Pelvic organ prolapse

Question 1

What are the main presenting complaints in urogynaecology?

Answer 1

incontinence
vaginal prolapse

(+interstitial cystitis)

Question 2

List the supporting structures for utero-vaginal

Answer 2

Ligaments:
pubocervical ligamenets, cardinal ligaments, uterosacral ligaments

Muscle: levator ani muscles

Question 3

How is the pelvic floor damaged?

Answer 3

increase in abdominal pressure

• parity
• obesity
• smoking, coughing, constipation, weight lifting
• occupation
• increase weight of the uterus (e.g. fibroid)

Question 4

What are the symptoms of prolapse?

Answer 4

lump, urinary, bowels, sex, pain

Question 5

What are the background/key questions to ask in gynae history?

Answer 5

Background:
age
parity
menstrual history
contraception
smears
STIs
sexual history

Question 6

What are the types of prolapse?

Answer 6

cystocele- anterior/front (bladder)
rectocoele- posterior
uterine- top
enterocoele- upper vagina, descent of vagina and peritoneal sac

Question 7

What is the management of prolapse?

Answer 7

watch and wait
conservative
trial of pessary
surgery

Question 8

What is POP-Q?

Answer 8

quantitative assessment for prolapse- grading system for severity of prolapse, based on position of most distal portion of prolapse during straining

Question 9

What is the conservative management?

Answer 9

eliminate precipitating factors
pelvic floor exercise (physio)
lifestyle modifications (weight and smoking)
estrogen vaginal cream (most patients are post-menopausal therefore vagina is dry, worsening symptoms)

Question 10

For how long can you leave pessary in?

Answer 10

must take out every night

Question 11

What is the absolute contraindications for colpocleisis?

Answer 11

sexually active

Question 12

List three risk factors for prolapse

Answer 12

Increasing age/menopause
vaginal delivery
increasing parity
raised intra abdo pressure

Question 13

List two causes of raised intra abdo pressure

Answer 13

obesity
chronic cough
chronic constipation

Question 14

Why does menopause render you more prone to prolapse?

Answer 14

loss of oestrogen and connective tissue strength reduction

Question 15

How can vaginal delivery result in prolapse

Answer 15

direct trauma with forceps- avulsion of the levator ani or ligaments

pudendal nerve damage

Question 16

List three vaginal symptoms of prolapse

Answer 16

pressure, fullness, heaviness
bulge- something coming down, worse at end of day better when lying down
bleeding/discharge
backache

Question 17

List two urinary symptoms of prolapse

Answer 17

incontinence, frequency,, urgency

need to manually reduce prolapse prior to voiding

Question 18

List two bowel symptoms of prolapse

Answer 18

constipation/straining
faecal incontinence or urgency of stool
incomplete evacuation

Question 19

Why is the hymenal ring important?

Answer 19

marker for grading of prolapse POP-Q

Question 20

Which is the most common type of prolapse?

Answer 20

cystocele

Question 21

In which group of patients is vaginal vault prolapse observed?

Answer 21

post hysterectomy

Question 22

Name two factors which will influence the management of prolapse

Answer 22

severity + QoL
Age + wish for further pregnancies
Sexual acitivity
Urinary symptoms
Smoking and obesity

Question 23

List two complications of pessaries

Answer 23

sexual intercourse interference
ulceration
infection
difficulty and discomfort when removed

Question 24

Where are pessaries placed?

Answer 24

between posterior aspect of symphysis pubis and post fornix of vagina

Question 25

What are the stages of prolapse

Answer 25

stage 1-2= inside vagina
stage 3-4= outside vagina

hymenal ring!!

Question 26

Why should you be cautious when treating incontinence in elderly population?

Answer 26

elderly more susceptible to antimuscarinic cognitive side effects due to pre-existing cognitive impairment