Prolapse of the uterus and vagina

Question 1

what is the definition of prolapse of the uterus and vagina

Answer 1

descent of the uterus/vagina beyond the anatomical confines, usually occuring due to a weakness of the surrounding structures

Question 2

what are the 3 levels of support of the vagina and uterus

Answer 2

1 - cardinal and uterosacral ligaments support the cervix and upper 1/3 of the vagina from the pelvic side walls and sacrum respectively

2 - the mid portion of the vagina is attached by endopelvic fascia

3 - lower 1/3 is supported by the levator ani and the perineal body which form the pelvic floor muscles

these 3 layers are arranged in a descending staircase with 1 being the most proximal

Question 3

what are the types of pelvic organ prolapse

Answer 3

urethrocele - lower vaginal wall involving urethra only

cystocele - upper vaginal wall involving bladder

rectocele - lower posterior vaginal wall involving upper rectum

enterocele - upper posterior vaginal wall involving Small intestine

apical - prolapse of uterus, cervix and vagina

Question 4

what is used to classify pelvic organ prolapse

Answer 4

baden-walker scale

Question 5

what are the stages of the Baden-Walker scale for pelvic organ prolapse

Answer 5

Stage 0 = no descend of pelvic organs whilst straining

Stage 1 = leading edge of prolapse does not descend 1cm above hymenal ring

Stage 2 = leading edge of prolapse is between 1cm above and below the hymenal ring

Stage 3 = >1cm from hymenal ring but not complete eversion

Stage 4 = complete vaginal eversion

Question 6

what is the aetiology for complete vaginal prolapse

Answer 6

pregnancy and vaginal delivery - esp if instruments used/multiple births/large infants
iatrogenic (surgery)
increased IAP (e.g. obesity/chronic cough)
connective tissue disorders
menopause

Question 7

what are the clinical features of pelvic organ prolapse

Answer 7

usually asymptomatic

If symptomatic they feel a dragging sensation/lump, worse at the end of the day and on standing up

Question 8

how do you treat mild-moderate pelvic prolapse

Answer 8

weight loss
stop smoking
physio

Question 9

after lifestyle interventions what is the next intervention for pelvic prolapse

Answer 9

ring or shelf pessary + oestrogen cream/HRT if post-menopausal to prevent ulceration

Question 10

how often should you change a pessary

Answer 10

every 6-9 months

Question 11

what are complications of pessary insertion

Answer 11

pain
failure
infection
falling out
urinary retention

Question 12

what are the surgical options for pelvic prolapse (uterine, vaginal wall/vault)

Answer 12

uterine prolapse:
hysterectomy - traditional
hysteroplexy - attach the uterus/cervix to the sacrum via a mesh

vaginal vault prolapse
sacrocolpoplexy - for women who have had a hysterectomy, similar to hysteroplexy
sacrospinous fixation - also post hystectomy, sutures vaginal vault to sacrospinous ligament (less effective, better recovery)

vaginal wall prolpase
anterior/posterior repair

Question 13

what are some surgical options for urodynamic stress incontinence related to pelvic prolpase

Answer 13

tension free vaginal tape

transobturator tape

Question 14

what are complications for hysteroplexy/sacrocolpoplexy

Answer 14

mesh erosion

haemorrhage

Question 15

what are the complications for sacrospinous fixation

Answer 15

nerve/vessel injury
buttock pain
infection