Pelvic organ prolapse

Question 1

What is pelvic organ prolapse?

Answer 1

Descent of the pelvic organs into the vagina

Question 2

What causes pelvic organ prolapse?

Answer 2

Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

Question 3

Describe uterine prolapse

Answer 3

Where the uterus itself descends into the vagina

Question 4

Describe vault prolapse

Answer 4

Occurs in women who have had hysterectomy and no longer have a uterus
Top of the vagina descends into the vagina

Question 5

Describe rectocele

Answer 5

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

Question 6

What can faecal loading lead to?

Answer 6

Constipation
Urinary retention
Palpable lump in the vagina

Question 7

What is a cystocele?

Answer 7

Defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina

Question 8

What is cystourethrocele?

Answer 8

Prolapse of both bladder and urethra

Question 9

List some risk factors for pelvic organ prolapse

Answer 9

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and post menopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

Question 10

Describe the presentation of pelvic organ prolapse

Answer 10

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

Question 11

Describe the examination of pelvic organ prolapse

Answer 11

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

Question 12

What grading system is used for pelvic organ prolapse

Answer 12

The pelvic organ prolapse quantification system

Question 13

Describe the pelvic organ prolapse quantification system

Answer 13

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

Question 14

What is a prolapse extending beyond the introitus referred to as?

Answer 14

Uterine procidentia

Question 15

What are the 3 management options for pelvic organ prolapse

Answer 15

Conservative
Vaginal pessaries
Surgical

Question 16

Describe conservative management of pelvic organ prolapse

Answer 16

Physiotherapy
Weight loss
Lifestyle changes - reduce caffeine intake and incontinence pads
Treatment of related symptoms - Treat stress incontinence with anticholinergic medications
Vaginal oestrogen cream

Question 17

Describe vaginal pessary management of pelvic organ prolapse

Answer 17

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

Question 18

List some types of pessary

Answer 18

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

Question 19

What can vaginal pessaries lead to?

Answer 19

Vaginal irritation and erosion

Question 20

What can be used to protect against vaginal irritation

Answer 20

Oestrogen cream

Question 21

What is the definitive treatment for pelvic organ prolapse?

Answer 21

Surgery - many methods exist depending on the organ prolapsing including hysterectomy

Question 22

What are the possible complications of surgery

Answer 22

Pain
Bleeding
DVT
Anaesthetic risk 
Damage to bladder or bowel 
Altered experience of sex

Question 23

Describe mesh repairs and the complications

Answer 23

No longer recommended as complications such as chronic pain, altered sensation, dyspareunia, abnormal bleeding, urinary or bowel problems