18: Pelvic organ prolapse

Question 1

Pelvic organ prolapse

Answer 1

herniation of the anterior, apical, or posterior vaginal walls into the vaginal lumen. Traditionally, these were named by the organ presumed to be behind the prolapse including bladder (cystocele), urethra (urethrocele), rectum (rectocele), small bowel (enterocele), and/or uterus (uterine prolapse).

Question 2

Vaginal vault prolapse occurs most commonly in patients who have undergone

Answer 2

hysterectomy but may occur in conjunction with weakness or laxity of the cardinal/uterosacral ligaments as seen with uterine prolapse. The vagina can then invert into the vaginal canal and potentially prolapse outside the body in its most severe form.

Question 3

risk factors for prolapse

Answer 3

obstetric trauma (vaginal deliveries), advancing age, menopause, and parity, chronic elevations in intra-abdominal pressure, obesity, chronic cough (COPD), heavy lifting, hypoestrogenic state, and inherent poor tissue quality, such as associated with musculoskeletal syndromes/CT disorders, hysterectomy (apical)

Question 4

Pelvic organ prolapse primarily manifests as ?

Answer 4

pelvic pressure and vaginal bulging although urinary, defecatory, and sexual dysfunction can be present

Question 5

Pelvic organ prolapse is diagnosed primarily by ?

Answer 5

H+P, may also require urine cultures, cystoscopy, urethroscopy, urinary dynamic studies, anoscopy, sigmoidoscopy, and defecography as indicated.

Question 6

Both the ? and the ? are used for the quantification of pelvic organ prolapse.

Answer 6

POP-Q and the Baden-Walker systems
POP-Q is used more in research, whereas Baden-Walker halfway system is used more clinically to quantify the degree of pelvic organ prolapse.

Question 7

Pelvic organ prolapse can be treated nonsurgically with ?

Answer 7

Kegel exercises, pelvic floor physical therapy, and biofeedback. Vaginal pessary use is the mainstay of nonsurgical management of POP
-low-dose vaginal estrogen to improve tone and reverse atrophy

Question 8

Surgical treatment options for POP

Answer 8

anterior and posterior colporrhaphy for cystoceles and rectoceles, respectively. These procedures repair the fascial defect and strengthen the existing vaginal wall support.

Question 9

Uterine prolapse is most commonly treated with ?

Answer 9

abdominal or vaginal hysterectomy with apical suspension of the vault.

Question 10

Vaginal vault prolapse is repaired by ?

Answer 10

resuspending the vaginal vault to a fixed structure in the pelvis.

Question 11

women who are poor surgical candidates and no longer plan vaginal intercourse may be offered a ?

Answer 11

colpocleisis. This vaginal obliterative procedure is less invasive with a shorter operative time, fewer complications and recurrences and a high patient satisfaction rate.

Question 12

technique to best visualize prolapse

Answer 12

split-speculum examination: using a Sims speculum or the lower half of a Grave speculum to retract the posterior vaginal wall (to visualize cystocele) and split speculum placed upside down retracting the anterior vaginal wall (to visualize rectoceles and enteroceles)

Question 13

Complete procidentia

Answer 13

complete eversion of the vagina with the entire uterus prolapsing outside the vagina

Question 14

Baden-Walker Halfway Scoring System

Answer 14

0 represents normal anatomic position (i.e., no descensus)
1 represents descensus halfway to the hymen
2 represents descensus to the hymen
3 represents descensus halfway past the hymen
4 represents maximum descent.

Question 15

Pelvic Organ Prolapse Quantitative scale (POP-Q)

Answer 15

focuses on the physical extent of the vaginal wall prolapse

-uses six points within the vagina that are measured relative to a fixed point of reference: the hymen.

Question 16

ddx for cystocele and urethrocele

Answer 16

urethral diverticula, Gartner cysts, Skene gland cysts, and tumors of the urethra and bladder

Question 17

ddx for rectocele

Answer 17

obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)

Question 18

ddx for uterine prolapse

Answer 18

Cervical elongation, prolapsed cervical polyp, prolapsed uterine fibroid, and prolapsed cervical and endometrial tumors, lower uterine segment fibroids.

Question 19

Pessaries act as ?

Answer 19

mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area
-fitted in the vagina, positioned like a diaphragm, and serve to hold the pelvic organs in their normal position

Question 20

cystocele repair

Answer 20

Anterior colporrhaphy: Plication (reinforcement) of the endopelvic fascia and reattachment to the apex or uterine cervix (if present) to resuspend the anterior vaginal wall and bladder

Question 21

rectocele repair

Answer 21

Posterior colporrhaphy: Similar to anterior colporrhaphy, except the posterior endopelvic fascia is identified and reattached to the apical support or uterine cervix (if present) and distally to the perineal body

Question 22

enterocele repair

Answer 22

Vaginal enterocele repair: The enterocele is repaired along with the reattachment of the rectovaginal fascia to the apex or uterine cervix (if present)

Question 23

Uterine prolapse repair

Answer 23

Hysterectomy (abdominal or vaginal) and McCall culdoplasty: Hysterectomy followed by attachment of the resulting vaginal cuff to the uterosacral ligaments to decrease the risk of future vault prolapse

Question 24

repair of Vaginal vault prolapse (after hysterectomy)

Answer 24

Sacrospinous ligament fixation
Or
Abdominal sacral colpopexy: The vaginal apex is suspended to the sacrospinous ligaments via a vaginal approach
Uses mesh to attach the vaginal apex to the sacrum via an abdominal, laparoscopic, or robotic approach