Pelvic organ prolapse and urinary incontinence

Question 1

What is pelvic organ prolapse

Answer 1

Descent of the pelvic organs into the vagina as a result of weakness and lengthening of the ligaments and muscles surrounding the uterus rectum and bladder

Question 2

Types of prolapse

Answer 2

Uterine prolapse - uterus descends into the vagina

Vault prolapse - occurs in women who have had a hysterectomy, the vault (top) of the vagina descends into the vagina

Rectocele - defect in posterior vaginal wall allowing the rectum to prolapse forwards into the vagina. Foecal loading in the prolapsed part of the rectum can cause constipation, urinary retention and palpable lump that can be pushed backwards

Cystocele - defect in the anterior vaginal wall, bladder prolapses backwards (if urethra also prolapses it is called a cystourethrocele)

Question 3

Risk factors for prolapse

Answer 3

Multiple vaginal deliveries
Instrumental, prolonged or traumatic deliveries

Advanced age
Being post-menopausal (lack of oestrogen after menopause)
Obesity

Chronic respiratory disease causing coughing
Chronic constipation causing straining

Question 4

Presentation of prolapse

Answer 4

Feeling of something coming down into the vagina
Dragging/heavy sensation in the pelvis

Urinary Sx - incontinence (particularly stress incontinence), urgency, frequency and retention

Bowel sx - constipation, incontinence, urgency

Sexual dysfunction - pain, altered sensation and reduced enjoyment

Question 5

Management options (brief outline)

Answer 5

Conservative
Vaginal pessary
Surgery

Question 6

Conservative management

Answer 6

Pelvic floor exercises
Weight loss
Stop smoking
Avoid constipation (fibre rich diet)
Avoid heavy lifting
Vaginal oestrogen cream

If have stress incontinence alongside - reduce caffeine intake, medications e.g. duloxetine (meds are second line where surgery is less preferred)

Question 7

Vaginal pessaries

Answer 7

Provide extra support to the pelvic organs

Ring pessary - sits around cervix and holds uterus up - can be sexually active, usually used for people with a uterus
Shelf pessary - used for people without a uterus usually, cannot be sexually active
Cube pessary

Change every 4-6 months
May cause vaginal mucosal erosion - can use oestrogen cream to protect the vaginal walls from irritation

Question 8

Surgical options

Answer 8

Cystocoele - anterior colporrhaphy
Rectocoele - posterior colporrhaphy

Uterine prolapse options include Hysterectomy and pelvic floor repair, hysterosacropexy or combination of the two

VV prolapse - sacrospinous or sacral colpoplexy - attaching the top of the vagina either to the sacrospinous lig or the sacrum

Colpocleisis (done in older women usually who are not sexually active) bringing together the anterior and posterior wall to close the vagina - treats all types of prolapse

Question 9

Questions to ask in prolapse

Answer 9

Vaginal deliveries - how many?
Any prolonged, traumatic or instrumental deliveries?
Gone through the menopause?
Obesity? BMI?

Any urinary incontinence or other urinary symptoms
Any bowel symptoms esp constipation

Currently sexually active and is there any interference with intercourse?

Question 10

Grades of a uterine prolapse

Answer 10

Grade 1 - lowest part is more than 1cm above vaginal opening

Grade 2 - within 1cm of vaginal opening

Grade 3 - more than 1cm below the vaginal opening but not fully descended

Grade 4 - full descent with eversion of the vagina

Prolapse extending beyond the introitus is called uterine procidentia

Question 11

Examination

Answer 11

With a sims- speculum to examine for recto/cystocoele - supports one wall while other is examined

Ask women to cough/bear down to assess the descent of the prolapse

Examine in different positions including dorsal and left lateral position

Question 12

Types of urinary incontinence

Answer 12

Urge incontinence
Stress incontinence
Mixed incontinence