Pelvic Organ Prolapse

Question 1

Classification

Answer 1

Anterior Vaginal Wall Prolapse
Posterior Vaginal Wall Prolapse
Apical Vaginal Prolapse

Question 2

Definition

Answer 2

Protrusion of organ/structure beyond its normal anatomical confines - e.g. descent of pelvic organs towards/through vagina

Question 3

Presentation

Answer 3

Vaginal Symptoms:
• SENSATION of BULGE/PROTRUSION

• SEEING/FEELING BULGE/PROTRUSION
• PRESSURE
• HEAVINESS in VAGINA (& pulling from down below)
• DIFFICULTY INSERTING TAMPONS - imp. as surgery not offered until child-bearing years over

Urinary Symptoms:
• URINARY INCONTINENCE

• FREQ./URGENCY
• WEAK/PROLONGED URINARY STREAM or HESISTANCY or FEELING of INCOMPLETE EMPTYING
• MANUAL REDUCTION of PROLAPSE to START/COMPLETE VOIDING - manually retract prolapsed vaginal wall to reduce bend of urethra to allow for micturition

Bowel Symptoms:
• INCONTINENCE of FLATUS/LIQUID/SOLID STOOL

• FEELING of INCOMPLETE EMPYTING/STRAINING
• URGENCY
• DIGITAL EVACUATION to COMPLETE DEFAECATION

SPLINTING or PUSHING ON/~ VAGINA or PERINEUM to START/COMPLETE DEFAECATION

Question 4

Risk Factors

Answer 4

Main = pregnancy + vaginal delivery, obesity, advancing age, previous pelvic surgery

Other = hormonal factors, occupation w/ heavy lifting, exercise - wgt lifting, high intensity, poor connective tissue support, constipation

Question 5

Investigations/diagnosis

Answer 5

Examination to rule out pelvic mass

QoL

Objective assessment - POPQ score

Urodynamics - incontinence (urinary/stress)

IVU/renal USS - ureteric obstruction

Question 6

Management

Answer 6

Prevention = avoid constipation, effective management of chronic chest pathology, smaller family sizes, ANTENATAL + POSTNATAL PELVIC FLOOR EXERCISES

Treatment = PELVIC FLOOR EXERCISES (physiotherapy), SILICONE VAGINAL PESSARIES, SURGERY (function > anatomy)

Question 7

Functions of Pelvic Floor

Answer 7

flexible enough to withstand changes in cavity pressure + organ vol.

tonic/strong enough to support viscera

3 distinct layers = endo-pelvic fascia (uterosacrals, pubocervical ligaments, rectovaginal ligaments), pelvic diaphragm, urogenital diaphragm

Question 8

Lvls of endopelvic support

Answer 8

lvl 1 = uterosacrals + cardinal ligaments

lvl 2 = pubocervical/rectovaginal fascia

lvl 3 = urogenital diaphragm, perineal body