Pelvic Organ Prolapse

Question 1

What does the word prolapse refer to

Answer 1

• Falling or slipping of the viscous
• Protrusion of an organ or structure beyond its normal anatomical confines

Question 2

What is female pelvic organ prolapse (POP)

Answer 2

• refers to the descent of the pelvic organs towards or through the vagina

Question 3

Incidence of POP

Answer 3

• 12-30% of multiparous women
• 2% of null parous

Question 4

Prevalence of POP

Answer 4

• 2% symptomatic prolapse to 50% asymptomatic prolapse
• Leading cause of hysterectomies

Question 5

What is the pelvic floor

Answer 5

• The bottom of the abdomino-pelvic cavity (box)
• Consists of all the soft tissue structures that close the space between the pelvic bones
• If normal, pelvic viscera maintained in position both at rest and during increased intra-abdominal pressure
• The pelvic floor is 1 functional unit

Question 6

What are the layers of the pelvic floor

Answer 6

• 3 distinct layers - do not parallel each other and vary in strength and thickness
• Endopelvic fascia
• Pelvic diaphragm
• Urogenital diaphragm

Question 7

Describe the endopelvic fascia layer of the pelvic floor

Answer 7

• Network of fibro-muscular connective tissue that has a ‘hammock-like’ configuration and surrounds the various visceral structures (uterosacral ligaments/pubocervical fascia/rectovaginal fascia)

Question 8

Describe the pelvic diaphragm layer of the pelvic floor

Answer 8

• Layer of striated muscle with its fascial coverings (levator ani & coccygeus)

Question 9

Describe the urogenital diaphragm layer of the pelvic floor

Answer 9

• The superficial & deep transverse perineal muscles with their fascial coverings

Question 10

How do the components of the endopelvic fascia act

Answer 10

• Fibro-muscular component can stretch (uterosacrals)
• Connective tissue does not stretch or attenuate - breaks

Question 11

What forms the utero-sacral/cardinal complex

Answer 11

• Medially to uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia
• Laterally to the sacrum & fascia overlying the piriforms muscle

Question 12

What are the features of the utero-sacral/cardinal complex

Answer 12

• Easily palpated by down traction on the cervix and if intact allows limited side-side movement of the cervix
• Tends to break medially (around the cervix)

Question 13

What is the anatomy of the pubocervical fascia

Answer 13

• Trapezoidal fibro-muscular tissue: provide the main support of the anterior vaginal wall
• Centrally - merges with the base of the cardinal ligament & cervix
• Laterally - arcus tendinous fascia pelvis
• Distally - urogenital diaphragm

Question 14

Where does the pubocervical fascia tend to break

Answer 14

• 3 support = 3 defects
• Tends to break at lateral attachments or immediately in front of cervix

Question 15

What is the anatomy of the rectovaginal fascia

Answer 15

• Fibro-musculo - elastic tissue
• Centrally - merge with the base of cardinal/uterosacral ligaments & peritoneum
• Laterally - fuses with fascia over the levator ani
• Distally - firmly to the perineal body

Question 16

Where does the rectovaginal fascia tend to break

Answer 16

• Centrally
  
  • If upper - enterocele
  • If lower - perineal body descent & rectcocele

Question 17

What are the levels of endopelvic support

Answer 17

• Level I
  
  • Utero-sacral ligaments
  • Cardinal ligaments
• Level II
  
  • Paravagina to argus tendinous fascia: pubocervical/rectovaginal fascia
• Level III
  
  • Urogenital diaphragm
  • Perineal body

Question 18

What are the risk factors for POP

Answer 18

• Pregnancy and vaginal birth
• Advancing age
• Obesity
• Previous pelvic floor surgery
• Others

Question 19

What are specific risk factor of pregnancy for POP

Answer 19

• forceps delivery
• Large baby (>4500g)
• Prolonged second stage
• Parity - strongest risk factor with adjusted relative risk of 10.9
  
  • Increase with parity but slows after 2

Question 20

What previous pelvic floor surgery is a risk of POP

Answer 20

• Continence procedures while elevating the bladder neck may lead to other defects in the pelvic compartments
• Burch colposuspension - can leave defects with predispose to rectocele and enterocele formation

Question 21

What are some other risk factors of POP

Answer 21

• Hormonal factors
• Quality of connective tissue
• Constipation
• Occupation with heavy lifting
• Exercise
  
  • Weight lifting, high impact aerobic and long-distance running

Question 22

What is the traditional classification of POP

Answer 22

• Urethrocele - prolapse of the lower anterior vagina involving the urethra only
• Cystocele - prolapse of the upper anterior vaginal wall involving the bladder
• Uterovaginal prolapse - 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 23

What is the current classification of POP

Answer 23

• Anterior vaginal wall prolapse
  
  • Cystocele
  • Due to breaking of the pubocervical fascia centrally
• Posterior vaginal wall prolapse
  
  • Rectocele
  • Rectovaginal fascia broken
• Apical prolapse
  
  • Uterine prolapse (not anterior or posterior) - just comes down
  • Enterocele

Question 24

What are the vaginal symptoms of POP

Answer 24

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

Question 25

What are the urinary symptoms of POP

Answer 25

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

Question 26

What are the bowel symptoms of POP

Answer 26

* 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 27

How is POP assessed

Answer 27

* Examination to exclude pelvic mass * Record the position of examination: left vs lithotomy vs standing * Quality of life

Question 28

What scoring systems are used to objectively assess POP

Answer 28

* Baden-Walker-Halfway Grading * POPQ score

Question 29

What is the POP score

Answer 29

Question 30

Investigations of POP

Answer 30

* USS/MRI - allow identification of fascial defects/measurements of levator any thickness * Urodynamics - concurrent UI to exclude occult SI * IVU or renal USS - if suspicion of ureteric obstruction

Question 31

Prevention of POP

Answer 31

* Avoid constipation * Effective management of chronic chest pathology (COAD & asthma) * Smaller family size * Improvements in antenatal and intrapartum care

Question 32

What is the physiotherapy treatment of POP

Answer 32

* Pelvic floor muscle training (PFMT) - stages 1 & 2 * Increase the pelvic floor strength & bulk --\> relieves tension on ligaments * For women who have not yet completed their family * Cannot treat fascial defects * Can be supplemented with the use of perineometer and biofeedback, vaginal cones and electric stimulation

Question 33

Other treatment of POP

Answer 33

* Pessaries - usually silicone * Surgery - function not anatomy * Relive symptoms * Restore bladder and bowel function * Maintain vaginal capacity for sexual function

Question 34

What should be remembered in surgery for POP

Answer 34

* Propjhylactic antibiotics * Thrombo-embolic prophylaxis * Postoperative urinary vs SPC