Pelvic Organ Prolapse Flashcards
What is pelvic organ prolapse?
Pelvic organ prolapse refers to the descent of pelvic organs into the vagina. Prolapse is the result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
Types of pelvic organ prolapse?
Uterine Prolapse
Uterus itself descends into the vagina.
Vault Prolapse
Vault prolapse occurs in women that have had a hysterectomy, and no longer have a uterus. The top of the vagina (the vault) descends into the vagina.
Rectocele
Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina. Rectoceles are particularly associated with constipation. Women can develop faecal loading in the part of the rectum that has prolapsed into the vagina. Loading of faeces results in significant constipation, urinary retention (due to compression on the urethra) and a palpable lump in the vagina. Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels.
Cystocele
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele). Prolapse of both the bladder and the urethra is called a cystourethrocele.
Risk factors for pelvic organ prolapse?
Pelvic organ prolapse is the result of weak and stretched muscles and ligaments. The factors that can contribute to this include:
Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining
How does pelvic organ prolapse present?
Typical presenting symptoms are:
A feeling of “something coming down” in the vagina
A dragging or heavy sensation in the pelvis
Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
Bowel symptoms, such as constipation, incontinence and urgency
Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves. They may notice the prolapse will become worse on straining or bearing down.
What will examination of pelvic organ prolapse involve?
Ideally, the patient should empty their bladder and bowel before examination of a prolapse. When examining for pelvic organ prolapse, various positions may be attempted, including the dorsal and left lateral position.
A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined. It is held on the anterior wall to examine for a rectocele, and the posterior wall for a cystocele.
The women can be asked to cough or “bear down” to assess the full descent of the prolapse.
How are UTERINE prolapses graded?
The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system:
Grade 0: Normal
Grade 1: The lowest part is more than 1cm above the introitus
Grade 2: The lowest part is within 1cm of the introitus (above or below)
Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
Grade 4: Full descent with eversion of the vagina
A prolapse extending beyond the introitus can be referred to as uterine procidentia.
How are pelvic organ prolapses managed?
There are three options for management:
Conservative management
Vaginal pessary
Surgery
Conservative management is appropriate for women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery. Conservative management involves:
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs. They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems. There are many types of pessary:
Ring pessaries are a ring shape, and sit around the cervix holding the uterus up
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Cube pessaries are a cube shape
Donut pessaries consist of a thick ring, similar to a doughnut
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
Women often have to try a few types of pessary before finding the correct comfort and symptom relief. Pessaries should be removed and cleaned or changed periodically (e.g. every four months). They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.
Surgery is the definitive option for treating a pelvic organ prolapse. There are many methods for surgical correction of a prolapse, including hysterectomy.
Mesh repairs have been the subject of a lot of controversy over recent years. Mesh repairs involve inserting a plastic mesh to support the pelvic organs. After review, NICE recommend that mesh procedures should be avoided entirely.
Potential complications for pelvic organ prolapse surgery?
Possible complications of pelvic organ prolapse surgery include:
Pain, bleeding, infection, DVT and risk of anaesthetic
Damage to the bladder or bowel
Recurrence of the prolapse
Altered experience of sex
Potential complications of mesh repair for pelvic prolapse?
Mesh repairs have been the subject of a lot of controversy over recent years. Mesh repairs involve inserting a plastic mesh to support the pelvic organs. After review, NICE recommend that mesh procedures should be avoided entirely. Potential complications associated with mesh repairs are:
Chronic pain Altered sensation Dyspareunia (painful sex) for the women or her partner Abnormal bleeding Urinary or bowel problems
