Pelvic Organ Prolapse

Question 1

What are the three distinct layers of the pelvic floor?

Answer 1

Endo-pelvic Fascia: network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
Pelvic Diaphragm: layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
Urogenital Diaphragm: the superficial & deep transverse perineal muscles with their fascial coverings.

Question 2

What are the risk factors for POP?

Answer 2

Obesity
Increasing age
Forceps Delivery 
Large baby (> 4500 gm) 
Prolonged Second Stage 
Parity (vaginal delivery)
Previous Pelvic Surgery
Hormonal factors 
Quality’ of Connective Tissue
Constipation 
Occupation with Heavy Lifting 
Exercise

Question 3

What kind of prolapses can you get?

Answer 3

Urethrocele: Prolapse of the lower anterior vaginal wall involving the urethra only
Cystocele: Prolapse of the upper anterior vaginal wall involving the bladder
Uterovaginal prolapse. This term is used to describe prolapse of the uterus, cervix and upper vagina
Enterocele: Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
Rectocele: Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina

Question 4

What are the symptoms of a prolapse?

Answer 4

Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
Urinary Incontinence
Frequency/ Urgency
Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
Incontinence of flatus, or liquid or solid stool
Feeling of incomplete emptying/ Straining
Urgency
Digital evacuation to complete defecation
Splinting, or pushing on or around the vagina or perineum, to start or complete defecation

Question 5

How is a POP assessed?

Answer 5

Clinically using the Baden- Walker- Halfawy Grading or the POPQ Score

Question 6

What investigations can be done for a POP?

Answer 6

USS / MRI: Allow identification of fascial defects/ measurement of Levator ani thickness (research only).
Urodynamics: concurrent UI or to exclude Occult SI.
IVU or Renal USS (if suspicion of ureteric Obstruction).

Question 7

How can POP be prevented?

Answer 7

Avoid constipation.
Effective management chronic chest pathology (COAD & asthma)
Smaller family size.
Pelvic floor exercises

Question 8

What is the management of POP?

Answer 8

For asymptomatic use pelvic floor exercises

If symptomatic, use pessaries as first line then move on to surgical intervention

Question 9

What are the three aims of surgery for POP?

Answer 9

Relieve symptoms,
Restore/maintain bladder & bowel function and
Maintain vaginal capacity for sexual function