7.7 - Pelvic Organ Prolapse

Question 1

A patient presents with a cystocele what are the expected symptoms?

Answer 1

Urinary sx: Stress incontinence (Leakage of urine via exacerbating factors, incomplete emptying, slow stream, urgency, frequency.
Any prolapse: Dyspareunia, coital obstruction, feeling of lump (dull draggy sensation)

Question 2

Give the surgical management of a cystourethrocele

Answer 2

Anterior colporrhaphy

Question 3

A patient presents with a vaginal vault prolapse. What symptoms will they have?

Answer 3

Dyspareunia, coital obstruction, feeling of lump (dull draggy sensation)
+/- urinary, rectal sx

Question 4

Give the surgical management of uterovaginal prolapse:

Answer 4

Ask the patient if the family is complete. If there is a desire for fertility then go for hysteropexy and if not go for a hysterectomy.

Question 5

What is a hysteropexy?

Answer 5

It is a procedure performed for the treatment of a uterovaginal prolapse where by the patient is put under GA or spinal anesthesia and the uterus is surgically lifted and suspended via sutures (or mesh but thats banned in ireland)

Question 6

Give the surgical management of a vaginal vault prolapse

Answer 6

Sacrospinous ligament fixation

Question 7

What is sacrospinous ligament fixation?

Answer 7

Sacrospinous ligament fixation is a surgical procedure used to correct prolapse of the vagina (vaginal vault prolapse) or uterus by anchoring the vaginal vault to the sacrospinous ligament.

Question 8

A patient presents with a rectocele. What symptoms will they have?

Answer 8

Tenesmus + digitation +/- constipation, lower back pain worse when standing and better when sitting down, fecal urgency, incontinence.

Question 9

Differentiate between a rectocele and an enterocele

Answer 9

A rectocele involves rectum herniation into the lower posterior vaginal wall
An enterocele involves herniation of the Pouch of Douglas and/or loops of bowel into the upper posterior vaginal wall

Question 10

Give the surgical management of an enterocele

Answer 10

Posterior colporrhaphy

Question 11

A patient presents with a rectocele. What pain are they likely to have?
You go through socrates and what are exacerbating factors?

Answer 11

lower back pain worse when standing and better when sitting down

Question 12

A patient presents to you with coital obstruction. What is your differential diagnoses and take a focused history

Answer 12

Ddx: Cystocele, urethrocele, vaginal vault prolapse/uterovaginal prolapse, rectocele, enterocele

Onset
Urinary sx: Stress incontinence (Leakage of urine via exacerbating factors, incomplete emptying, slow stream, urgency, frequency.
Any prolapse: Dyspareunia, coital obstruction, feeling of lump (dull draggy sensation)
Posterior: Tenesmus + digitation +/- constipation, lower back pain worse when standing and better when sitting down, fecal urgency, incontinence.
QoL: e.g. Sexual activity (post-coital obstruction, dyspareunia)
Desire for future fertility

Question 13

Give the RFs for pelvic organ prolapse (10)

Answer 13

1) Stretching of pelvic support: Prolonged 2nd stage of labour, operative delivery (esp forceps), multiparity, big babies
2) Weakened pelvic support: Menopause (reduced estrodiol), CTD (Ehler Danlos)
3) Increased intra abdominal pressure => Obesity, ascites, chronic cough (COPD, ACEi, smoking), weight lifting, occupation involving lifting

Question 14

What is the relevant pathology behind Ehler Danlos Syndrome?

Answer 14

Abnormal collaged formation

Question 15

What are the 3 levels of pelvic organ support starting with most superficial as level 1

Answer 15

Level 1 - Uterosacral ligaments/ transverse ligaments
Level 2 - Pelvic fascia
Level 3 - Pelvic diaphragm (levator ani, coccygeus)

Question 16

What ligament maintains anteversion of the uterus?

Answer 16

Broad ligament

Question 17

Are perineal muscles part of the pelvic floor? what part of the vagina do they support?
What supports the rest?

