Pelvic Organ Prolapse

Question 1

What is Female Pelvic Organ Prolapse (POP)?

Answer 1

• Descent of the pelvic organs towards or through the vagina
• affects 12-30% of multiparous women + 2% of nulliparous women
• 2% symptomatic prolapse + 50% asymptomatic prolapse

Question 2

What are risk factors for POP?

Answer 2

• pregnancy + vaginal birth
• forceps delivery
• large baby (> 4500gm)
• prolonged 2nd stage
• advancing age
• obesity
• previous pelvic surgery
• continence procedures (Burch colposuspension)
• hysterectomy
• hormonal factors
• quality of connective tissue
• constipation
• occupation with heavy lifting
• exercise
• weight lifting, high-impact aerobics, long-distance running

Question 3

What measures can be taken to avoid POP?

Answer 3

• avoid contstipation
• effective management chronic chest pathology (COAD + asthma)
• smaller family size
• improvements in antenatal and intrapartum care
• pelvic floor muscle training

Question 4

What are the different classifications of POP?

Answer 4

• urethrocele- prolapse of lower anterior vaginal wall, involving urethra only
• cystocele- prolapse of upper anterior vaginal wall, involving bladder
• uterovaginal prolapse- prolapse of cervix, uterus and upper vagina
• enterocele- prolapse of upper posterior vaginal wall, usually containing loops of small bowel
• rectocele- prolapse of lower posterior vaginal wall, involving rectum bulging forwards into vagina

Question 5

What are the typical symptoms of POP?

Answer 5

• vaginal
• sensation of a bulge/protrusion
• seeing a bulge/protrusion
• pressure
• heaviness
• difficulty inserting tampons
• urinary
• urinary incontinence
• frequency/urgency
• weak/prolonged urinary stream, hesitation, feeling of incomplete emptying
• manual reduction of prolapse to start/complete voiding
• bowel
• incontinence of flatus, liquid/solid stool
• feeling of incomplete emptying/straining
• urgency
• digital evacuation to complete defecation
• splinting/pushing on/around vagina/perineum to start/complete defecation

Question 6

What are the investigations for POP?

Answer 6

• pelvic exam- exclude pelvic mass
• QoL
• Baden-Walker-Halfawy Grading
• POPQ Score (*gold-standard*)
• stage 0- (TVL -2cm)
• stage I- (< -1cm)
• stage II- (≥ - 1cm ≤ + 1cm)
• stage III- (> -1cm but < +TVL -2cm)
• stage IV- (≥ + TVL -2cm )
• USS/MRI
• urodynamics
• IVU/renal USS- exclude uterine obstruction

Question 7

What are the treatments for POP?

Answer 7

• physiotherapy
• pelvic floor muscle training (PFMT)
• pessaries
• surgery