Urogenital Prolapse

Question 1

What are the different types of urogenital prolapse?

Answer 1

• Uterine prolapse – prolapse of uterus into the vagina
• Cystocele – prolapse anterior vaginal wall involving the bladder
• Rectocele – prolapse of lower posterior vaginal wall involving the anterior wall of the rectum
• Enterocele – prolapse of the upper posterior vaginal wall containing loops of small bowel
• Vault prolapse – prolapse of the vaginal vault after hysterectomy

Question 2

What are the risk factors for urogenital prolapse?

Answer 2

• Increasing age
• high parity
• Menopause
• Obesity
• Pelvic surgery
• Pregnancy
• Chronic cough (e.g. smoking)
• Heavy lifting
• High-impact sports
• Chronic constipation
• Pelvic mass
• FHx
• Connective tissue disorders

Question 3

What are the signs and symptoms of urogenital prolapse?

Answer 3

• Feelings of heaviness of descent PV/Dragging/Back pain – worse on standing/end of the day or straining
• Recurrent UTI
• Dyspareunia
• Urinary symptoms if cystocele
• Constipation or faecal incontinence if rectocele

Question 4

What grading systems are used for urogenital prolapses?

Answer 4

• POP-Q - measures different anatomical landmarks in relation to the hymen
  
  • NICE recommended
• Shaw’s
  
  • First degree – descent to the introitus
  • Second degree – extends to the introitus and descend past the introitus on straining
  • Third degree – prolapse descends through the introitus
• Baden-Walker - like Shaw’s but uses the hymen as a reference point

Question 5

What are the appropriate investigations for suspected urogenital prolapse?

Answer 5

• Speculum - assess grade and severity
• Urodynamics - assess for incontinence
• MC&S

Question 6

What is the management of urogenital prolapse?

Answer 6

• 1st line = conservative - weight loss, minimise weightlifting, stop smoking
• 2nd line
  
  • Pelvic floor exercises
  • Topical oestrogen in elderly patients
  • Pessary
    
    • Ring - soft and don’t prevent sex
    • Shelf - hard, more supportive but does
    • Gellhorn - similar to a shelf but soft
    • Gehrung - disk-shaped, used for more serious prolapse
    • Cube - for very advanced prolapse, uses suction to keep things in place
  • Botox or Neuromodulation
• 3rd line = surgical options
  
  • Uterine prolapse
    
    • Do not preserve uterus
      
      • Vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures
    • Preserve uterus
      
      • Vaginal sacrospinous hysteropexy with sutures
      • Sacro-hysteropexy with mesh (abdominal or laparoscopic)
• Vault prolapse
  
  • Sacrocolpopexy (abdominal or laparoscopic) with mesh
• Anterior prolapse:
  
  • Colporrhaphy

Question 7

What counselling should be given to women with urogenital prolapse?

Answer 7

• Risk Factors: multiparity, age, obesity, prolonged second stage of labour, heavy lifting
• Explain the diagnosis
• Explain lifestyle modifications - lose weight, healthy diet, stop smoking
• Explain conservative management
• Explain ring pessary or surgery