Prolapse of the uterus and vagina

Question 1

Define Prolapse.

Answer 1

Decent of uterus and/or vaginal walls beyond normal anatomical confines.

Genitourinary prolapse occurs when the normal support structures for organs inside a women’s pelvis (uterus, bladder and lower bowel/ rectum) are weakened and no longer effective

Question 2

What are the types of prolapses?

Answer 2

• Urethrocoele
• Cystocoele
• Apical
• Enterocoele
• Rectocoele

Question 3

Define urethrocoele.

Answer 3

Prolapse of lower anterior vaginal wall, involving the urethra only

Question 4

Define Cystocoele.

Answer 4

Prolapse of upper anterior vaginal wall, involving the bladder

Associated prolapse of urethra = cystourethrocoele

Question 5

Define apical prolapse.

Answer 5

Prolapse of uterus, cervix and upper vagina
If uterus has been removed, the vault can itself prolapse

Question 6

Define enterocoele.

Answer 6

Prolapse of upper posterior wall of vagina

Pouch usually contains small loops of bowel

Question 7

Define rectocoele.

Answer 7

Prolapse of lower posterior wall of vagina

Involves anterior wall of the rectum

Question 8

In what types of prolapse is the anterior vaginal wall affected?

Answer 8

• Cystocele (bladder into vagina)
• Urethrocele (urethra into vagina)
• Cystourethrocele

Question 9

In what types of prolapse is the posterior vaginal wall affected?

Answer 9

• Enterocele (small intestine into the vagina)
• Rectocele
• Sigmoidcele

Question 10

In what types of prolapse is the apical vagina affected?

Answer 10

• Uterine prolapse
• Vaginal vault prolapse (occurs after a hysterectomy)

Question 11

What system is used in grading prolapses?

Answer 11

Pelvic Organ Prolapse - Quantification

Question 12

What are the stages of urogenital prolapse?

Answer 12

Question 13

Describe the epidemiology of urogenital prolapse?

Answer 13

The prevalence of pelvic organ prolapse is high; in primary care in the UK, 8.4% of women reported vaginal bulge or lump, and on examination prolapse is present in up to 50% of women. One in 10 women will need at least 1 surgical procedure, and the rate of re‑operation is as high as 19%

Question 14

Describe the Aetiology of pelvic organ prolapses.

Answer 14

 Attenuation of the vaginal support mechanisms may occur as a result of:

 Vaginal delivery and pregnancy

o Prolapse uncommon in nulliparous women
o VD → mechanical injuries and denervation of pelvic floor
o Risks increase with large infants, prolonged second stage and instrumental delivery

 Congenital factors
o Abnormal collagen metabolism e.g. Ehlers-Danlos Syndrome

 Menopause
o Deterioration of collagenous connective tissue after oestrogen withdrawal

 Chronic predisposing factors

o Obesity

o Chronic cough

o Constipation
o Heavy lifting
o Pelvic mass

 Iatrogenic factors
o Pelvic surgery e.g. hysterectomy
o Continence procedures e.g. Burch colposuspension may predispose to rectocoele and enterocoele formation

Question 15

What are the RFs of prolapses?

Answer 15

• Childbirth
• Ageing
• Post-menopausal
• Following pelvic surgery
• Increased abdominal pressure
• Congenital
• Collagen defect
• Ethnicity

Question 16

What are the clinical features of pelvic organ prolapses?

Answer 16

 Hx

o Sx absent
o Dragging sensation
o Sensation of a lump
o Worst at end of day or when standing up
o Severe prolapse may interfere with intercourse
o May ulcerate and cause bleeding and discharge
o Cystourethrocoele: urinary frequency and incomplete bladder emptying
o Stress incontinence common
o Rectocoele: no sx, occasionally difficulty defaecating
o Some women have to reduce prolapse with their fingers to enable passing of urine or stool

 Ex
o Abdominal examination + bimanual (exclude masses)
o Large prolapse visible from outside
o Sim’s speculum allows separate inspection of anterior and posterior vaginal walls

o Ask patient to bear down to demonstrate prolapse
o Enterocoele can be mistaken for rectocoele

 Finger in rectum will bulge into rectocoele and not enterocoele

o Large polyps and vaginal cysts may be mistaken for prolapse

Question 17

What are the investigations for pelvic organ prolapse?

Answer 17

• History and examination (Sims speculum)
• Assess degree of prolapse using POP-Q system
• Urodynamic assessment and functional test of lower bowel
  
  • Endoanal ultrasound
  • Rectal manometry
  • Flexible sigmoidoscopy
  • Defecating proctogram

Question 18

How do we think of the management of a pelvic organ prolapse?

Answer 18

• General Lifestyle Advice
• Medical
• Surgical

Question 19

What general advice would you give for pelvic organ prolapses?

Answer 19

• Watchful waiting
• Lose weight if BMI >30
• Minimise heavy lifting
• Preventing or treating constipation

Pelvic floor exercises - symptomatic POP-Q stage 1-2, 16 weeks of training

Question 20

What medical treatment can be used?

Answer 20

Oestrogens – pill, patch, cream or implant (can help with symptom relief + if woman also has signs of vaginal atrophy)

Vaginal ring pessary (changed every 6 months) - lifts up wall of vagina

o Side-Effects: unpleasant discharge, irritation, UTI, interference with sex (sex is not possible with a shelf pessary)

Question 21

What are the surgical treatments for pelvic organ prolapses?

Answer 21

• Anterior prolapse → anterior repair without mesh
• Posterior prolapse → posterior vaginal repair without mesh
• Uterine prolapse

• No preference regarding preservation of uterus
o Vaginal hysterectomy ± vaginal sacrospinous fixation (removal of the uterus ± stitching the top of the vagina to a ligament in the pelvis)
o Vaginal sacrospinous hysteropexy (cervix is stitched to aligament in the pelvis)
o Manchester repair(shortening of the cervix to support the uterus)
o Sacro-hysteropexy with mesh (mesh used to attach the uterus to sacral vertebra)

• Preservation of uterus
o Vaginal sacrospinous hysteropexy
o Manchester repair (unless the woman wishes to have children in the future)

Vault prolapse

o Vaginal sacrospinous fixation

o Sacrocolpopexy(mesh used to attach the vagina to sacral vertebra)

Colposleisis = only offered if the woman does not intend to have penetrative sex or they are at high surgical risk (the procedure involves closure of the vagina)

Offer review 6 months after surgery

Question 22

How successful is surgery?

Answer 22

No operation can be guaranteed to cure your prolapse, but most offer a good chance of improving your symptoms. The benefits of some last longer than others.

About 25–30 out of 100 women having surgery for prolapse will develop another prolapse in the future. There is a higher chance of the prolapse returning if you are overweight, constipated, have a chronic cough or undertake heavy physical activities. Prolapse may occur in another part of the vagina and may need repair at a later date.