Prolapse

Question 1

PRE-DISPOSING FACTORS:

Answer 1

1. Childbirth
   - Multiple, operative, vaginal, macrosomia
2. Surgery
   - suprapubic operation for urinary incontinence, hysterectomy
3. Menopause
4. Congenital
5. Genetics

Question 2

AGGRAVATING FACTORS:

Answer 2

Conditions which raise intra-abdominal pressure:

• Obesity
• Chronic cough
• Constipation

Question 3

TYPES:

Answer 3

1. Urethrocele
   - Stress incontinence
2. Cystocele
   - Cystourethrocele if together with urethra
3. Uterus and Cervis
   a) First degree: Cervix does not reach introitus
   b) Second degree: Descent of cervix to level of introitus
   c) Third degree: Cervix and uterus protrude out of vagina
   d) Procidentia: Cervix, uterus and vaginal wall completely prolapse through introitus.
   - can lead to ulceration of cervix and thickening of vaginal mucosa
4. Rectocele
5. Enterocele
   - hernia
   - has sac, neck and contents
   - protrusion of peritoneum of pouch of Douglas, may contain small bowel/omentum
6. Total Vault Prolapse
   - Complete eversion of vagina following hysterectomy

Question 4

SYMPTOMS:

1. General
2. Specific

Answer 4

1. • asymptomatic
     - Dragging feeling
     - Backache that improves when lying down
2. a) Anterior wall prolapse
   - Urinary symptoms: stress incontinence, frequency
   * large cystocele can cause incomplete emptying, urinary retention, recurrent UTI
   b) Uterine prolapse
   - Feeling of lump
   - Procidentia causes bleeding/discharge
   c) Rectocele
   - Incomplete evacuation
   - Have to press posterior wall backwards to pass stool
   d) Enterocele
   - Usually presents as lump
   - May be associated with non-specific lower abdominal discomfort

Question 5

SIGNS

Answer 5

1. Obesity, signs of chronic chest condition
2. On pelvic exam:
   - ask to strain
   - bimanual examination can help identify type and severity
   - Sims position

Question 6

MANAGEMENT:

1. Conservative
2. Surgical

Answer 6

1. • treat underlying cause of raised abdominal pressure: weight loss, reduce cough, treat constipation
     - Pelvic floor exercises
     - Oestrogen cream(eg. vagifem) if atrophy present
     - Pessaries: Ring/shelf/gel horn. Change every 4-6 months.
2. a) Anterior colporrhapy(anterior repair)
   - anterior vaginal wall prolapse.

b) Uterine descent
- Vaginal hysterectomy
- Manchester/Fothergill repair

c) Posterior colpo-perineorrhapy
- Rectocele
- Rectocele combined with enterocele

d) Total vault prolapse:
- Sacrocolpopexy
- Sacrospinous fixation
- Vaginal mesh repair

e) Complications:
- narrowed and shortened vagina which can cause dyspareunia- C-section likely indicated for deliveries

Question 7

TYPES OF PESSARIES:

Answer 7

1. Ring
   - Most common
2. Shelf
   - useful in procidentia
3. Gelhorn
   - Softer so allows folding for insertion.

Question 8

COMPLICATIONS FROM PESSARIES:

Answer 8

1. Urinary symptoms
   - frequency, infection
2. Might not stay
3. Vaginal discharge/bleeding
   - important to replace every 6/12
4. Vaginal ulceration
   - if ring too large
5. Fistula formation
6. Granulation tissue
   - if not changed regularly

Question 9

VAGINAL MESH REPAIR COMPLICATIONS:

Answer 9

1. Operative:
   - Bladder, rectal, vascular injuries.
2. Long Term:
   - Dyspareunia, erosion/rejection of mesh
   - mesh-related infection
   - necrotising fasciitis