Gynaecology - Pelvic organ prolapse

Question 1

Mechanism of pelvic organ support

Answer 1

Question 2

Delancey’s levels of uterovaginal support

Answer 2

Question 3

Types of prolapse caused by damage to levels of uterovaginal support

Answer 3

Question 4

Types of pelvic organ prolapse

Answer 4

Question 5

Cystocele

Cause
Symptoms

Answer 5

Question 6

Urethrocele

Cause
Symptoms

Answer 6

Question 7

Uterine/ vault prolapse

Cause
Symptoms

Answer 7

Question 8

Rectocele

Cause
Symptoms

Answer 8

Question 9

Enterocele

Cause
Symptoms

Answer 9

Question 10

Pelvic organ prolapse

Epidemiology
Risk factors

Answer 10

Question 11

POP

Classification

Answer 11

Question 12

POP-Q

Measurements

Answer 12

6 points: Aa, Ba, C, D, Ap, Bp
- A = anterior (distal) half of vagina;
- B = posterior (proximal) half of vagina;
- C = cervix;
- D = posterior fornix (Pouch of Douglas)
- a = anterior; p = posterior

3 measurements: gh (genital hiatus), pb (perineal body), tvl (total vaginal length)
- gh = middle of external urethral meatus to posterior hymen
- pb = posterior margin of genital hiatus to middle of anal opening
- tvl = greatest depth of vagina without straining

Question 13

POP

History taking question

Answer 13

Question 14

POP

P/E

Answer 14

Question 15

POP

Conservative management

Answer 15

Question 16

Ring pessaries

Types
Complications
Management of erosions

Answer 16

Other types of pessaries
- Hodge pessary: rigid elongated curved ovoid inserted same way as ring pessary; Used in retroverted uterus
- Gellhorn pessary: shaped like a collar stud; Used in severe prolapse
- Shelf pessary: shaped like a coat hook  Used in uterine or vault prolapse

Question 17

POP

Surgical treatment options
- for cystocele, enterocele, rectocele, vault prolapse and perineal body deficiency

Answer 17

Surgical management: more definitive

Aim: restore vaginal anatomy/function

Pre-operative preparation:
- local estrogen for 2-4 weeks
- prophylactic Cefazolin 1g IV at induction

Route: usu done transvaginal, can be done under RA

Choice: exact procedure depend on type of prolapse
- anterior colporrhaphy for cystocele alone
- McCall culdoplasty for enterocele
- posterior colporrhaphy for rectocele
- perineorrhaphy for deficient perineal body
- pelvic floor repair procedures for vault prolapse: sacrospinous colpopexy, abdominal sacrocolpopexy, olpocleisis
- vaginal hysterectomy with pelvic floor repair vs uterus-sparing procedures for apical prolapse

Question 18

Apical prolapse

Surgical treatment options

Answer 18

Procedures with hysterectomy
- Vaginal hysterectomy with high uterosacral ligament suspension: recommended in protocol
- Total abdominal/laparoscopic hysterectomy with sacrocolpopexy (or sacrocervicopexy)

Uterus-sparing procedures
- Manchester (Fothergill) repair: vaginal, rarely used nowadays
- Hysterosacropexy: open or laparoscopic transabdominal
- Sacrospinous hysteropexy: vaginal
- Total mesh technique: PERIGEE, APOGEE, Anterior and Posterior Elevate