Pelvic organ prolapse Flashcards
What is pelvic organ prolapse?
Descent of the pelvic organs into the vagina
What causes pelvic organ prolapse?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder
Describe uterine prolapse
Where the uterus itself descends into the vagina
Describe vault prolapse
Occurs in women who have had hysterectomy and no longer have a uterus
Top of the vagina descends into the vagina
Describe rectocele
Defect in posterior vaginal wall allowing the rectum to prolapse forwards into the vagina
Rectoceles are commonly associated with constipation
Women can develop faecal loading in the part of the rectum that has prolapsed
What can faecal loading lead to?
Constipation
Urinary retention
Palpable lump in the vagina
What is a cystocele?
Defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina
What is cystourethrocele?
Prolapse of both bladder and urethra
List some risk factors for pelvic organ prolapse
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and post menopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
Describe the presentation of pelvic organ prolapse
A feeling of something coming down in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms - incontinence, urgency, frequency, weak stream and retention
Bowel symptoms - constipation, incontinence, urgency
Sexual dysfunction - pain, altered sensation and reduced enjoyment
Describe the examination of pelvic organ prolapse
Patient should empty bladder and bowel before the examination
Various positions attempted - dorsal and left lateral
Sim’s speculum (U-shaped, single bladed speculum) used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. Held on the anterior wall to examine for rectocele and posterior wall for a cystocele
Women can be asked to cough or bear down to assess the full descent of the prolapse
What grading system is used for pelvic organ prolapse
The pelvic organ prolapse quantification system
Describe the pelvic organ prolapse quantification system
Grade 0 - normal
Grade 1 - The lowest part is >1cm above the introitus
Grade 2 - The lowest part is <1cm of the introitus
Grade 3- The lowest part is >1cm below the introitus, but not fully descended
Grade 4 - Full descent with eversion of the vagina
What is a prolapse extending beyond the introitus referred to as?
Uterine procidentia
What are the 3 management options for pelvic organ prolapse
Conservative
Vaginal pessaries
Surgical
Describe conservative management of pelvic organ prolapse
Physiotherapy
Weight loss
Lifestyle changes - reduce caffeine intake and incontinence pads
Treatment of related symptoms - Treat stress incontinence with anticholinergic medications
Vaginal oestrogen cream
Describe vaginal pessary management of pelvic organ prolapse
Pessaries are inserted into the vagina to provide extra support to the pelvic organs
They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems
List some types of pessary
Ring - sit around the cervix and hold the uterus up
Shelf and Gellhorn - flat disc with stem that sits below the uterus with stem pointing down
Cube
Donut - thick ring
Hodge - rectangular - one side around the posterior aspect of the cervix and the other into the vagina
What can vaginal pessaries lead to?
Vaginal irritation and erosion
What can be used to protect against vaginal irritation
Oestrogen cream
What is the definitive treatment for pelvic organ prolapse?
Surgery - many methods exist depending on the organ prolapsing including hysterectomy
What are the possible complications of surgery
Pain Bleeding DVT Anaesthetic risk Damage to bladder or bowel Altered experience of sex
Describe mesh repairs and the complications
No longer recommended as complications such as chronic pain, altered sensation, dyspareunia, abnormal bleeding, urinary or bowel problems
