Pelvic Organ Prolapse

Question 1

what is the pelvic floor?

Answer 1

one functional unit with 3 distinct layers

• endo-pelvic fascia
  
  • fibro-muscular type connective tissue surrounding various structures
• pelvic diaphragm
  
  • striated muscle with its fascial coverings
• urogenital diaphragm
  
  • superifical and deep transverse perineal muscles and their fascial coverings

Question 2

what are the components of the endo-pelvic fascia and where are these most likely to break?

Answer 2

• uterosacral ligament
  
  • most likely to break around cervix
• pubocervical fascia
  
  • supports anterior vaginal wall and if it fails- bladder prolapse
• rectovaginal fascia
  
  • if upper defect- enterocele
  • if lower defect rectocele

Question 3

what are the 3 levels of endopelvic support?

Answer 3

level 1: uterosacral ligament + cardinal ligaments

level 2: rectovaginal / pubocervical fascia

level 3: urogenital diaphragm and perineal body

Question 4

risk factors?

Answer 4

• pregnancy and vaginal birth
  
  • large child
  • forceps delivery
  • prolonged 2nd satge
• increased age
• obesity
• constipation
• hormonal factors
• pevious pelvic surgery
• lifting weights
• exercise - aerobics/ long distance running

Question 5

Classification of prolapse

What is urethrocele?

Answer 5

prolapse of lower part of anterior vaginal wall involving urethra

Question 6

Classification of prolapse

What is cystocele?

Answer 6

prolapse of upper anterior vaginal wall involving bladder

Question 7

Classification of prolapse

What is uterovaginal prolapse?

Answer 7

prolapse of uterus, cervix and upper vagina

Question 8

Classification of prolapse

What is enterocele?

Answer 8

prolapse of upper posterior vaginal wall with loops of small bowel

Question 9

Classification of prolapse

What is rectoocele?

Answer 9

prolapse of lower posterior vaginal wall involving rectum

Question 10

symptoms?

Answer 10

• urinary
  
  • UI/ urgency / frequency
  • voiding symptoms - poor stream / hesitancy
• bowel
  
  • incontinence of flatus / stool
  • feeling of incomplete emptying
  • urgency

Question 11

assessment ?

Answer 11

• clinical diagnosis
• impact on QoL
• POPQ score

Question 12

what further investigations can be done?

Answer 12

• USS/ MRI
  
  • to assess for any complicatons
• urodynamics
  
  • ir concomitant UI

Question 13

treatment?

Answer 13

• physio
  
  • PFMT
• conservative
  
  • pessaries
• surgery