Pelvic Organ Prolapse

Question 1

Definition

Answer 1

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.

Question 2

Uterine Prolapse

Answer 2

Where the uterus itself descends into the vagina

Question 3

Vault prolapse

Answer 3

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 4

Rectocele definition + characteristic sign

Answer 4

• Caused by a defect in the posterior vaginal wall, allowing the rectum to prolapse forwards into the vagina.
• Rectoceles are esp. 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 5

Cystocele

Answer 5

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 urethra = cystourethrocele

Question 6

Aetiology

Answer 6

Result of weak and stretched muscles and ligaments.

Question 7

Risk factors

Answer 7

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

Question 8

Signs and symptoms

Answer 8

• A feeling of “something coming down” in the vagina
• A dragging or heavy sensation in the pelvis
• Urinary symptoms:
  = incontinence,
  = urgency,
  = frequency,
  = weak stream
  = retention
• Bowel symptoms,
  = constipation,
  = incontinence
  = urgency
• Sexual dysfunction:
  = pain,
  = altered sensation
  = reduced enjoyment

Question 9

Examination

Answer 9

Ideally Px should empty their bladder + bowel before.
When examining various positions may be attempted, including the dorsal and left lateral position
Sim’s speculum = 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 the 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 10

Grading of uterine prolapse

Answer 10

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.

Question 11

Management

Answer 11

There are three options for management:
- Conservative management
- Vaginal pessary
- Surgery

Question 12

Conservative management

Answer 12

For women able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery:
- Physio
- Wt loss
- Lifestyle changes for associated stress incontinence
= reduced caffeine
= incontinence pads
- Treatment of related symptoms
= stress incontinence with anticholinergic medications
- Vaginal oestrogen cream

Question 13

Vaginal pessaries

Answer 13

Inserted into the vagina to provide extra support to the pelvic organs = Create a significant improvement in symptoms + can easily be removed and replaced. Types:
- Ring: sit around cervix
- Shelf and Gellhorn: flat disc with a stem = sits below uteris with the stem poiting downwards
- Cube
- Donut
- Hodge: almost rectangular, one side is hooked around the posterior aspect of the cervix and the other extends into the vagina

Question 14

Side effect to pessaries

Answer 14

They can cause vaginal irritation and erosion over time. Oestrogen cream helps protect the vaginal walls from irritation.

Question 15

Surgery complications

Answer 15

• Pain, bleeding, infection, - DVT and risk of anaesthetic
• Damage to the bladder or bowel
• Recurrence of the prolapse
• Altered experience of sex

Question 16

Mesh repairs

Answer 16

Mesh repairs involve inserting a plastic mesh to support the pelvic organs.
Potential complications:
- Chronic pain
- Altered sensation
- Dyspareunia (painful sex) for the women or her partner
- Abnormal bleeding
- Urinary or bowel problems