12. Pelvic prolapse

Question 1

Name types of female GU prolapse (5)

Answer 1

• Cystocele
• Uterine prolapse
• Vaginal vault prolapse
• Rectocele
• Enterocele

Question 2

Describe: Cystocele (1)

Answer 2

Herniation of the bladder with associated descent of the anterior vaginal segment

Question 3

Describe: Uterine prolapse (1)

Answer 3

Descent of the uterus and cervix

Question 4

Describe: Vaginal vault prolapse (1)

Answer 4

Descent of the vaginal apex (posthysterectomy)

Question 5

Describe: Rectocele (1)

Answer 5

Herniation of the rectum with associated descent of the posterior vaginal segment

Question 6

Describe: Enterocele (1)

Answer 6

Herniation of the small bowel with associated descent of the posterior vaginal segment

Question 7

Pelvic organs are supported by what? (3)

Answer 7

• the pelvic floor musculature
• fascial supports
• nervous system.

Question 8

The muscular pelvic floor is composed of what? (2)

Answer 8

• of the levator ani (combination of puborectalis, pubococcygeus, and iliococcygeus)
• the coccygeus muscles attached to elements of the bony pelvis, coccyx, and sacrum.

Question 9

The majority of women with clinically significant prolapse will have at least two RFs. Name them (7)

Answer 9

• Damage to support
  
  • Obstetric causes: pregnancy (multiparity), delivery (vacuum/forceps), fetal macrosomia, perineal laceration (third- and fourth-degree tears)
  • Surgical causes: hysterectomy
  • Estrogen deficiency
  • Chronically ↑ abdo pressure: obesity, smoking, pulmonary disease (chronic cough), constipation (chronic strain), recreational/occupational activities (weight lifting), ascites
  • Pelvic masses
• Neuromuscular/connective tissue disorders
• Genetics

Question 10

Name stages of prolapse (5)

Answer 10

• Stage 0: no prolapse
• Stage I: most distal prolapse is 1 cm above the hymen.
• Stage II: most distal prolapse between 1 cm above or below the hymen
• Stage III: most distal prolapse > 1 cm distal to the hymen
• Stage IV: total prolapse (“procidentia”)

Question 11

Describe link between parity and prolapse (1)

Answer 11

Although ↑ parity is a RF for prolapse, nulliparity does not provide absolute protection against prolapse.

Question 12

Describe: Occult/latent incontinence (2)

Answer 12

• Many women with anterior vaginal prolapse are continent either due to a competent urethral sphincter (despite lack of support) or an incompetent sphincter kinked by the prolapse, which when repaired results in new onset of stress incontinence known as occult/ latent stress incontinence.
• Stress incontinence is not a Sx of prolapse, rather a coincident Sx.

Question 13

Describe Post Void Residual Volume cut-off normal values (3)

Answer 13

• There is no consensus on PVR cut-off normal values.
• If the initial voided volume is > 1 5 0 mL, a PVR of < 100 mL is indicative of appropriate bladder emptying.
• A PVR of > 100 mL indicates impaired bladder emptying, which may or may not be due to prolapse.

Question 14

Describe: Pelvic Organ Prolapse Quantification System (POP–Q) (3)

Answer 14

• Standard system approved by the International Continence Society is the POP-Q.
• Measures nine locations on the vagina and vulva in centimeters relative to hymen
• More detailed than necessary for clinical care, but used routinely in studies

Question 15

Describe HX: Evaluation of pelvic prolapse (12)

Answer 15

• Pelvic pressure/heaviness
• Protrusion of tissue from vagina
• Inability to wear tampons
• Incontinence, including urge or stress
• Defecatory dysfunction
• Excessive straining
• Difficult or incomplete emptying of bladder or bowel
• Digitation to aid in urination or defecation (“splinting”)
• ↓ Sexual activity (due to fear/ embarrassment/incontinence)
• Vaginal bleeding (due to mucosal irritation)
• Screen for prolapse risk factors
• PMH, Sx, Hx, meds, social Hx

Question 16

Describe Physical Exam: Evaluation of pelvic prolapse (7)

Answer 16

• Inspect vulva and vagina for erosions/ ulcerations and estrogen status
• Examine all aspects of vaginal support:
  
  • a. In dorsal lithotomy position without pessary
  • b. Using single-bladed speculum to retract an- terior/posterior/lateral vaginal walls
• Standing straining exam to assess maximal prolapse
• Examine for stress incontinence
• Digital assessment of pelvic muscle/anal sphincter baseline and voluntary contraction tone (strength, duration, symmetry)
• ± Rectovaginal exam to detect enterocele
• Neuro exam: lower extremity neuromuscular exam

Question 17

Describe Investigations: Evaluation of pelvic prolapse (5)

Answer 17

• No specific tests for prolapse
• Imaging not usually necessary (unless procidentia to R/O urinary retention)
• Biopsy all suspicious persistent vulvovaginal lesions
• Cystocele evaluation:
  
  • a. UTI screen
  • b. Postvoid residual (PVR)
• ± Refer to gynecologist for urodynamic testing

Question 18

Name: Relative CI to pessary

Answer 18

• Inability to comply with pessary maintenance → risk rectovaginal or vesicovaginal fistulae
• Persistent vaginal erosions (consider local E, change size of pessary or potential vaginal neoplasm)
• Active genital infection or neoplasm

Question 19

All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.

Answer 19

All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.

Question 20

All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.

Answer 20

All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.

Question 21

Name different managements of Pelvic prolapse (5)

Answer 21

• Conservative
• Nonsurgical
• Pelvic Floor Muscle Training
• Pessaries
• Surgical

Question 22

Describe nonsurgical management: Pelvic prolapse (2)

Answer 22

• Sx relief and prevention of worsening prolapse
• Reasonable choice when observation not suitable but surgery high-risk or refused by patient

Question 23

Describe Pelvic Floor Muscle Training management: Pelvic prolapse (3)

Answer 23

• Improving support to pelvic organs with ↑ strength and endurance of pelvic muscles
• No evidence for treating or preventing prolapse, but may benefit
• Is effective for urinary and fecal incontinence

Question 24

Describe pessaries: Pelvic prolapse (5)

Answer 24

• Device placed in vagina to provide support and/or fill space
• Support pessaries (the ring) for earlier stages (II and III)
• Space-filling pessaries (Gellhorn) for more advanced prolapse
• Ideally changed and rinsed weekly with F/U q3mo
• Lubricants or vaginal E (if atrophy) is often employed with pessaries in postmenopausal women

Question 25

Describe surgical management: Pelvic prolapse (2)

Answer 25

• An attempt to improve prolapse Sx and concomitant Sx (GI, urinary, and sexual) through techniques to restore normal anatomy or obliterate the vagina
• Surgery may combine repairs to anterior vagina, vaginal apex, posterior vagina, and perineum, as well as concomitant bladder neck or anal sphincter repair

Question 26

Name indications for surgery in pelvic prolapse (4)

Answer 26

• Surgery not recommended in woman with asymptomatic prolapse
• If advanced prolapse and asymptomatic: must assess efficiency of bladder emptying due to risk for complications of urinary retention (recurrent UTI, urosepsis) and assess exposed vaginal epithelium for erosions at risk for infection
• More frequent F/U (q3 mo) if decided against surgery
• Patient fails conservative management, is unable or unwilling to use pessary, or desires surgical management