Prolapse

Question 1

What is a prolapse?

Answer 1

Protrusion of the uterus and/or vaginal beyond normal anatomical confines.

Bladder, urethra and rectum can also be involved

Question 2

What structures support the uterus?

Answer 2

Vaginal walls,
Transverse cervical ligaments,
Round and broad ligaments,
Indirect support from pelvic floor

Question 3

What structures support the cervix and upper 1/3rd of vagina?

Answer 3

Transverse cervical ligaments and uterosacral ligaments

Question 4

What are the risk factors for prolapse?

Answer 4

Increasing age/menopause,
Vaginal delivery (big babies and prolonged 2nd stage) either due to direct trauma or pudendal nerve damage.
Increasing parity.
Raised intra-abdominal pressure.
Abnormal collagen metabolism.

Question 5

what are the symptoms of a prolapse?

Answer 5

Sensation of pressure/fullness/heaviness,
Sensation of a buldge,
Bleeding/dischage,
Backache,
Dysparunia.
May have urinary symptoms,
May have bowel symptoms (constipation/straining, fecal incontinence and incomplete evacuation)

Question 6

What is the grading of prolapse?

Answer 6

Pelvic organ prolapse quantification. This is base on the position of the most distal prolapse during straining.
Grade 1 - No prolapse.
Stage 1 - More than 1cm above hymenal ring.
Stage 2 - Prolapse extends from 1cm above to 1 cm below hymenal rring.
Stage 3 - Prolapse extends 1cm+ below hymenal ring
Stage 4 - Vagina completely everted

Question 7

What is the following:
Cystocele,
Urethrocele,
Rectocele,
Enterocele,
Uterine prolapse,
Vaginal vault prolapse

Answer 7

Cystocele - bladder protrudes into vagina (anterior prolapse)
Urethrocele - Descent of the anterior vaginal wall where the urethra sits.
Rectocele - rectum protrudes.
Enterocele - Seen in upper vagina
Uterine prolapse,
Vaginal vault prolapse.
Either anterior, apical or posterior prolapse

Question 8

What is the most common type of prolapse?

Answer 8

Cystocele

Question 9

What is the management of prolapses?

Answer 9

Conservative - Lifestyle advice, pelvic floor exercises, intravaginal oestrogen or devices.
Surgical - Vaginal or abdominal.

Question 10

What are some examples of intravaginal devices for prolapses

Answer 10

Ring pessary - placed between posterior aspect of symphysis pubis and posterior fornix of vagina.
Shelf pessary, gelhorn, hodge, cube or donut.

Question 11

What are the complications of pessaries?

Answer 11

May interfere with sexual intercourse,
Ulceration,
Infection,
Difficulty and discomfort during removal,
Fistula if neglected

Question 12

what are the surgical procedures for anterior compartment defect and its complications?

Answer 12

Anterior colporrhaphy (anterior repair)
Complications - dyspareunia, incontinence, failure and recurrence.

Question 13

Explain the surgical procedure for posterior compartment

Answer 13

Posterior colporrhaphy - incision in posterior wall of vagina, sutures, reposition of leavator muscles and removal of excess skin.
Complication is dyspareunia

Question 14

Explain the surgical repair of uterovaginal prolapse

Answer 14

Vaginal hysterectomy
Manchester repair
Sacrohysteropexy - use of mesh to attach uterus to anterior longitutinal ligament of the sacrum

Question 15

Explain the surgical repair of vaginal vault prolapse

Answer 15

Sacrospinous ligament fixation - vault sutures to sacrospinous ligament.

Sacrocolpopexy - vault attached to sacrum using mesh

Question 16

What is colpocleisis?

Answer 16

Vaginal closure - used in women who do not desire future vaginal intercourse

Question 17

What is the prevention for prolapses?

Answer 17

Weight reduction,
Treatment of constipation,
Treatment of chronic cough and smoking cessation,
Avoid heavy lifting,
Encourage pelvic floor exercises,
Good intrapartum care.