Pelvic Organ Prolapse

Question 1

What is prolapse?

Answer 1

Protrusion of an organ or structure beyond its normal anatomical confines.

Question 2

What is Female POP?

Answer 2

The descent of the pelvic organs towards or through the vagina.

Question 3

What are the 3 distinct layers of the pelvic floor?

Answer 3

Endo-Pelvic fascia - network of fibromuscular connective type tissue that has a hammock like configuration. Surrounds the various visceral structures (uterosacral ligaments, pubocervical fascia, retrovaginal fascia).

Pelvic Diaphragm - Layer of striated muscles with its fascial coverings (elevator ani and coccygeus)

Urogential Diaphragm - the superficial and deep transverse perineal muscles with their fascial coverings.

Question 4

What is the function of the coccygeus muscle?

Answer 4

Rudimentary, would only move our tail if we still had one.

Question 5

What are the boundaries of the utero-sacral/ cardinal complex?

Answer 5

Medial to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia.

Lateral to sacrum and fascia overlying Piriformis muscle.

Question 6

Where can the utero-sacral complex be palpated?

Answer 6

Easily palpated by down traction on the cervix and if intact allows limited side-side movement of cervix.

Question 7

How does the utero-sacral complex tend to break?

Answer 7

Breaks medially around the cervix, so it will drop down.

Question 8

What are the boundaries of the pubocervical fascia?

Answer 8

Centrally it merges with base of carinal ligaments and cervix.
Laterally Arcus tendinous, fascia pelvis.
Distally with the urogenital diaphragm.

Question 9

What is the function of the pubocervical fascia?

Answer 9

Trapezoidal fibromuscular tissue that provides the main support of the anterior vaginal wall.

Question 10

Where does the pubocervical fascia tend to break?

Answer 10

Laterally at attachments or immediately infront of cervix.

Question 11

What are the boundaries of the rectovaginal fascia?

Answer 11

Centrally merges with base of cardinal ligaments and peritoneum.
Laterally fuses with fascia over the levator ani.
Distally it firmly attaches to the perineal body.

Question 12

What sort of tissue is the rectovaginal fascia?

Answer 12

Fibro-musculo-elastic tissue.

Question 13

Where does the rectovaginal fascia tend to break?

Answer 13

Centrally - upper then enterocele and if lower defect the perineal body descent and rectocele.

Question 14

What are the 3 levels of endopelvic support?

Answer 14

Level I - uterosacral ligaments & cardinal ligaments.

Level II - Para-vagina to Arcus tendineus fascia: pubocervical/rectovaginal fascia.

Level III - Urogenital diaphragm & perineal body

Question 15

What are the risk factors for Pelvic Organ Prolapse?

Answer 15

Pregnancy - forceps delivery, large baby, prolonged second stage. 
Advancing Age
Previous pelvic surgery 
Obesity
Hormonal factors
Quality of connective tissue
Occupation with heavy lifting
Exercise

Question 16

What is Burch Colposuspension?

Answer 16

Procedure to fix the lateral vaginal fornices to the ipsilateral iliopectineal ligaments. May leave a potential defect in the posterior vaginal wall which predisposes to enterocele and rectocele formation .

Question 17

What is a urethrocele?

Answer 17

Prolapse of the lower anterior vaginal wall involving urethra only.

Question 18

What is a cystocele?

Answer 18

Prolapse of the upper anterior vaginal wall involving the bladder.

Question 19

What is a uterovaginal prolapse?

Answer 19

Prolapse of the uterus, cervix and upper vagina.

Question 20

What is an Enterocele?

Answer 20

Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel.

Question 21

What is a rectocele?

Answer 21

Prolapse of the lower posterior wall of vagina involving the rectum bulging forwards into vagina.

Question 22

What are the typical symptoms of women with pelvic organ prolapse?

Answer 22

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

Question 23

How is POP assessed?

Answer 23

Examination to exclude pelvic mass
Record position of examination
Quality of life
Baden-walker-Halfawy Grading
POPQ score (gold standard)

Question 24

What investigations do you carry out for POP?

Answer 24

Ultrasound scan
MRI
Urodynamics
IVU or Renal USS

Question 25

How is POP prevented?

Answer 25

Avoid constipation
Effective management of chronic chest conditions
Smaller family size!
improvements in antenatal and intra-partum care.

Question 26

How is POP treated?

Answer 26

Pelvic Floor muscle training - increase pelvic floor strength and bulk.
Pessaries - devices used to hold organs in place.
Surgery

Question 27

What is the advantage of using a silicone pessary?

Answer 27

Long shelf life
Resistance to autoclaving/repeated cleaning
Non-absorbent to secretions and odours
Inertness
Hypoallergenic nature

Question 28

What are the aims of POP surgical treatment?

Answer 28

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