Prolapses

Question 1

What are the 5 types of prolapse?

Answer 1

Urethrocoele - Anterior vagina wall and urethra.

Cystocoele - Anterior vagina wall and bladder.

Apical prolapse - Prolapse of uterus, cervix and upper vagina.

Enterocoele - Upper posterior vagina wall, normally contains bowel.

Rectocoele - Lower posterior vagina wall and rectum.

Question 2

What grading system is used in prolapse? What does it relate to? What are the scores?

Answer 2

Pelvic organ prolapse score (POP). Scores given based on descent relative to hymenal ring.

0 = no prolapse

1 = 1cm above

2 = 1cm above to 1cm below

3 = 1cm below, but not total eversion

4 = Vagina everted

Question 3

What causes prolapse? (5 groups)

Answer 3

Vaginal delivery and pregnancy: mechanical injury and denervation to pelvic floor; risk increased with big babies, prolonged second stage and instrumental delivery.

Congenital: abnormal collagen (ehlers-danlos).

Menopause: Collagen deterioration.

Chronic factors: increased pressure (obesity, cough, constipation, lifting, pelvic mass)

Iatrogenic: Pelvic surgery.

Question 4

How does prolapse present?

Answer 4

Dragging sensation, lump. Usually worse at the end of the day / standing up. Severe prolapse may cause bleeding / discharge and interfere with intercourse.

Cystourethrocoele can cause urinary frequency and incomplete voiding.

O/E: Sims speculum examination. Ask PT to bear down to demonstrate prolapse.

Question 5

How would you investigate a prolapse?

Answer 5

USS.

If incontinence - urodynamic testing.

Question 6

How would you treat a prolapse?

Answer 6

Symptomatic treatment.

Conservative = weight reduction, smoking cessation, physiotherapy.

Pessaries - ring or shelf. If atrophic vagina, may require oestrogen replacement to prevent ulceration.

Surgery - hysteropexy, sacrocolpopexy, etc.