pelvic organ prolapse

Question 1

what is prolapse?

Answer 1

Prolapse – weakness and lengthening of ligaments and muscles surrounding muscles around uterus, rectum and bladder

Question 2

what is uterus prolapse?

Answer 2

uterus descends into vagina

Question 3

what is vault prolapse?

Answer 3

Vault prolapse: occurs in woman who have had a hysterectomy and no longer have a uterus  top of vagina descends into vagina

Question 4

what is a rectocele?

Answer 4

Rectocele: defect in posterior vaginal wall and rectum prolapses forwards into vagina

Question 5

what are signs of rectoceles?

Answer 5

• Signs: faecal loading – constipation, urinary retention and palpable lumps
• May have to push lump in order to defecate

Question 6

what is a cystocele?

Answer 6

Cystocele: caused by defect in anterior vaginal wall – bladder prolapses back into vagina

Question 7

what complication can arise from cystocele?

Answer 7

• Can prolapse into urethra (urethrocele)

Question 8

what are RF for organ prolapse?

Answer 8

• Multiple vaginal deliveries
• Instrumental, prolonged, traumatic births
• Advanced age/ post-menopause status
• Obesity
• Chronic resp disease – coughing
• Chronic constipation – straining

Question 9

how does pelvic organ prolapse present?

Answer 9

• Feeling of something coming down within vagina
• Dragging or heavy sensation within pelvis
• Urinary: incontinence, urgency weak stream, retention
• Bowel: constipation, incontinence, urgency
• Sexual dysfunction: pain, altered sensation, reduced enjoyment

Question 10

what should be done prior to examination?

Answer 10

ideally empty bowel/ bladder prior

Question 11

what examination should be done for pelvic organ prolapse?

Answer 11

• Sims speculum: U shaped, single bladed speculum that can support anterior or posterior wall while examination other  asked to cough to see descent of prolapse

Question 12

how many grades of PO - prolapse?

Answer 12

4

Question 13

what is grade 0 in uterine prolapse?

Answer 13

• Grade 0: normal

Question 14

what is grade 1 in uterine prolapse?

Answer 14

• Grade 1: lowest part is more than 1cm above introitus

Question 15

what is grade 2 within uterine prolapse?

Answer 15

• Grade 2: lowest part is within 1cm of introitus

Question 16

what is grade 3 within uterine prolapse?

Answer 16

• Grade 3: lowest part is more than 1cm below introitus but not fully descended

Question 17

what is grade 4 of uterine prolapse?

Answer 17

• Grade 4: full descent with eversion of vagina

Question 18

what is uterine procidentia?

Answer 18

prolapse extending beyond introitus

Question 19

what is the introitus?

Answer 19

external opening of vaginal canal

Question 20

when would conservative management be appropriate within pop?

Answer 20

Conservative: if can cope with mild symptoms, do not tolerate pessaries, not surgically suitable

Question 21

what are the conservative management options for pop?

Answer 21

• Physio (pelvic floor exercises)
• Weight loss
• Lifestyle: anything stress incontinence linked (reduce caffeine, incontinence pads)
• Treatment of related symptoms: stress incontinence with anticholinergic (oxybutulin)
• Vaginal oestrogen cream

Question 22

what is the role of vaginal pessaries within pop?

Answer 22

Vaginal pessaries: can be inserted into vagina for extra support to pelvic organs

Question 23

what are the different types of pessaries?

Answer 23

• Ring: sit around cervix and hold uterus up
• Shelf and Gellhorn: pessaries consist of flat disc with stem – sit below uterus with stem pointing down
• Cube
• Donut: like a thick ring
• Hodge: pessaries are almost rectangular  one side is hooked around posterior aspect of cervix and other extends into vagina

Question 24

how often should a pessary for pop be removed?

Answer 24

• Should be removed and cleaned every 4mths

Question 25

what side effect is commonly given oestrogen cream for within pessary use?

Answer 25

• Can cause vaginal irritation and erosion
• Oestrogen creams helps protects against irritation

Question 26

what is the definite management option?

Answer 26

surgery

Question 27

what are surgical complications for pop?

Answer 27

• Pain, bleeding infection, DVT, anaaesthetic risk
• Damage to bladder/ bowel
• Recurrence of prolapse
• Altered experience of sex

Question 28

what is a mesh repair?

Answer 28

plastic mesh to support pelvic organs

Question 29

why does NICE advice against mesh repairs?

Answer 29

NICE says to avoid due to risks:
- Chronic pain
- Altered sensation
- Dyspareunia (painful sex) for women/ partner
- Abnormal bleeding
- Urinary/ bowel problems