Pelvic Organ Prolapse

Question 1

How is the female pelvic floor supported?

Answer 1

The pelvic floor is one functional unit made up of three distinct layers: endopelvic fascia (fibromuscular connective tissue eg uterosacral ligaments, Pubocervical fascia, rectovaginal fascia), pelvic diaphragm (striated muscles: levator ani and coccygeus), urogential diaphragm (superficial and deep transverse perineal muscles and facial coverings).

Question 2

What are the predisposing factors for uterovaginal prolapse?

Answer 2

Pregnancy and vaginal birth (forceps, large baby, prolonged second stage)
Advancing age
Obesity
Previous pelvic surgery eg continence procedure
Hormonal factors
Quality of connective tissue
Constipation
Occupation with heavy lifting
Exercise eg weight lifting, high impact aerobics and long distance running

Question 3

What are the different types of prolapse?

Answer 3

Urethrocele : Lower anterior vaginal wall involving only urethra
Cystocele: upper anterior wall involving the bladder
Uterovaginal: prolapse of uterus, cervix and upper vagina
Enterocele: upper posterior wall of vagina usually containing loops of small bowel
Rectocele: lower posterior wall of vagina involving rectum bulging forwards into the vagina

Question 4

What are the available systems for examination and grading of POP?

Answer 4

POPQ score is endorsed by ICs and is currently gold standard

Others include: Baden-walker-halfawy grading

Investigations include USS / MRI, urodynamics, IVU or renal USS

Question 5

What effects can POP have on a women’s life?

Answer 5

Impact on sexual function

Incontinence eg socials

Emotional/psychological

Question 6

What are the principles of conservative and surgical management of POP?

Answer 6

Conservative

• pelvic floor muscle training. Can be supplemented with perineometer, biofeedback, vaginal cones, electrical stimulation
• pessaries

Surgical

• relieve symptoms, restore or maintain bladder bowel function and capacity for sexual function
• prophylactic antibiotics
• thromboembolic prophylaxis
• post op urinary vs SPC

Question 7

What are the symptoms of POP?

Answer 7

Sensation or seeing bulge or protrusion
Pressure/heaviness
Difficulty inserting tampons
Incontinence (flatus, liquid, stool)
Frequency/urgency
Weak or prolonged stream/hesitancy/feeling of incomplete emptying (urine/faeces)