Pelvic Organ Prolapse

Question 1

What does POP stand for?

Answer 1

Pelvic organ prolapse

Question 2

What is prolapse?

Answer 2

Prolapse = protrusion of an organ or structure beyond its normal anatomical confines

Question 3

What is female POP?

Answer 3

Female POP = refers to the descent of the pelvic organ towards or through the vagina

Question 4

What are the 3 layers of the pelvic floor?

Answer 4

• Endo-pelvic fascia
  
  • Network of fibro-muscular connective tissue, includes
  • Uteroscral ligaments
    
    • Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
    • Laterally – to sacrum and fascia overlying the piriforms muscle
    • Easily palpated by down traction of cervix
    • Tends to break medially
  • Pubocervical fascia
    
    • Provides the main support of anterior vaginal wall
    • Centrally – merge with the base of cardinal ligaments and cervix
    • Laterally – arcus tendinous fascia pelvis
    • Distally – urogenital diaphragm
    • Tends to break at lateral attachments or immediately in front of cervix
  • Rectovaginal fascia
    
    • Made from elastic tissue
    • Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
    • Laterally – fuses with fascia over levator ani
    • Distally – firmly to the perineal body
    • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele
• Pelvic diaphragm
  
  • Layer of striated muscles with its fascial coverings, includes levator ani and occygeus
• Urogenital diaphragm
  
  • Superficial and deep transverse perineal muscles with fascial coverings

Question 5

What composes the endo-pelvic fascia?

Answer 5

• Network of fibro-muscular connective tissue, includes
• Uteroscral ligaments
  
  • Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
  • Laterally – to sacrum and fascia overlying the piriforms muscle
  • Easily palpated by down traction of cervix
  • Tends to break medially
• Pubocervical fascia
  
  • Provides the main support of anterior vaginal wall
  • Centrally – merge with the base of cardinal ligaments and cervix
  • Laterally – arcus tendinous fascia pelvis
  • Distally – urogenital diaphragm
  • Tends to break at lateral attachments or immediately in front of cervix
• Rectovaginal fascia
  
  • Made from elastic tissue
  • Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
  • Laterally – fuses with fascia over levator ani
  • Distally – firmly to the perineal body
  • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele

Question 6

What are the attachments of the uterosacral ligaments?

Answer 6

• Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
• Laterally – to sacrum and fascia overlying the piriforms muscle

Question 7

Where does the uterosacral ligaments tend to break?

Answer 7

Medially

Question 8

What is the function of the pubocervical fascia?

Answer 8

• Provides the main support of anterior vaginal wall

Question 9

What are the attachments of the pubocervical fascia?

Answer 9

• Centrally – merge with the base of cardinal ligaments and cervix
• Laterally – arcus tendinous fascia pelvis
• Distally – urogenital diaphragm

Question 10

Where does the pubocervical fascia tend to break?

Answer 10

• Tends to break at lateral attachments or immediately in front of cervix

Question 11

What are the attachments of the rectovaginal fascia?

Answer 11

• Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
• Laterally – fuses with fascia over levator ani
• Distally – firmly to the perineal body

Question 12

Where does the rectovaginal fascia tend to break?

Answer 12

• Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele

Question 13

What are the 2 kinds of defects of the rectovaginal fascia?

Answer 13

• Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele

Question 14

What is the pelvic diaphragm composed of?

Answer 14

• Layer of striated muscles with its fascial coverings, includes levator ani and occygeus

Question 15

What is the urogenital diaphragm composed of?

Answer 15

• Superficial and deep transverse perineal muscles with fascial coverings

Question 16

What are the 3 levels of endopelvic support?

Answer 16

• Level 1
  
  • Uterosacral ligaments
  • Cardinal ligaments
• Level 2
  
  • Para-vagina to arcus tendinous fascia
  • Pubocervical/rectovaginal fascia
• Level 3
  
  • Urogenital diaphragm
  • Perineal body

Question 17

What are the different classifications of POP?

