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
Broad ligament
Round ligament
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
What is Colpocleisis?
- Obliterative surgery corrects prolapse by removing and/or closing off all or a portion of the vaginal canal to reduce the viscera back into the pelvis
- Suitable for women who are not intending for future vaginal intercourse; better tolerated by frail older women who have failed conservative mx
How to diagnose occult stress urinary incontinence?
Done by inserting vaginal pessary before urodynamics study which unkinks the urethra and hence unmasks SUI
Symptoms of POP
- Feeling a lump down below
- 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
Symptoms of POP are relieved by….
lying down
- sx tend to be worse in the evening and improve in the morning
