pelvic organ prolapse Flashcards
what does POP stand for?
pelvic organ prolapse
what is prolapse?
protrusion of an organ or structure beyond its normal anatomical confines
prevalence 12-30% multiparous woman, 2% nulliparous woman
what is female POP?
refers to the descent of the pelvic organ towards or through the vagina
what are the 3 layers of the pelvic floor?
endo-pelvic fascia
- network of fibro-muscular connective tissue
pelvic diaphragm
- layer of striated muscles with fascial coverings (levator ani & coccygeus)
urogenital diaphragm
- superficial and deep transverse perineal muscles with fascial coverings
what composes the endo-pelvic fascia?
uterosacral/cardinal complex: tends to break medially
pubocervical fascia: tends to break laterally
rectovaginal fascia: tend to break centrally
- upper defect = enterocele
- lower defect = perineal body descent and rectocele
what are the 3 levels of endopelvic support?
level 1
- uterosacral ligaments
- cardinal ligaments
level 2
- pubocervical fascia
- rectovaginal fascia
level 3
- urogenital diaphragm
- perineal body
what are risk factors for POP?
exam question
pregnancy and vaginal birth: forceps delivery, large baby (>4.5kg), prolonged second stage of labour, greater parity (parity is the amount of times a woman has been pregnant)
advancing age
obesity
previous pelvic surgery: continence procedures or hysterectomy
other: hormonal factors, constipation, heavy lifting, exercise (weight lifting, high impact aerobics and long distance running)
what are the different classifications of POP?
urethrocele: prolapse of lower anterior vaginal wall involving urethra only
cystocele: prolapse of upper anterior vaginal wall involving the bladder
uterovaginal: 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
what is the presentation of POP?
vaginal symptoms
- bulging 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, 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)
what are different methods of measuring the severity of POP?
Baden-Walker-Halfaway grading
POPQ score – gold standard (image below)
what investigations are done for POP?
clinical diagnosis
investigations only for associative symptoms
- USS/MRI: fascial defects/measurement of levator ani thickness
- urodynamics: concurrent UI or to exclude occult SI
- IVU or renal USS: ureteric obstruction
describe the management of POP?
prevention
- avoid constipation
- effective management of chronic chest pathology (COPD and asthma)
- smaller family size
- improvements in antenatal and intra-partum care
conservative
- physiotherapy: Pelvic floor muscle training (PFMT)
- pessaries: prosthetic device inserted into vagina
surgery
- anterior vaginal wall repair
- posterior vaginal wall repair
- apical: vaginal hysterctomy/hysteropexy, sacrospinous fixation, abdominal sacro-colpo-pexy/hysteropexy
- colpocleisis: vaginal disclosure
+ prophylactic antibiotics + thrombo-embolism prophylaxis
