Pelvic Organ Prolapse

Question 1

Define Vault Prolapse

Answer 1

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.

Question 2

Rectoceles are caused by a defect in the …

Answer 2

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.

Question 3

… are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.

Answer 3

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.

Question 4

Cystoceles vs Rectocele

Answer 4

Rectoceles are caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.

Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina.

Question 5

Risk Factors for pelvic organ prolapse

Answer 5

Multiple vaginal deliveries
Instrumental, prolonged or traumatic delivery
Advanced age and postmenopause status
Obesity
Chronic respiratory disease causing coughing
Chronic constipation causing straining

Question 6

Typical presenting symptoms of pelvic organ prolapse:

Answer 6

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.

Question 7

What speculum can be used to examine pelvic organ prolapse?

Answer 7

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.

Question 8

The severity of a uterine prolapse can be graded using the pelvic organ prolapse quantification (POP-Q) system:

Answer 8

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.

Question 9

There are three options for management:

Answer 9

Conservative management
Vaginal Pessary
Surgery

Question 10

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:

Answer 10

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

Question 11

Vaginal pessaries for pelvic organ prolapse

Answer 11

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.