Pelvic organ prolapse

Question 1

What is a prolapse?

Answer 1

Protrusion of an organ or structure beyond its normal anatomical confines

Question 2

What is female pelvic organ prolapse?

Answer 2

Descent of pelvic organs towards or through the vagina

Question 3

Are nulliparous or multiparous women more likely to get pelvic organ prolapse?

Answer 3

Multiparous

Question 4

What is the pelvic floor?

Answer 4

The bottom surface of the pelvic cavity

Question 5

What is the purpose of the pelvic floor?

Answer 5

Keeps pelvic viscera in position at rest and when there is increased intra-abdominal pressure

Question 6

What are the 3 layers of the pelvic floor?

Answer 6

Endo-pelvic fascia
Pelvic diaphragm
Urogenital diaphragm

Question 7

What is the endo-pelvic fascia?

Answer 7

Network of fibro-muscular connective tissue that has a hammock-like configuration and surrounds various visceral structures

Question 8

What structures male up the endo-pelvic fascia?

Answer 8

Uterosacral ligaments
Pubocervical fascia
Rectovaginal fascia

Question 9

What is the pelvic diaphragm?

Answer 9

Layer of striated muscles with fascial coverings

Question 10

What structures make up the pelvic diaphragm?

Answer 10

Levator ani

Coccygeus

Question 11

What is the urogenital diaphragm?

Answer 11

Superficial and deep transverse perineal muscles with their fascial coverings

Question 12

What is the anatomical position of the utero-sacral ligament?

Answer 12

Medial to the uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
Lateral to sacrum and fascia overlying piriformis muscle

Question 13

How can the utero-sacral ligament be palpated?

Answer 13

Down traction on the cervix

Question 14

What does the utero-sacral ligament provide?

Answer 14

Limited side-side movement of the cervix

Question 15

Which part of the utero-sacral ligament tends to break?

Answer 15

Medial part

Question 16

Why is it important that the ligament normally breaks medially?

Answer 16

Allows the surgeon to access it vaginally

Question 17

What are the 3 supports of the pubocervical fascia?

Answer 17

Centrally - merges with the base of cardinal ligaments and cervix
Laterally - arcus tendineus fascia pelvis
Distally - Urogenital diaphragm

Question 18

Where does the pubocervical fascia tend to break?

Answer 18

Lateral attachments or immediately in front of cervix

Question 19

What tissue makes up the rectovaginal fascia?

Answer 19

Fibro-musculo-elastic tissue

Question 20

What are the 3 supports for the rectovaginal fascia?

Answer 20

Centrally merge with base of the cardinal/uterosacral ligaments and peritoneum
Laterally fuses with fascia over levator ani
Distally attaches firmly to the perineal body

Question 21

Where does the rectovaginal fascia tend to break?

Answer 21

Centrally
If upper defect - enterocele
If lower defect - perineal body descent and rectocele

Question 22

What is enterocele?

Answer 22

Descent of the small intestine into the vagina

Question 23

What is rectocele?

Answer 23

Protrusion of the rectum into the vagina

Question 24

What are risk factors of pelvic organ prolapse?

Answer 24

Forceps delivery of vaginal birth
Large baby - over 4500 grams
Prolonged second stage of labour
Advancing age
Obesity
Previous pelvic surgery
Hormonal factors
Constipation
Occupation with heavy lifting
Some forms of exercise

Question 25

What pelvic surgery increases risk of pelvic organ prolapse?

Answer 25

Continence procedures

Hysterectomy

Question 26

What is urethrocele?

Answer 26

Prolapse of the lower anterior vaginal wall involving the urethra only

Question 27

What is a cystocele?

Answer 27

Prolapse of the upper anterior vaginal wall involving the bladder

Question 28

What is uterovaginal prolapse?

Answer 28

Term used to describe prolapse of the uterus, cervix, and upper vagina

Question 29

What are typical vaginal symptoms in women with pelvic organ prolapse?

Answer 29

Sensation of bulge or protrusion
Seeing or feeling bulge or protrusion
Pressure
Heaviness
Difficulty inserting tampons

Question 30

What are typical urinary symptoms in women with pelvic organ prolapse?

Answer 30

Urinary incontinence
Frequency/urgency
Weak or prolonged urinary stream/feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding

Question 31

What are typical bowel symptoms in women with pelvic organ prolapse?

Answer 31

Incontinence of flatus or liquid stool
Feeling of incomplete emptying
Urgency
Digital evacuation to complete defecation

Question 32

What is the gold standard assessment of pelvic organ prolapse?

Answer 32

POPQ score

Question 33

What investigations can be done into pelvic organ prolapse?

Answer 33

USS or MRI to allow identification of fascial defects
Urodynamics
IVU or renal USS

Question 34

How can pelvic organ prolapse be prevented?

Answer 34

Avoid constipation
Effective management of chronic chest pathology
Smaller family size
Improvements in antenatal and intra-partum care

Question 35

How can pelvic organ prolapse be treated?

Answer 35

Physiotherapy - pelvic floor muscle training

Surgical treatment

Question 36

What are factors of pelvic floor muscle training that make it an effective option?

Answer 36

Increase pelvic floor strength and bulk leading to decreased tension on ligaments
Improves cases of mild prolapse
Effecting in young women who have not completed their family

Question 37

What are negative factors of pelvic floor muscle training?

Answer 37

No role in advanced diseases

Cannot treat fascial defects