Prolapse of the uterus and vagina Flashcards
Define Prolapse.
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
What are the types of prolapses?
- Urethrocoele
- Cystocoele
- Apical
- Enterocoele
- Rectocoele
Define urethrocoele.
Prolapse of lower anterior vaginal wall, involving the urethra only
Define Cystocoele.
Prolapse of upper anterior vaginal wall, involving the bladder
Associated prolapse of urethra = cystourethrocoele
Define apical prolapse.
Prolapse of uterus, cervix and upper vagina
If uterus has been removed, the vault can itself prolapse
Define enterocoele.
Prolapse of upper posterior wall of vagina
Pouch usually contains small loops of bowel
Define rectocoele.
Prolapse of lower posterior wall of vagina
Involves anterior wall of the rectum
In what types of prolapse is the anterior vaginal wall affected?
- Cystocele (bladder into vagina)
- Urethrocele (urethra into vagina)
- Cystourethrocele
In what types of prolapse is the posterior vaginal wall affected?
- Enterocele (small intestine into the vagina)
- Rectocele
- Sigmoidcele
In what types of prolapse is the apical vagina affected?
- Uterine prolapse
- Vaginal vault prolapse (occurs after a hysterectomy)
What system is used in grading prolapses?
Pelvic Organ Prolapse - Quantification
What are the stages of urogenital prolapse?
Describe the epidemiology of urogenital prolapse?
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%
Describe the Aetiology of pelvic organ prolapses.
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
What are the RFs of prolapses?
- Childbirth
- Ageing
- Post-menopausal
- Following pelvic surgery
- Increased abdominal pressure
- Congenital
- Collagen defect
- Ethnicity
What are the clinical features of pelvic organ prolapses?
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
What are the investigations for pelvic organ prolapse?
- 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
How do we think of the management of a pelvic organ prolapse?
- General Lifestyle Advice
- Medical
- Surgical
What general advice would you give for pelvic organ prolapses?
- 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
What medical treatment can be used?
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)
What are the surgical treatments for pelvic organ prolapses?
- 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
How successful is surgery?
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.
