Pelvic Organ Prolapse

Question 1

Define female pelvic organ prolapse

Answer 1

Descent of pelvic organs towards or through vagina

Question 2

What is the rate of pelvic organ prolapse?

Answer 2

12-30% multiparous women

2% nulliparous

Question 3

The pelvic floor consists of 3 layers working as one functional unit. Name the 3 layers

Answer 3

Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm

Question 4

The endopelvic fascia is a fibrous connective tissue surrounding visceral structures. Which structures does it cover?

Answer 4

Uterosacral ligaments
Rectovaginal fascia
Pubocervical fascia

Question 5

The pelvic diaphragm is a layer of striated muscle made up of which muscles?

Answer 5

Levator ani

Coccygeus

Question 6

What does the urogenital diaphragm consist of?

Answer 6

The superficial and deep transverse perineal muscles with their fascial coverings

Question 7

Which ligament is the cardinal ligament?

Answer 7

Uterosacral ligament

Question 8

The uterosacral ligament is medial to which structures

Answer 8

Uterus, cervix, lateral fornices of vagina, pubocervical and rectovaginal fascia

Question 9

The uterosacral ligament is lateral to which structures?

Answer 9

Sacrum

Fascia covering the piriformis

Question 10

Where does the uterosacral ligament tend to break?

Answer 10

Medially

Question 11

What shape is the pubocervical fascia?

Answer 11

Trapezoid

Question 12

What structure does the pubocervical fascia mainly provide support to?

Answer 12

Anterior wall of vagina

Question 13

What merges with the pubocervical fascia centrally?

Answer 13

Cardinal ligaments and cervix

Question 14

What is lateral to the pubocervical fascia?

Answer 14

Arcus tendineus fascia of pelvis

Question 15

What is distal to the pubocervical fascia?

Answer 15

Urogenital diaphragm

Question 16

Where does the pubocervical fascia most commonly tend to break?

Answer 16

Immediately in front of cervix

Or at lateral attachments

Question 17

How is a break in the pubocervical fascia immediate to the cervix treated?

Answer 17

Midfascial ligation

Question 18

How does a midfascial ligation affect lateral defects?

Answer 18

Will further disrupt

Pubocervical fascia defects -> 3 defects due to 3 attachments

Question 19

What type of tissue is the rectovaginal fascia?

Answer 19

Fibromuscular ELASTIC tissue

Question 20

What structures does the rectovaginal fascia fuse with centrally?

Answer 20

Base of uterosacral ligament and peritoneum

Question 21

Which fascia does the rectovaginal fascia fuse with laterally?

Answer 21

Fascia covering the levator ani

Question 22

To which structure does the rectovaginal fascia merge with distally?

Answer 22

Perineal body

Question 23

Where does the rectovaginal fascia tend to break?

Answer 23

Centrally

Question 24

Which organ prolapse does an upper defect in the rectovaginal fascia lead to?

Answer 24

Enterocele

Question 25

Which organ prolapse doe a lower defect in the rectovaginal fascia lead to?

Answer 25

Rectocele | Perineal body descent

Question 26

Describe the 3 levels of endopelvic support

Answer 26

Level I - Uterosacral ligaments Level II- Para vagina to arcus tendinous fascia - Pubocervical and rectovaginal fascia Level III- Urogenital diaphragm, perineal body

Question 27

Name 7 Risk factors for pelvic organ prolapse

Answer 27

``` Pregnancy and vaginal birth Previous pelvic surgery Hormonal factors Quality of Connective Tissue Constipation Occupation with heavy lifting Exercise - weight lifting, high impact aerobics, long distance running ; urogenital prolapse ```

Question 28

What factors associated with pregnancy and vaginal birth in particular pose a risk of pelvic organ prolapse?

Answer 28

``` Forceps delivery Large baby - obstructed labour Prolonged second stage labour Advanced age Obesity ```

Question 29

Which pelvic surgeries increase risk of subsequent pelvic organ prolapse?

Answer 29

Burch culposuspension | Hysterectomy

Question 30

Which defect and prolapse is associated with burch colposuspension?

Answer 30

Defect in posterior vaginal wall | Leads to increased risk of rectocele and enterocele

Question 31

Define urethrocele

Answer 31

Prolapse of lower anterior vaginal wall involving the urethra only

Question 32

Define cystocele

Answer 32

Prolapse of upper anterior vaginal wall involving bladder

Question 33

Define uterovaginal prolapse

Answer 33

Prolapse of uterus, cervix and upper vagina - Apical

Question 34

Define Enterocele

Answer 34

Prolapse of upper posterior vaginal wall involving small loops of bowel

Question 35

Define rectocele

Answer 35

Prolapse of lower posterior vaginal wall involving rectum bulging forward - Posterior

Question 36

Symptoms of prolapse can be categorised into which 3 groups

Answer 36

Vaginal Bowel Urinary

Question 37

Vaginal symptoms of prolapse

Answer 37

``` Sensation of bulge or protusion Visible bulge or protrusion Pressure Heaviness Difficulty inserting tampons ```

Question 38

Urinary symptoms of prolapse

Answer 38

Urinary incontinence Frequency/Urgency Weak/prolonged urinary stream or hesistancy Feeling of incomplete emptying Manual reduction of prolapse necessary to start or complete void

Question 39

Bowel symptoms of prolapse

Answer 39

Incontinence of flatus/liquid/solid stool Feeling of incomplete emptying/straining Urgency Digital evacuation to complete defecation Splinting/ pushing around vagina or perineum to start/complete defecation

Question 40

Assessment of pelvic organ prolapse

Answer 40

Examination Quality of life Objective assessment - Baden-Walker Halfway grading, POPQ score

Question 41

What is the gold standard for objective assessment of pelvic organ prolapse?

Answer 41

POPQ score

Question 42

Stages of Pelvic Floor Evaluation

Answer 42

``` Stage 0 (TVL – 2 cm ) Stage I (< - 1cm) Stage II (> - 1cm < + 1cm) Stage III (> _ 1cm but + TVL – 2cm ) ```

Question 43

Investigations for Pelvic Organ Prolapse

Answer 43

Ultrasound Urodynamics - urinary incontinence or occult stress incontinence IVU or Renal Ultrasound - if suspected ureteric obstruction

Question 44

Purpose of IVU or Renal US in investigating POP?

Answer 44

If suspected ureteric obstruction

Question 45

Prevention of POP

Answer 45

Prompt management and prevention of constipation Manage chronic chest pathology (COPD) Smaller family size Improve antenatal and intrapartum care No evidence for pelvic floor training postnatal to prevent but logical conclusion to advise anyway

Question 46

Treatment for pelvic organ prolapse

Answer 46

Physiotherapy- pelvic floor training Pessaries Surgery

Question 47

Aims of surgery in treatment of pelvic organ prolapse

Answer 47

Relieve symptoms Restore and maintain bladder and bowel function Maintain vaginal capacity for sexual function

Question 48

Risk and considerations for surgery

Answer 48

Prophylactic antibiotics Thrombo-embolic prophylaxis Post-operative urinary vs SPC (suprapubic catheter)