Pelvic Organ Prolapse

Question 1

Define prolapse

Answer 1

Protrusion of an organ/structure beyond its normal anatomical confines

Question 2

Define pelvic organ prolapse

Answer 2

Descent of an organ towards/through the vagina

Question 3

Define cystocele

Answer 3

Prolapse of upper anterior vaginal wall involving the urethra only

Question 4

Define anterior vaginal wall prolapse

Answer 4

Herniated anterior vaginal wall

Question 5

Define rectocele

Answer 5

Prolapse of the lower posterior vaginal wall involving the rectum bulging into the vagina

Question 6

Define posterior vaginal wall prolapse

Answer 6

Herniated posterior vaginal wall

Question 7

Define urethrocele

Answer 7

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 8

Define apical prolapse

Answer 8

Downward displacement of the vaginal apex

Question 9

What is the scale of POP?

Answer 9

Around 50% of parous woman will have some degree of POP

Question 10

If all the pelvic floor is normal the pelvic viscera will _________________

Answer 10

Be maintained in their position at rest and during periods of increased intraabdominal pressure

Question 11

What are the three distinct layers of the pelvic floor?

Answer 11

Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm

Question 12

What is the endopelvic fascia?

Answer 12

Network of fibromuscular connective type tissue that has a hammock like configuration and surrounds the various visceral structures
(Uterosacral ligament & pubocervical & rectovaginal ligaments)

Question 13

What does the pelvic diaphragm consist of?

Answer 13

Layers of striated muscle & fascial coverings (levator ani & coccygeus)

Question 14

What does the urogenital diaphragm consist of?

Answer 14

Superficial & deep transverse perineal muscles & their fascial coverings

Question 15

Where does the uterosacral ligament pass?

Answer 15

Medial to uterus, cervix, lateral to vaginal fornices, pubocervical & rectovaginal fascia
Overlies the piriformis muscle

Question 16

How can you palpate the uterosacral ligament?

Answer 16

Down traction on cervix

If in tact allows limited side to side movement of cervix

Question 17

Where does the uterosacral ligament tend to break?

Answer 17

Medially (around cervix)

If it fails usually get uterine prolapse

Question 18

Which fascia provides the main support of the anterior vaginal wall?

Answer 18

Pubocervical fascia

Question 19

What does the pubocervical fascia merge with centrally?

Answer 19

Base of cardinal ligaments and cervix

Question 20

What occurs if the pubocervical fascia breaks?

Answer 20

Bladder comes down into anterior vaginal wall

Question 21

Where is the rectovaginal fascia?

Answer 21

Centrally merges with base of cardinal ligaments, uterosacral ligaments & peritoneum
Laterally fuses with fascia over levator ani
Distally attaches to peritoneal body

Question 22

If the rectovaginal fascia fails what results?

Answer 22

Rectal/posterior wall prolapse

If upper defect may even get enterocele

Question 23

What are the risk factors for POP?

Answer 23

Factors increasing intrabdominal pressure and putting strain on the anatomical structure

Pregnancy & vaginal birth - forcep delivery, large babies (>4.5kg), prolonged second stage
Advanced age - muscles & ligaments weaken
Obesity - inc. pressure on pelvic floor
Prev pelvic floor surgery (heals with fibrous tissue which is weaker and less elastic)
Hormonal factors (menopause)
Quality of connective tissue (certain syndromes lead to weak connective tissue)
Constipation
Exercise - heavy lifting, high impact & long distant running

Question 24

Define enterocele

Answer 24

Prolapse of the upper posterior vaginal wall usually containing loops of small bowel

Question 25

Define uterovaginal prolapse

Answer 25

Prolapse of the uterus, cervix and upper vagina

Question 26

How can you distinguish between an anterior and posterior vaginal wall prolapse?

Answer 26

Use sims speculum to hold one of the walls and ask patient to push - check both sides to see which it is

Question 27

What occurs in apical prolapse?

Answer 27

Pure prolapse - central compartment (cervix/vagina) prolapses (NOT involving posterior/anterior walls)

Question 28

What are the vaginal symptoms of POP?

Answer 28

``` Sensation of bulge/protrusion/fullness Seeing/feeling bulge Pressure Heaviness/dragging sensation Difficulty inserting tampons Difficulty during sex ```

Question 29

What are the urinary symptoms of POP?

Answer 29

Urinary incontinence Frequency/urgency Weak/prolonged urinary stream/hesitancy/feeling of incomplete emptying

Question 30

What are the bowel symptoms of POP?

Answer 30

Incontinence of flatus/liquid/stool Feeling of incomplete emptying Urgency Digital evacuation to complete defaecation Splinting/pushing around/on vagina/perineum to start defaecation

Question 31

How do you assess a POP?

Answer 31

Examination only!! Urodynamics only if concurrent urinary incontinence IVU/Renal USS only if suspicion of ureteric obstruction

Question 32

How do you prevent POP?

Answer 32

Avoid constipation Management of chronic chest pathology - asthma/COPD Small family size Improvements in antenatal/intrapartum care

Question 33

How do you treat POP?

Answer 33

POP inside introitus - pelvic floor muscle exercises | POP outside - pelvic floor muscles wont bring prolapse back inside

Question 34

Why are pelvic floor muscle exercises the mainstay of Rx for POP?

Answer 34

There is little pressure on the ligaments supporting the pelvic viscera so long as the pelvic floor muscles are strong It increases pelvic floor bulk and relieves tension on ligaments

Question 35

How do you carry out pelvic floor muscle exercises?

Answer 35

Sit on hard surface Legs open & lean forward Lift up and squeeze 10x quickly, 10x slowly

Question 36

When should pelvic floor muscle exercises be carried out?

Answer 36

In mild prolapse/young woman that have not completed their family

Question 37

What can education about pelvic floor muscle training be supplemented with?

Answer 37

Use of perineometer (measures strength of voluntary contractions of the pelvic floor muscles) Biofeedback (sensors & monitor indicate if doing it correctly) Vaginal cones Electrical stimulation (helps them find muscle & contract it if v. weak)

Question 38

Apart from pelvic floor muscle training, what are the other Rx for POP?

Answer 38

Pessaries | Surgery

Question 39

What are the most common pessaries used for POP?

Answer 39

Ring pessaries | Cup holds prolapse up with pelvic bones, stalk of pessary allows patient to reposition

Question 40

How long can pessaries stay in for?

Answer 40

9m

Question 41

What are the SEs of using pessaries?

Answer 41

Discharge | No other complications apart from this

Question 42

What is more effective in Rx POP: surgery or pessaries?

Answer 42

Just as good as each other | Pessaries have less SEs

Question 43

What does surgery aim to do in Rx of POP?

Answer 43

Relieve symptoms, restore/maintain bladder/bowel function, maintain vaginal capacity for sexual function