Pelvic Organ Prolapse

Question 1

What is female pelvic organ prolapse (POP)?

Answer 1

Descent of the pelvic organs towards or through the vagina

Question 2

What are the 3 distinct layer of the pelvic floor?

Answer 2

• Endopelvic fascia
• Pelvic diaphragm
• Urogenital diaphragm

Question 3

What is the endopelvic fascia?

Answer 3

fibro-muscular connective tissue that surrounds various visceral structures (uterosacral ligaments, pubocervical fascia, rectovaginal fascia)

Question 4

What is the pelvic diaphragm?

Answer 4

Layer of striated muscles with its fascial coverings (levator ani and coccygeus)

Question 5

What is the urogenital diaphragm?

Answer 5

Superficical and deep transverse perineal muscles with their fasical coverings

Question 6

What direction does the utero-sacral/cardinal complex tend to break in?

Answer 6

Medially (around the cervix)

Question 7

What provides the main support of the anterior vaginal wall?

Answer 7

Pubocervical fascia

Question 8

Where does the pubocervical fascia tend to break?

Answer 8

At lateral attachments or immediately infront of the cervix

Question 9

How does the rectoaginal fascia tend to break?

Answer 9

• Usually breaks centrally

- If upper break it is called entrocele

Question 10

What is included in level 1 of endopelvic support?

Answer 10

• Utero-sacral ligaments

- Cardinal ligaments

Question 11

What is included in level 2 of endopelvic support?

Answer 11

• Para-vagina to arcus tendineus fascia

- Pubocervical/rectovaginal fascia

Question 12

What is included in level 3 of endopelvic support?

Answer 12

• Uritogenital diaphragm

- Perineal body

Question 13

Main risk factors for POP?

Answer 13

• Pregnancy and vaginal birth (forceps baby, large baby, prolonged second stage)
• Advancing age
• Obesity
• Previous pelvic surgery

Question 14

Other risk factors for POP?

Answer 14

• Hormonal factors
• Quality of connective tissue
• Constipation
• Occupation with heavy lifting
• Exercise (weight lifting, high impact aerobics, long distance running)

Question 15

What is an urethrocele?

Answer 15

Prolapse of lower anterior vaginal wall involving urethra only

Question 16

What is a cystocele?

Answer 16

Prolapse of upper anterior vaginal wall involving the bladder

Question 17

What is a uterovaginal prolapse?

Answer 17

Prolapse of uterus, cervix and upper vagina

Question 18

What is an enterocele?

Answer 18

Prolapse of upper posterior wall of vagina usually containing loops of small bowel

Question 19

What is a rectocele?

Answer 19

Prolapse of lower posterior vaginal wall involving rectum bulging forwards into the vagina

Question 20

Symptoms of POP (vaginal)?

Answer 20

• Sensation of bulge or protrusion
• Seeing or feeling bulge or protrusion
• Pressure
• Heaviness
• Difficulty inserting tampons

Question 21

Symptoms of POP (urinary)?

Answer 21

• Incontinence
• Frequency/urgency
• Weak or prolonged stream/hesitancy/incomplete emptying
• Manual reduction of prolapse to start or complete voiding

Question 22

Symptoms of POP (bowel)?

Answer 22

• Incontinence of flatus/liquid/solid stool
• Incomplete emptying/straining
• Urgency
• Digital evacuation to complete defecation
• Splinting or push on or around vagina or perineum to start or complete defecation

Question 23

How is POP assessed?

Answer 23

• Examination to exclude pelvic mass
• Record position of examination (left lateral vs lithotomy vs standing)
• QofL

Question 24

What scoring tools are used to assess POP?

Answer 24

• POPQ

- Banden-walker

Question 25

What investigations are done for a prolapse?

Answer 25

None it is a clinical diagnosis (investigations are done for associated symptoms)

Question 26

How is POP prevented?

Answer 26

• Avoid constipation
• Effective management of chronic chest pathology (COPD + asthma)
• Smaller family size?
• Improvements in antenatal and intra-partum care

Question 27

How and when prolapse managed through physiotherapy?

Answer 27

Pelvic floor muscle training in cases of mild prolapse

Question 28

When can physiotherapy not be used for prolapse?

Answer 28

In advanced cases and/or fascial defects

Question 29

What devices can be used for prolapse and what are their advantages?

Answer 29

Silicone pessaries

• long shelf life
• resistance to autoclaving and repeated cleaning
• non-absorbent to secretions and odors
• inertness
• hypoallergenic

Question 30

What are the aims of surgery on prolapse?

Answer 30

• Relieve symptoms (not correct the anatomy)
• Restore/maintain bladder + bowel function
• Maintain vaginal capacity for sexual function

Question 31

What types of surgery are used in anterior and posterior wall prolapses?

Answer 31

• Anterior vaginal wall repair

- Posterior vaginal wall repair

Question 32

What types of surgery are used in apical prolapses?

Answer 32

• Vaginal hysterectomy/hysteropexy
• Sacrospinous fixation
• Adominal sacro-colpo-pexy / hysteropeyx