Prolapse and incontinence

Question 1

Definition of pelvic organ prolapse

Answer 1

Displacement of the uterus, anterior vaginal wall, posterior vaginal wall or vaginal vault due to weakness of connective tissue in pelvic floor

Question 2

Prevalence of pelvic organ prolapse

Answer 2

31%
2% severe
11% will require surgery by 80y

Question 3

Risk factors for pelvic organ prolapse

Answer 3

Modifiable:
- obesity
- smoking
- occupational (heavy lifting/abdominal strain)
- medical conditions (chronic cough, respiratory conditions, menopause, iatrogenic)
Non-modifiable:
- age
- parity
- Large birth weight of babies
- medical conditions
- iatrogenic (e.g. surgery)

Question 4

Cause of pelvic organ prolapse

Answer 4

Direct trauma (e.g. childbirth) and pelvic neuropathy are the main causes

Question 5

Muscles of the pelvic floor

Answer 5

Levator ani group (3 muscles)

• pubococcygeus (posterior aspect of os to coccyx)
• Iliococcygeus
• ischiococcygeus

Question 6

Innervation of the levator ani group

Answer 6

Pudendal nerve (inferior and lateral to ischial spines)

Question 7

Causes of pudendal neuropathy

Answer 7

secondary to chronic pressure (e.g. foetal head during pregnancy)

Question 8

Ligaments and fascia of pelvic floor

Answer 8

Sacrospinous (landmark for attachment of vaginal vault)
Uterosacral ligament (rarely avulses, can become elongated - attaches posteriorly to the cervix)
Arcus tendinous fascia pelcis - from ischial spine to posterior symphysis pubis, gives rise to normal appearance of vaginal sulci (avulsino is common in prolapse, will cause anterior compartment prolapse)
Obturator fascia (relevant for surgical approach location)

Question 9

Presentation of pelvic floor prolapse

Answer 9

2Ds2Bs2Ss
Discomfort
Dysfunction
Bowel and bladder
Sex and pSyche

Pelvic heaviness or dragging
Bulge when wiping
digitation (pushing back in)
Constipation/urinary incontinence
Sexual dysfunction

Question 10

Investigations in pelvic organ prolapse

Answer 10

Anatomical: objective measurement with POP-Q staging system

Functional (more important than anatomical defect): QOL questionnaires

Question 11

Management of prolapse

Answer 11

Reassurance
Address lifestyle issues (smoking cessation, obesity)
Address modifiable risk factors (constipation, chronic cough)
Conservative (pelvic floor exercises under physio assistance at least 6 months, intravaginal oestrogen, pessaries)
Surgery - for severe stages

Question 12

Post-operative complications of pelvic organ prolapse repair

Answer 12

Urinary retention
UTI
Urinary tract injuries (rare)
New and persisting symptoms (bladder and bowel especially)
Concealed haemorrhage
Constipation
Complications related to positioning of patient (e.g. lithotomy position)

Question 13

Definition of stress incontinence

Answer 13

leaking of urine with increased intra-abdominal pressure e.g. cough, valsalva, jumping etc

Question 14

Definition of urge incontinence

Answer 14

Clinical diagnosis, based on detrusor overactivity in which patient suffers having to rush to reach the toilet in time