Pelvic Organ Prolapse

Question 1

List the 3 types of pelvic organ prolapses and define them

Answer 1

Cystocele: herniating or bulging of anterior vagina wall with underlying bladder and urethra (anterior prolapse)

Rectocele: herniating or bulging posterior vagina wall with underlying rectum

Enterocele: herniating or bulging of peritoneum with or without small bowel between rectum and uterus at the apex of vagina

Question 2

Which organs provides structural support to uterus to help keep it in place (2)

Answer 2

Transverse cervical ligaments
Uterosacral ligaments

Question 3

Differentiate between the pubo-cervical and rectovaginal fascia

Answer 3

Pubocervical is anterior, between vagina and bladder
Rectovaginal is posterior between vagina and rectum

Question 4

Outline the stages of uterine prolapse

Answer 4

Stage 1: uterus is in the upper half of vagina
Stage 2: uterus is nearly into the opening of the vagina (hymenal ring)
Stage 3: uterus has protruded out of vagina but not maximal descent
Stage 4: maximal descent, uterus is completely out of vagina

Question 5

List some of the causes of uterine prolapse (4/5

Answer 5

-Childbirth
-Family hx of prolapse, poor collagen (uncommon in black population)
-Oestrogen deficiency (prolapses more common in post menopause)
-Increased intraabdomunal pressure ei chronic cough (COPD&smoking), obesity
-Spinal bifida in children (CNS)

Question 6

List the symptoms of anterior prolapse (6/10)

Answer 6

Stress incontinence
Urge incontinence
Urgency
Incomplete emptying
Recurrent UTI
Post micturition dribbling
Straining inorder to void
Poor stream

Question 7

List the symptoms of posterior prolapse (5/7)

Answer 7

Constipation
Defeacation difficulty
Incomplete bowel emptying
Faecal incontinence
Pelvic pressure
Digitation to aid defeacation
Digital splinting : digital evacuation, placing fingers and pressing against back wall of vagina to aid in defeacation

Question 8

List some of the sexual symptoms of pelvic organ prolapse

Answer 8

Vaginal dryness
Dyspareunia (pain during sex)
Coital incontinence (incontinence with sex)
Slackness during intercourse (feeling loose)

Question 9

How do you examine a woman with prolapse

Answer 9

Part the Labia and ask the woman to push and you may see the prolapse

Traction of the cervix with tenaculum
- traction to the back for anterior prolapse
-traction to the anterior to see posterior prolapse

Rectal exam to separate rectocoele and enterocoele

Use simms speculum

Question 10

Discuss management of prolapse

Answer 10

Non surgical
-weight loss to reduce intraabdominal pressure
-pelvic floor exercises
-diet change to softer foods to reduce constipation

Surgical
1. Anterior colporraphy (anterior repair)
-Repair of anterior wall where vagina is incised and the fascia shortened and reinforced to support bladder

2. Posterior colpo-perineorrphy (posterior repair)
   -repair at 3 levels, Pouch of Douglas superiorly, the rectovaginal fascia in middle and rebuilding of perineal body inferiorly
3. Vaginal hysterectomy and vault suspension
   -Uterus removed, remaining vault suspended by attaching it to sacrospinous ligament or remnants of uterosacral ligaments
4. Sacrospinous fixation
   -in vaginal vault prolapse, sacrospinous ligament is used as point of suspension
5. Sacrocolpopexy
   -mesh or graft places into vagina anteriorly or posteriorly through abdo, then attached to sacral promontory.
6. Vaginal mesh procedures

Question 11

List some of the complications of surgical repair of prolapse

Answer 11

Vault abscess
Dyspareunia due to excessive tightening
Difficulty urinating after vaginal repairs
Fistula formation
Bladder and/or bowel injury
Bowel dysfunction
Stress incontinence
Mesh: infection & vaginal exposure of graft
General: anaesthesia and haemorrhage

Question 12

How do you manage/ counsel a pt post operative key after surgical repair of prolapse

Answer 12

Off work 4-6 weeks
Avoid intercourse for 6 weeks
Avoid increase in ado pressure eg constipation
Avoid straining exercise