Answer 17

Classification, depends on the site of the defect and presumed pelvic viscera involved:

• Urethrocele
  
  • Prolapse of lower anterior vaginal wall involving urethra only
• Cystocele
  
  • Prolapse of upper anterior vaginal wall involving the bladder
• Uterovaginal prolapse
  
  • Prolapse of uterus, cervix and upper vagina
• Enterocele
  
  • Prolapse of the upper posterior wall of the vagina usually containing small loops of bowel
• Rectocele
  
  • Prolapse of the lower posterior wall of vagina involving rectum bulging into vagina

Question 18

What is urethrocele?

Answer 18

Prolapse of lower anterior vaginal wall involving urethra only

Question 19

What is cystocele?

Answer 19

• Prolapse of upper anterior vaginal wall involving the bladder

Question 20

What is uterovaginal prolapse?

Answer 20

• Prolapse of uterus, cervix and upper vagina

Question 21

What is enterocele?

Answer 21

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

Question 22

What is rectocele?

Answer 22

• Prolapse of the lower posterior wall of vagina involving rectum bulging into vagina

Question 23

What is the prevalence of POP?

Answer 23

• Prevalence 12-30% multiparous woman, 2% nulliparous woman

Question 24

What are risk factors for POP?

Answer 24

• Greater parity (parity is the amount of times a woman has been pregnant)
• Forceps delivery
• Large baby (>4.5kg)
• Prolonged second stage of labour
• Advanced age
• Obesity
• Previous pelvic surgery
  
  • Such as continence procedures or hysterectomy
• Hormonal factors
• Constipation
• Occupation with heavy lifting
• Exercise
  
  • Such as weight lifting, high impact aerobics and long distance running

Question 25

What is the presentation of POP?

Answer 25

• Vaginal symptoms
  
  • Sensation of bulge or protrusion
  • Seeing or feeling a bulge or protrusion
  • Pressure
  • Heaviness
  • Difficulty in inserting tampons
• Urinary symptoms
  
  • Urinary incontinence
  • Frequency/urgency
  • Weak or prolonged urine stream/hesitancy/feeling of incomplete emptying
  • Manual reduction of prolapse to start or complete voiding
• Bowel symptoms
  
  • Incontinence of flatus, or liquid or solid stool
  • Feeling of incomplete emptying/straining
  • Urgency
  • Digital evacuation to complete defecation
  • Splinting (pushing on or around vagina or perineum) to start or complete defecation)

Question 26

What are different methods of measuring the severity of POP?

Answer 26

• Baden-Walker-Halfaway grading
• POPQ score – gold standard (image below)
• Others

Question 27

What are the different stages of POPQ score?

Answer 27

Question 28

What investigations are done for POP?

Answer 28

• USS/MRI
  
  • Identification of fascial defects/measurement of levator ani thickness
• Urodynamics
  
  • Concurrent UI or to exclude occult SI
• IVU or renal USS
  
  • If suspicious of ureteric obstruction

Question 29

Describe the management of POP?

Answer 29

• Prophylaxis
  
  • Avoid constipation
  • Effective management of chronic chest pathology (COAD and asthma)
  • Smaller family size
  • Improvements in antenatal and intra-partum care
• Physiotherapy
  
  • Pelvic floor muscle training (PFMT)
    
    • Increase pelvic floor strength and bulk to relieve tension of ligaments
    • Can be supplemented with perineometer and biofeedback, vaginal cones and electrical stimulation
    • Indication – mild cases of prolapse, younger woman who have not yet completed family
    • Contraindication – no role in advanced cases, cannot treat fascial defects
• Pessaries
  
  • Prosthetic device inserted into vagina
  • Made from different materials, silicone is best due to long shelf life, resistance to autoclaving and repeated cleaning, non-absorbent towards secretions and odors
• Surgery
  
  • Aim is to relieve symptoms, restore/maintain bladder and bowel function, maintain vaginal capacity for sexual function
  • Done with prophylactic antibiotics and thrombo-embolism prophylaxis

Question 30

What can be done for prophylaxis of POP?

Answer 30

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

Question 31

What does PFMT stand for?

Answer 31

Pelvic floor muscle training

Question 32

What are pessaries?

Answer 32

• Prosthetic device inserted into vagina
• Made from different materials, silicone is best due to long shelf life, resistance to autoclaving and repeated cleaning, non-absorbent towards secretions and odors

Question 33

What is surgery for POP done with?

Answer 33

• Done with prophylactic antibiotics and thrombo-embolism prophylaxis