Pelvic organ prolapse

Question 1

What is meant by pelvic organ prolapse?

Answer 1

Weakness of supporting structures causing descent of vaginal walls and/or uterus beyond normal anatomical confines. Structures from beyond the vaginal boundary may then herniate.

Question 2

What is the prevalence of prolapse?

Answer 2

Affects up to 50% of women (typically parous)

By age 80, 10% will have had surgery for prolapse

Question 3

What percentage of patients need further surgery for recurrent prolapse?

Answer 3

30%

Question 4

In the normal pelvis, how are the vagina and uterus suspended?

Answer 4

Pelvic floor, split into 3 levels

Level 1 - cervix/upper third vagina supported by cardinal and uterosacral ligaments
Level 2 - middle third vagina attached to pelvic side walls by endopelvic fascia
Level 3 - lower third vagina supported by levator ani muscles and perineal body (pelvic diaphragm)

Question 5

What types of prolapse can occur?

Answer 5

Anterior wall prolapse
Posterior wall prolapse
Uterine/vaginal vault prolapse

Question 6

What terms are given when surrounding structures herniate in a prolapse?

Answer 6

Cystocele/urethrocele
Rectocele
Enterocele

Question 7

What can be responsible for the weakness behind prolapse?

Answer 7

Prolonged labour
Traumatic delivery (use of instruments etc)
Lack of pelvic floor exercises
Obesity
Prolonged straining (chronic cough, constipation)
Congenital (e.g. Ehlers-Danlos)
Previous pelvic surgery
Post-menopausal (oestrogen withdrawal causes breakdown in collagen)

Question 8

What may accompany an anterior wall prolapse, and how may it present?

Answer 8

Cystocele (urethrocele)
Frequency
Incomplete emptying, hesitancy, difficulty urinating, dysuria
Recurrent UTI
Leakage on straining
Dragging sensation, feel a bulge, visible bulge
Back ache
Sexual dysfunction

Question 9

What may accompany a posterior wall prolapse, and how may it present?

Answer 9

Rectocele, enterocele
Constipation
Incomplete emptying (may require digitation)
Dragging sensation, feel a bulge
Back ache 
Sexual dysfunction
May be asymptomatic

Question 10

What is uterine prolapse?

Answer 10

Cervix and uterus descend into vagina
Complete procidentia (displacement) when excludes past introitus (hymenal ring)
-Can become swollen/difficult to replace
-Can cause acute urinary retention

Question 11

What is vaginal vault prolapse?

Answer 11

Top of vagina descends further down into vagina (post hysterectomy)

Question 12

How would a pt present with uterine/vaginal vault prolapse?

Answer 12

Bladder and bowel dysfunction
Dragging sensation, feel a bulge
Sexual dysfunction
Pain/bleeding (ulceration of extruding portion) 
Backache

Question 13

How can prolapse be prevented?

Answer 13

Lower parity
Better obstetric practice
Maintain pelvic floor exercises

Question 14

How should patients with suspected prolapse be examined?

Answer 14

Bimanual to rule out pelvic masses
Speculum (Simms) - check for atrophy/descent
Prolapse may not be obvious - ask patient to strain/stand (‘John Wayne’)
If urinary incontinence - refer to urodynamics
POP-Q scoring (grid score, tells where prolapse is)

Question 15

How can prolapse be graded?

Answer 15

Baden-Walker classification
0 - No descend of pelvic organs during straining
First degree - lowest part of prolapse moves towards, but does not reach, introitus
Second degree - lowest part extends to introitus, and extends beyond introitus on straining
Third degree - lowest part extends beyond introitus and outside the vagina
Procidentia - uterus lying outside of vagina (fourth degree uterine prolapse)

Question 16

What conservative management options can be used for prolapse?

Answer 16

Do nothing
Pelvic floor exercises (ref to physio)
Weight loss
Stop smoking
Avoid straining (reduce intra-abdo pressure)

Question 17

What medical options are available for prolapse?

Answer 17

Vaginal oestrogen

Pessaries

Question 18

How can prolapse be managed?

Answer 18

Reassure
Ring (pessaries)
Repair (surgery)

Question 19

What kind of pessaries are available?

Answer 19

Ring (placed posterior aspect of symphysis pubis and posterior fornix)
Shelf
Gelhorn (mushroom shape)

Question 20

What is it important to consider when offering a pessary?

Answer 20

Type of prolapse
Degree of prolapse
Sexual activity
Patient choice

Question 21

How are pessaries fitted?

Answer 21

Trial and error
Use oestrogen cream (most pts post-meno so have atrophic vagina; oestrogen stimulates secretion, more comfortable for pt)
Ensure comfort and able to urinate after first fitting
Change every 6m and perform speculum to ensure no ulceration/bleeding

Question 22

When would surgery be considered for prolapse?

Answer 22

Severe symptoms
Sexually active pt
Failure of pessary

Question 23

What surgical options are available in prolapse?

Answer 23

Pelvic floor repair (colporrhaphy, perineorrhaphy)
Sacrospinous fixation (vaginal vault/cervix attached to sacrospinous ligament)
Sacrocolpopexy (vaginal vault attached to sacral promontory with mesh)
Hysteropexy (uterus attached to sacral promontory with mesh)
Hysterectomy (although risk of vaginal vault prolapse)
Colpocleisis/vaginal closure

Question 24

How successful is anterior vaginal wall repair and what complications are associated with it?

Answer 24

70-90% success

Assoc with cystitis, constipation, dyspareunia and recurrence

Question 25

What are the pros and cons for vaginal hysterectomy in uterine prolapse?

Answer 25

85% cured

Risk of damage to ureters, bladder and bowel, urinary retention and UTI

Question 26

What are the pros and cons to sacrospinous fixation for vault prolapse?

Answer 26

80-90% success rate

Risk of buttock pain, constipation and dyspareunia

Question 27

What are the pros and cons of posterior repair for prolapse?

Answer 27

80-90% success rate and 50% improvement in bowel symptoms

Risk of constipation, bowel injury and dyspareunia

Question 28

What are the pros and cons for colpocleisis/vaginal closure?

Answer 28

90-95% success rate

10% women do not feel satisfied and 20% regret their decision later

Question 29

What are the pros and cons of sacrocolpopexy for vault prolapse?

Answer 29

80-90% success rate
Pain (generally/intercourse) in 2-3%
Exposure of mesh in vagina
Damage to bladder, bowel or ureters

Question 30

What are the pros and cons of vaginal mesh?

Answer 30

85-90% success rate
Mesh exposure, reoperation rate 25%, chronic pain, discharge/spotting and dyspareunia risk
PAUSE ON MESH USE CURRENTLY

Question 31

What does prolapse often co-exist with?

Answer 31

Urinary incontinence