes of POP:
• -IAP causes
• • chronic cough
• -neurologic process

Question 9

What is the Q tip test?

Answer 9

Extent of urethral hyper mobility:
- patient in lithotomy position
- cotton tipped swabbed with lidocaine jelly
inserted into bladder and pulled back until resistance met
- Patient asked to bear down
- UVJ deflects downwards if there is urethral hyper mobility causing swab to rise
30+ degrees = positive test

Question 10

Ddx of POP?

Answer 10

• UTI
• Skene gland abscess
• Fistulae (if Hx surgery, radiation)

Question 11

Non surgical management of POP?

Answer 11

• Pessaries - any situation where woman prefers non surgical alternative.
• Pelvic floor exercises
• Symptom management
• Oestrogen replacement

Question 12

Surgical Mx of POP?

Answer 12

• Hysterectomy for uterine prolapse
• Uterosacral or sacrospinous ligament fixation by vaginal approach for vault prolapse
• Sacral hysteropexy (abdominal attachment of the lower uterus or upper vagina to sacral promontory with synthetic mesh)
• Colpocleisis

Question 13

What is colpocleisis and for whom is it indicated?

Answer 13

Complete obliteration of vaginal lumen. For women at high risk of complications with reconstruction and do not desire vaginal intercourse.

Question 14

How may degree of POP be quantified?

Answer 14

POP-Q classification system