Pelvic organ prolapse Flashcards
Definition of pelvic organ prolapse
Descent of one or more of the
- anterior vaginal wall
- posterior vaginal wall
- uterus
- vaginal vault
Ligaments supporting the pelvic organs
Pubocervical ligament
Transversal cervical ligament
Uterosacral ligament
Most common indication for hysterectomy in post-menopausal women
Uterovaginal prolapse
Risk factors of pelvic organ prolapse
Think: weakened pelvic floor muscles
1. Pregnancy >20 weeks ++
2. Increase number of parity
3. Vaginal delivery (Esp instrumental)
4. Congenital/ Genetic (FHx of prolapse)
5. Aging/ Menopause
6. Chronic raised intra-abdominal pressure
- Obesity
- COPD, chronic cough
- Smoking
- Chronic constipation
- Occupations requiring manual labour (Avoid carrying >5kg)
7. Previous pelvic surgery
Types of pelvic organ prolapse
Anterior compartment
- Cystocele/Urethrocele
Central compartment
- Uterine prolapse
Posterior compartment
- Rectocele/Enterocele
Classification for pelvic organ prolapse
Baden-Walker Halfway System
Grade 1: Descends halfway to the hymen (Within vagina)
Grade 2: Descends to the level of hymen
Grade 3: Less than halfway below hymen
Grade 4: More than halfway below the hymen
Complications of pelvic organ prolapse
- Erosions -> bleeding
- Ulcerations -> superimposed infections
- Voiding dysfunction -> high residual urine -> recurrent UTIs, obstructive uropathy
- Hydroureters/hydronephrosis -> compromised renal function
- Discomfort for patient
- Occult stress urinary incontinence (a woman with POP only leaks urine when the prolapse is reduced)
History taking points for POP
- HOPC: Feeling a lump down below
- Associated symptoms
- Sensation of swelling or fullness in the vagina
- Pelvic heaviness, pain, discomfort
- Backache
- Vaginal discharge
- Abnormal vaginal bleeding
- Difficulty walking, sitting or having sex
- Associated urinary/ bowel symptoms:
eg. voiding difficulty, OAB, constipation, increase urinary frequency, sensation of incomplete emptying of bladder, leakage of urine during coughing/sneezing/straining - Complications of POP
- Risk factors for POP
- Impact on QOL
Physical examination for POP
- General:
- BMI, Obesity - Abdominal PE:
- Previous scars
- Abdominal distension/ masses
- Tenderness - Pelvic PE:
- Vulva: Excoriations/ previous scars
- Atrophic vaginitis (pale, loss of ruggae)
- Ulcerations/ erosions
- Bleeding/ abnormal vaginal discharge
- Assess Pop-Q
- Bedside stress urinary incontinence (Ask patient to cough)
- Pelvic floor tone via digital assessment
+/- anal tone
POP-Q (quantification)
Use hymen as reference point (point 0)
- All points are measured in relation to hymen and at straining
Investigations for POP
Urinary complaints:
- UTI: UFEME, urine culture
Abnormal vaginal bleeding:
- PAP smear/ HPV screen
- U/S pelvis
- Endometrial sampling if ET is thick
If suspect complication of SUI:
- check PVRU
- bladder diary
- urodynamic studies
*Note that can try to treat POP first, and SUI might resolve so might not need to jump into SUI ix
Management of POP
Conservative
1. Lifestyle modifications
- Weight loss
- Avoid constipation
- Avoid smoking
- Avoid prolonged standing/coughing
- Avoid heavy lifting
- Control medical conditions eg Asthma/COPD
- Pelvic floor exercises
- Kegel exercises
- Needs to be done consistently daily
- Strengthen pelvic floor muscle strength and tone
- Usually more helpful in stage 1/2
- Refer to PT - Topical vaginal oestrogen
- Helpful in postmenopausal women (low oestrogen envt)
- Esp if atrophic/ulcerations/erosions
- Premarin (cream) / Vagifem (tablet)
- Given 2x/week at night - Vaginal pessaries
- Ring vs Gellhorn
Surgical
*site specific
1. Vaginal/ abdominal
2. Open/ Lap/ Robot
+/- mesh placement (if recurrent POP)
Pros of vaginal pessaries
- Can be done outpatient
- Avoids surgical/ anesthetic risk
- Suitable for elderly/ patients surgically unfit/ not keen for surgery
Cons of vaginal pessaries
- Too small: Pessary can fall out
- Too big: Can cause discomfort, erosions, bleeding
- FB: Risk of increased vaginal discharge/ infection
- Gellhorn: Cannot have sex
- F/U: Requires 4 monthly review to remove/wash/replace
What type of surgery to be performed corresponding to type of POP?
Anterior compartment:
Anterior colporrhaphy
Posterior compartment:
Posterior colporrhaphy
Central compartment:
A. Non-uterine conserving
- Vaginal hysterectomy
- Combined with McCall’s culdoplasty +/- sacrospinous ligament fixation
B. Uterine conserving
- Manchester repair (cervical amputation)
- Sacrospinous hysteropexy
- Sacrohysteropexy (mesh)
For high risk patients: Colpocleisis
