Urinary incontinence & prolapse

Question 1

Pelvic organ prolapse

Answer 1

Descent of pelvic organs into the vagina

Result of weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder

Question 2

Pelvic organ prolapse risk factors

Answer 2

Vaginal childbirth, particularly with traumatic/complicated deliveries

Increasing age

Menopause

Hysterectomy

Obesity

Chronic cough

Heavy lifting

Connective tissue disorders

Question 3

Pelvic organ prolapse clinical features

Answer 3

Pelvic discomfort or a sensation of ‘heaviness’

Visible protrusion of tissue from the vagina

Urinary symptoms → incontinence, recurrent UTIs or difficulty voiding

Defecatory symptoms → constipation or incomplete bowel emptying

Sexual dysfunction

Question 4

Pelvic organ prolapse types

Answer 4

Defined according to the organ which has prolapsed into the vagina & their position:

Anterior vaginal wall

• cystocele: bladder (may lead to stress incontinence)
• urethrocele: urethra
• cystourethrocele: both bladder and urethra

Posterior vaginal wall

• enterocele: small intestine
• rectocele: rectum

Apical vaginal wall

• uterine prolapse: uterus
• vaginal vault prolapse: roof of the vagina (common after hysterectomy

Question 5

Pelvic organ prolapse ix

Answer 5

Detailed pelvic examination - Sim’s speculum can be used to support one wall of the vagina whilst other walls are examined

• women can be asked to cough or ‘bear down’ to assess the full descent of the prolapse

Ultrasound/MRI may also be useful in complex cases/surgical planning

Urodynamic studies may be indicated if co-existing urinary sx

Question 6

Pelvic organ prolapse conservative mx

Answer 6

Physiotherapy (pelvic floor exercises)

Weight loss

Lifestyle changes - reduced caffeine intake, incontinence pads

Treatment of related sx - anticholinergic meds

Vaginal oestrogen cream

Question 7

Vaginal pessaries

Answer 7

Inserted into the vagina to provide extra support to the pelvic organs

Many types - ring, cube, donut, hodge

Should be removed and cleaned/changed periodically

Can cause vaginal irritation & erosion over time → oestrogen cream helps protect the vaginal walls from irritation

Question 8

Pelvic organ prolapse surgical mx

Answer 8

Cystocele/cystourethrocele - anterior colporrhaphy, colposuspension

Uterine prolapse - hysterectomy, sacrohysteropexy

Rectocele - posterior colporrhaphy