Prolapse

Question 1

Define uterovaginal prolapse

Answer 1

Descent of the uterus and/or vagina beyond normal anatomical confines
- can also involve the bladder, urethra, rectum and bowel

Question 2

What are the pelvic floor anatomy supports of the uterus and vagina

Answer 2

Uterus
- vaginal walls
- transverse cervical ligaments 
- round and broad ligaments
- indirect pelvic floor support 
Cervix and upper 1/3 vagina 
- transverse cervical ligament 
- uterosacral ligament

Question 3

Aetiological factors associated with uterovaginal prolapse

Answer 3

Risk factors
- increasing age/menopause
- vaginal delivery (direct trauma, pudendal nerve damage)
- increasing parity
- raised intra-abdominal pressure (due to obesity, chronic cough or chronic constipation)
Congenital factors
- abnormal collagen metabolism
Very common - presents in older, parous women

Question 4

How to maximise prevention of uterovaginal prolapse

Answer 4

Weight reduction 
Treatment of constipation
Treatment of chronic cough + smoking cessation 
Avoid heavy lifting 
Encourage pelvic floor exercises
Good intrapartum care 
- avoid unnecessary trauma

Question 5

What are the clinical features of a uterovaginal prolapse

Answer 5

Asymptomatic 
Vaginal
- pressure, fullness + heaviness
- sensation of bulge
- bleeding/discharge
Sexual difficulties 
Urinary symptoms
- incontinence, frequency + urgency
- have to manually reduce the prolapse prior to voiding
Bowel symptoms
- constipation + straining 
- faecal incontinence 
- incomplete evacuation

Question 6

How to examine a uterovaginal prolapse

Answer 6

History and impact on quality of life
Ask patient to cough on vaginal examination
Feel for pelvic masses on bimanual and abdominal examination
Speculum should be able to confirm the prolapse

Question 7

Describe the grading system for uterovaginal prolapse

Answer 7

Based on the position of the most distal portion of prolapse during straining
Stage 0
- no prolapse
Stage 1
- more than 1cm above the hymenal ring
Stage 2
- prolapse extends from 1cm above hymenal ring to 1cm below
Stage 3
- prolapse extends 1cm or more below hymenal ring
Stage 4
- vagina is completely everted (a.k.a complete procidentia)

Question 8

What are the different classifications of pelvic organ prolapse?

Answer 8

Cystocele
Urethrocele
Rectocele
Enterocele
Uterine prolapse
Vaginal vault prolapse

Question 9

Define a cystocele

Answer 9

Prolapse of the upper anterior vaginal wall and bladder

Most common

Question 10

Define a urethrocele

Answer 10

Prolapse of the lower anterior vaginal wall and associated urethra
Often associated with a cystourethrocele

Question 11

Define a rectocele

Answer 11

Prolapse of the lower posterior wall of the vagina, and involving the associated anterior rectal wall

Question 12

Define an enterocele

Answer 12

Prolapse of the upper posterior wall of the vagina (posterior fornix), and pouch of Douglas
- can contain loops of small bowel

Question 13

Define a uterine prolapse

Answer 13

Prolapse of the uterus into the vagina

• 1st degree (cervix descends within the vagina)
• 2nd degree (cervix protrudes beyond vaginal introitus)
• 3rd degree (total prolapse of the uterus, bringing vaginal walls and associated structures with it)

Question 14

Define a vaginal vault prolapse

Answer 14

Prolapse of the vaginal vault, descending into/beyond the vagina
- commonly occurs following a hysterectomy

Question 15

Describe the conservative management for a uterovaginal prolapse

Answer 15

Physiotherapy (in younger women with mild prolapse)
Vaginal pessaries with vaginal oestrogen
- ring is most common form
- side effects include ulcers, infection and sexual dysfunction

Question 16

Indications for surgical management

Answer 16

Definitive treatment
Pessary failure
Urinary/faecal incontinence

Question 17

What surgeries can be performed for the management of a uterovaginal prolapse?

Answer 17

Vaginal hysterectomy
Manchester repair
- cervical amputation
- shortening of the transcervical ligaments
Sacrohysteropexy
- open abdominal or laparoscopic
- mesh is used to attach the uterus to the anterior longitudinal ligament over the sacrum

Question 18

What is the surgical management for an anterior compartment defect (repair of cystocele +/- urethrocele)

Answer 18

Anterior colporrhaphy (anterior repair)

Procedure 
- anterior wall incision
- buttressing sutures placed on the fascia
- surpless skin excised  
Complications
- dyspareunia
- incontinence
- failure

Question 19

What is the surgical management for a posterior compartment defect (repair of rectocele +/- enterocele)

Answer 19

Posterior colporrhaphy (posterior repair)

Procedure

• incision made in the posterior wall of vagina
• buttressing sutures
• reapposition of levator muscles
• removal of excess skin

Complications include dyspareunia

Question 20

What is the surgical repair of a vaginal vault prolapse

Answer 20

Sacrospinous ligament fixation 
- vaginal vault is sutured to sacrospinous ligaments, using a vaginal approach 
- 70-85% success rate 
Sacrocolpopexy
- open/laparoscopic
- vault attached to the sacrum using mesh
- success rate 90%
Colpocleisis - vaginal closure
- for women who don't desire future vaginal intercourse 
- performed vaginally
- skin removed from the vaginal bulge
- sutured upon itself