29 part 1Pelvic organ prolapse

Question 1

What is Pelvic organ prolapse

Answer 1

protrusion of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support

Question 2

Definition of pelvic organ prolapse

Answer 2

herniation or descent of pelvic organs into or beyond the vaginal walls

Question 3

Types of prolapse

Answer 3

Partial/subtotal prolapse: The pelvic organs are only partially outside the vaginal opening.

Total prolapse: The pelvic organs are everted and located outside of the vaginal opening.

Question 4

What is the anatomy of the pelvic floor

Answer 4

supported by a endopelvic fascia
Fascia consists of

1) Uterosacral ligament complex (suspends the uterus and vaginal apex from the sacrum and lateral pelvis)
2) Paravaginal attachments
3) Perineal body, perineal membrane, and the perineal muscles

Question 5

5 specific cites of pelvic organ prolapse

Answer 5

Anterior vaginal wall prolapse: 
herniated anterior vaginal wall
associated with
-cystocele (descent of the bladder) or 
-urethrocele (descent of the urethra)
can be due to weakness of the pubocervical fascia

Posterior vaginal wall prolapse: 
herniated posterior vaginal wall
associated with 
1)rectocele (descent of the rectum) 
2)enterocele (herniated section of the intestines); can be due to weakness of the rectovaginal fascia

Uterine prolapse: descent of the uterus

Vaginal vault prolapse: descent of the apex of the vagina

Uterine procidentia: protrusion of all vaginal walls or cervix beyond the vaginal introitus

Question 6

RF of pelvic organ prolapse

Answer 6

Anything that reduces strength of pelvic floor muscles and ligaments supporting the uterus and vagina e.g.

• Mx vaginal deliveries and/or traumatic births
• Low estrogen levels (menopause/OCP)
• Congenital connective tissue disorders
• Previous pelvic surgery (e.g., hysterectomy)
• Increase intraabdominal pressure (cough d/2chronic lung disease and/or smoking, ascites, obesity, pelvic tumors, or constipation.)
• Diabetes mellitus

Question 7

Sx of POP

Answer 7

• vaginal fullness/ pressure around the perineum
• lower back pain worse w/ walking or standing
• weakened pelvic floor muscles
• weakened rectal sphincter
• anterior prolapse (cystocele) May present w/ discharge

Question 8

What is the pelvic organ prolapse quantisation system

Answer 8

Means to clinically diagnose POP

Stage 0: no prolapse

Stage 1: The most distal portion of prolapse is more than 1 cm above the level of the hymen.

Stage 2: The most distal portion of prolapse is 1 cm or less proximal or distal to the hymenal plane.

Stage 3: The most distal portion of prolapse is more than 1 cm from the hymenal plane but no more than 2 cm less than the vaginal length.

Stage 4: The vagina is completely everted or uterine procidentia has occurred.

Question 9

How is POP treated

Answer 9

Conservative:
For assymptomatic Prolapse
For pts who decline surgery
For pts who are CI for surgery

Surgical:
Symptomatic prolapse if conservative rx fails

Question 10

Conservative rx types of POP

Answer 10

Vaginal pessary (to support the pelvic organs)

• short term rx as can cause ulcers
• need thorough cleaning

Reduce modifiable risk factors (e.g., avoid smoking to prevent a chronic cough, weight loss, prevent constipation)

Kegel exercises: pelvic floor muscle training (also prophylactic )

Question 11

Surgical rx of POP

Answer 11

Obliterating surgery: closure of the vagina

Reconstructive surgery: restores descended pelvic organs to their original place

Question 12

Four types of reconstructive surgery for POP

Answer 12

1) Sacrocolpopexy:
- Rx of apical or vaginal vault prolapse
- fix the vaginal apex to the sacrum, with hysterectomy- reduces recurrence

2) Suspension techniques:
- prolapsed organ is suspended using native tissues -e.g. endopelvic fascia, iliococcygeus muscle, uterosacral ligament, or sacrospinous ligaments.

3) Colporrhaphy:
- repair of cystocele or rectocele
- reinforce the anterior/posterior vaginal wall

4) Sacrohysteropexy:
- repair of uterine prolapse
- fixation of the cervix to the sacrum

Question 13

What are the 6 complications of POP

Answer 13

1)Pressure ulcers w/ hemmorhage

2) Ascending urinary infections
- cystitis, pyelonephritis, vagina infec, endometritis

3) urinary disorders
- stress Incontinence
- obstructive uropathy d/2 ureter comrpression

4) defecation disorders constipation/ diahhrhea
5) sexual dysfunction fear and embarrassment
6) recurrence and surgical complications