Pelvic Organ Prolapse

Question 1

Define Prolapse:

Answer 1

Is described by the compartment of the vagina in which it occurs:

• Apical
• Anterior vaginal wall prolapse
• Posterior vaginal wall prolapse
• Perineal descent syndrome
• Rectal prolapse

Question 2

Apical prolapse details

Answer 2

loss of support at the apex of the vagina:

• Uterine/cervix prolapse = procidentia (Uterocele) is the term used to describe complete protusion of the Uterus and vaginal walls outside the body
• Vaginal vault prolapse = complete or partial inversion of the vaginal apex, found in individuals who have had a hysterectomy
• Enterocele = due to herniation of the peritoneal sac and small intestines pushing at the vaginal apex, can also be posterior vaginal wall prolapse

Question 3

Anterior vaginal wall prolapse:

Answer 3

• Cystocele = bladder descent into anterior vaginal wall, most common location of prolapse (hendrix, 2002)
• Cystourethrocele = descent of the bladder and urethra into the anterior vaginal wall, hypermobility of the urethrovesical junction

Question 4

Posterior vaginal wall prolapse:

Answer 4

• rectocele = prolapse of the rectum into the posterior vaginal wall
• Enterocele = prolapse of the small bowel into the cul-de-sac or posterior vaginal wall

Question 5

Types of Enterocele:

Answer 5

• Traction enterocele = posterior cul-de-sac protrusion pulled into the vaginal wall by prolapse of the cervix or vaginal cuff
• Pulsion enterocele = posterior cul-de-sac protrusion into the vaginal wall caused by chronically increased intra-abdominal pressure

Question 6

Perineal descent syndrome:

Answer 6

• descent of the rectovaginal septum with the perineal body
• perineum “balloons” downward during increases intra-abdominal pressure
• perineum lies below the ischial tuberosities at rest or with bearing down

Question 7

Rectal prolapse:

Answer 7

Telescoping of the rectum through the anal sphincter

Question 8

Burden of POP

Answer 8

• significant public health impact
• financial burden includes both direct (routine care, medical care) and indirect (loss of productivity) costs
• MC data = direct care for ambulatory care for PFD in 2006 was estimated to be $412 million, expected to double in the future
• in 1997, > 225,000 IP procedures for POP were performed in the USA at the cost of over $1 billion (subek, 2001)
• significant impact on the patient QOL and self-perception of body image, decreased activity levels and exercise (Lowder, 2011)

Question 9

Etiology/Pathophysiology

Answer 9

multiple mechanisms have been hypothesized and described as contributors to the development of POP although none have fully explained the oigin or natural history of this process - there is little doubt that POP is multifactorial in etiology

Question 10

Risk Factors for POP:

Answer 10

• female gender
• vaginal childbirth
• increasing age
• increased intra-abdominal pressure
• increased body mass index
• CT disorders
• a combination of any of the above

Question 11

Urogenital Hiatus (UGH) is also called:

Answer 11

Levator hiatus - the opening between the left and right LA

Question 12

What passes through the UGH?

Answer 12

Urethra and Vagina

Question 13

LA contraction compresses…

Answer 13

the pelvic structures anteriorly against the pubic bones and closes the UGH

Question 14

What is the UGH measured by?

Answer 14

• MRI
• Transperineal US imaging
• palpation

Question 15

UGH is increased in

Answer 15

POP patients
- 9.5cm^2

vs normal = 5.25cm^2

Question 16

Andrew 2013 study suggests that excessive UGH distensibility

Answer 16

is a cause rather than effect of POP

Question 17

What is the common site of POP injury?

Answer 17

pubococcygeus or pubovisceral muscles - which may lead to a more vertical inclination to the levator plate increasing strain on the CT (Corton 2009)

Question 18

What nerve injury may denervate the LA leading to POP?

Answer 18

pudendal nerve injury

Question 19

Geometric models have predicted the pudendal nerve and branches may reach

Answer 19

35% maximum strain during vaginal birth

- 15% strain threshold is known to cause permanent damage in nerves

Question 20

Structural and Postural factors associated with POP

Answer 20

• increased diameter of the bony pelvis and changes in other bony dimensions, such as pelvis inlet/outlet may facilitate POP
• thoracic kyphosis is associated with uterine POP (lind, 1996)
• decreased lumbar lordosis is associated with POP (Nguyen 2000, Mattox 2000)

Question 21

Connective Tissue (CT) factors associated with POP

Answer 21

genetic CT abnormalities - mutations that result in collagen metabolism

• in a large multicenter study, hispanic race was shown to be a risk factor for POP development
• collagen and elastin have been shown to be decreased or disordered in women with POP compared to controls

Question 22

Reproductive factors can lead POP:

Answer 22

Pregnancy and vaginal delivery:

• stretching, tearing, and avulsion of perineal tissues
• pudendal neuropathy
• prolonged second stage = starts after the cervix is completely dilated and the fetal head begins to touch the PF, Normal is approx. 90 minutes duration
• larger baby weight =
• shoulder dystocia and occiput posterior fetal presentations
• instrumented delivery (forceps, vaccuum extraction)

Question 23

T/F elective C-section to avoid vaginal delivery is protective for POP

Answer 23

False. Not necessarily

Question 24

Increased risk of POP with parity:

Answer 24

• 4x increase in primiparous women
• 8x increase in women having 2 children
• 9-10x increase in women having 3 or 4 children

Question 25

Mechanical factors increasing risk of POP:

Answer 25

• Chronic increases IAP increase risk of POP:
  1) chronic coughing
  2) respiratory disease (COPD, asthma)
  3) Heavy lifting
• Straining with constipation
• increased BMI and body weight
• surgery - possible damage to the muscles, neurovascular structures, and connective tissues

Question 26

hysterectomy can lead to ?

Answer 26

vaginal vault prolapse (maher 2013)

Question 27

what procedure is recommended to suspend the vault to the sacral promontory

Answer 27

Sacrocolpopexy