Answer 17

They are not part of the pelvic floor but do provide support to the pelvic organs
They support the distal (lower 1/3 of the vagina)
Paravaginal muscles support the rest (proximal/upper 2/3) and are attached to the levator ani (level 3)

Question 18

A prolapse is staged based on the POPQ criteria. How would you stage a prolapse?

Answer 18

Stage 1: >1cm proximal to the hymenal remnants
Stage 2: Descends into Introitus (+/- 1cm from hymenal remnants)
Stage 3: >1cm distal to hymenal remnants
Stage 4: Maximal prolapse/eversion of vaginal mucosa (complete uterine procidentia)

Question 19

How would you ideally demonstrate vaginal wall prolapse?

Answer 19

Using a Simm’s speculum
Ask the patient to lie in the left lateral position (away from you) with knees up
Lubricate the blade and use it to hold back posterior vaginal wall => ask patient to cough or strain => demonstrates anterior wall prolapse
Do the same with holding the anterior wall and it will demonstrate posterior wall prolapse
Just asking the patient to strain may show vaginal vault or uterovaginal prolapse

Question 20

What investigations would you carry out after completing history and examination of a patient with prolapse?

Answer 20

MSU
Blood glucose
+/- urodynamic studies
+/- Intravenous Pyelogram (IVP)
These are done to rule out any alternate pathology that might present with urinary incontinence, slow stream, pain…

Question 21

What is an intravenous pyelogram?

Answer 21

An Intravenous Pyelogram (IVP) is a diagnostic imaging test used to visualize the kidneys, ureters, and bladder using X-rays and a contrast dye. It helps in diagnosing issues related to the urinary tract, such as kidney stones, tumors, or abnormalities in the urinary structure.

Question 22

A patient presents to the gynecology clinic for a routine check with her HRT. On examination an anterior wall prolapse was noted. She does not have any urinary symptoms. What is your full management plan

Answer 22

If the patient is asymptomatic, no treatment is necessary
Inform the patient and suggest RF reduction and pelvic floor exercises to reduce future risk

Question 23

A patient is presenting with complaints of urine leaking when coughing or laughing. What is your conservative and medical treatment of this?

Answer 23

Conservative: Physiotherapy referral for Kegel exercises (pelvic floor exercises)
+ RF reduction
Treat cough (update COPD med/check adherence, change ACEi, refer for smoking cessation)
High BMI -> refer to dietician, advise to lose weight, exercise
Avoid heavy lifting
Laxative for constipation
+ Vaginal Pessary (if failed before)

Medical: Local oestrogen cream

Question 24

Vaginal Pessaries provide a good alternative to surgery for pelvic organ prolapse (e.g. frail, unfit for surgery). It can also be used in pregnancy women or if the patient’s family isnt complete.
What are the types of vaginal pessaries and when are they indicated?
For how long are they prescribed for before needing to be changed?
State the complications associated with pessaries?

Answer 24

Non-space occupying such as the ring pessary (Stages 1,2, trial for 3) allows for sexual function
Space-occupying such as the Gellhorn, shelf, and donut (stages 3,4)
If the patient is capable of self-administering the pessary with safety, they are allowed to do so

Must be changed every 6 months

Complications: Infection, Pressure ulceration, granulation tissue, coital obstruction, discomfort, discharge (odorous). If the major ones present, they must come attend A&E

Question 25

If typical surgical management for pelvic organ prolapse fails, what can be used? What is it typically used for

Answer 25

Burch Colposuspension. Burch colposuspension is a surgical procedure aimed at treating stress urinary incontinence (SUI)

Question 26

What is Burch colposuspension?

Answer 26

Burch colposuspension is a surgical procedure aimed at treating stress urinary incontinence (SUI). The procedure involves lifting and securing the bladder neck and the proximal urethra to the pelvic bone, thus providing support to the urethra and reducing incontinence.