Pelvic Organ Prolapse

Question 1

Aetiology of prolapse

Answer 1

Pregnancy and VD
Congenital factor :abnornal collagen metabolism (ehler danlos)
Menopause
Chronic predisposing factors: ++IAP
iatrogenic factors: hysterectomy (vault prolapse) and burch colposuspension

Question 2

Classification of prolapse
According to the site of deffect and pelvic viscera that involved

Answer 2

**Cystocele: antior vaginal wall (bladder)
Uterine prolapse (apical): uterus, cervix, and upper vagina
Enterocele: upper posterior of vaginall wall (loops of small bowel)
Rectocele: lower posterior wall of the vagina (anterior wall of rectum).

Question 3

Symptoms:

Answer 3

Dragging sensation and heaviness
Dyspareunia
Discomfort and backache
Urinary urgency and frequency
Urinary retention (cysto-urethrocele)
Constipation(rectocele)
VD and VB (stage 3 and 4) dt mucusal ulceration

Question 4

Examination:

Answer 4

Exclude any mass with bimanual examination
Vaginal examination by sims speculum and volsellum
Sometimes, it may only be demonstrated with women standing or straining
Assessment of pelvic muscle strength

Question 5

Investigations

Answer 5

Uss to exclude pelvic or abdominal mass
Urodynamics are required if UI is present
ECG, CXR, FBC, and U&E: to assess fitness for surgery

Question 6

Prevention of pelvic organ prolapse:

Answer 6

Reduction of prolonged labor
Reduction kf trauma caused by instrumental delivery
Postnatal pelvic floow exercises
Weight reduction
Treatment of chronic constipation
Treatment of chronic cough

Question 7

Conservative mx:

Answer 7

1. Physiotherapy(mild):
   Kegel exercise
   Biofeedback and vagina cones
2. Intravaginal device (pessaries)

Question 8

Indications of pessaries:

Answer 8

For women who:
Decline surgery
Unfit for surgery
For whom surgery is contraindicated.

Question 9

Types of pessaries:

Answer 9

Ring pessary (most common)
Shelf pessary (less common): ring alternative
Hodge: uterine retroversion
Cube and doughnut: rare for significant prolapse

Question 10

Complications of pessaries use

Answer 10

Vaginal ulceration
Bleeding
Discharge
May become incarcerated
Rectovaginal or vesicovaginal fistula

Question 11

Surgical management of anterior compartment defect:

Answer 11

Anterior colporrhaphy (anterior repair):
Repair of cysto-urethrocele (vaginal approach)
Paravaginal repair : by pfannenstiel incision (may done Laproscopically) not common, very invasive, high cure rate and high recurrence rates

Question 12

Surgical management of posterior compartment defect:

Answer 12

Posterior colpoperineorrhaphy (posterior repair): for rectocele and deficient perineum
Perineoplasty for additional support

Question 13

Surgical management of uterovaginal prolapse:

Answer 13

Vaginal hysterectomy
Manchester repair (or fothergill repair)
Hysteropexy : If the patient wishes to preserve the uterus

Question 14

Surgical management of vaginal vault prolapse

Answer 14

Sacrospinous ligament fixation : risk of postoperative dyspareunia
Sacrocolpoplexy: higher success rate (late complication: mesh erosion into the vagina)

Question 15

Recurrent urogenital prolapse:

Answer 15

• Approximately 1/3 of all surgery
•Vaginal epithelium scarred and strophic
•++ risk of damage to bladder and bowel
• The use of synthetic meshes has become increasingly common