Uterine Prolapse

Question 1

Definition of uterovaginal prolapse

Answer 1

• Prolapse is defined as protrusion of the uterus and/or vagina beyond normal anatomical confines
• The bladder, urethra, rectum and bowel are also involved

Question 2

Pelvic floor anatomy

Answer 2

• Muscular and fascial structures provide support to the pelvic viscera and external openings of vagina, urethra and rectum
• Uterus
  
  • Vaginal walls
  • Transverse cervical ligaments
  • Round and broad ligaments
  • Indirect support from pelvic floow
• Cervic and upper 1/3 vagina
  
  • Transverse cervical ligament
  • Uterosacral ligaments

Question 3

Risk factors for uterovaginal prolapse

Answer 3

• Increasing age/menopause (loss of oestrogen + connective tissue strength)
• Vaginal delivery (big babies, prolonged 2nd stage)
  
  • Direct trauma - avulsion of the levator ani or ligaments
  • Pudendal nerve damage (crushedby bony pelvis, long labour worse)
• Increasing parity
• Raised intra-abdominal pressure
  
  • Obesity
  • Chronic cough
  • Chronic constipation
• Congenital factors
  
  • Abnormal collage metabolism

Question 4

Clinical features

Answer 4

• Vaginal
  
  • Sensation of pressure, fullness, heaviness
  • Sensation of a bulge - better lying down
  • Bleeding/discharge
  • Backache
• Coital difficulty
  
  • Dyspareunia
• Urinary
  
  • Incontinence, frequency, urgency
  • Need to manyally reduce prolapse prior to voiding
• Bowel
  
  • Constipation/straining
  • Faecal invoncinence or urgency of stool
  • Incomplete evacuation
• May be asymptomatic

Question 5

Examination

Answer 5

• Hx and impact on QoL
• Vaginal examination
• Abdominal/bimanual examination

Question 6

Grading system for prolapse

Answer 6

• Pelvic Organ Prolapse Quantification (POPQ)

Question 7

Classification of prolapse

Answer 7

• Cystocele - upper anterior vaginal wall and bladder protrudes (commonest)
• Urethrocele - decent of the anterior vaginal wall where the urethra sits
• Rectocele - posterior wall of vagina involving the anterior wal of rectum protrudes
• Enterocele - upper vaginal wall (posterior fornix) and peritoneal sac
• Uterine prolapse - prolapse of uterus into vagina (second most common)
• Vaginal vault prolapse - occurs following hysterectomy

Question 8

Management of prolapse

Answer 8

• Conservative
  
  • No treatment
  • Lifestyle advice (weight and smoking)
  • Pelvic floor exercises
  • Intravaginal devices (pessaries)
  • Vaginal oestrogens
• Surgical
  
  • Vaginal
  • Abdominal

Question 9

Pessaries

Answer 9

• Ring pessary
  
  • Placed between posterior aspect of the symphysis pubis and the posterior fornix of the vagina
  • Complressed into an oval shape for insertion and regains circular shape in vagina
• Other pessaries exist but complications include:
  
  • May interfere with intercourse
  • Ulceration
  • Infection
  • Difficulty and discomfort during removal
  • Fistula if neglected

Question 10

When to use surgical management

Answer 10

• Indicated if pessaries have failed, patient wants definitive treatment or if prolapse combine with urinary or faecal incontinence

Question 11

Anterior compartment defect surgical management

Answer 11

• Anterior colporrhaphy (anterior repair)
  
  • Repair of cystocele +/- urethrocele
• Procedure
  
  • Anterior vaginal wall incision
  • Buttressing sutures placed on fascia
  • Surplus skin excised
• Complications
  
  • Dyspareunia
  • Incontinence
  • Failure
  • Recurrence (30% within 5 years)

Question 12

Posterior compartment defect surgical management

Answer 12

• Posterior colporrhaphy
  
  • Correction of rectocele +/- perineoplasty
• Procedure
  
  • Incision made in posterior wall of vagina
  • Butressing sutures
  • Reapposition of levtor muscles
  • Removal of excess skin
• Complications
  
  • Dysparaeunia
• Enterocele repair
  
  • Vaginal epithelium is dissected from enterocele sac
  • Uterosacral ligaments brought together in midline

Question 13

Surgical repair of uterovaginal prolapse

Answer 13

• Vaginal hysterectomy
• Manchester repair
  
  • Cervical amputation
  • Shortening of transcervical ligaments
• Sacrohysteropexy
  
  • Open abdominal or laporoscopic
  • Mesh is used to attach the uterus to the anterior longitudinal ligament over the sacrum

Question 14

Surgical repair of vaginal vault prolapse

Answer 14

• Sacrospinous ligament fixation
  
  • Vaginal vault sutures to sacrospinous ligamnents using vaginal approach
• Sacrocolpopexy
  
  • Open/laparoscopic
  • Vault attached to sacrum using mesh
• Colpocleisis - vaginal closure
  
  • For women who don’t desire sexual intercourse
  • Performed vaginally
  • Skin removed from vaginal bulge
  • Sutured upon itself

Question 15

Prolapse prevention

Answer 15

• Weight reduction
• Treatment of constipation
• Treatment of chronic cough and smoking cessation
• Avoidance of heavy lifting
• Encourage pelvic floor exercises
• Good intrapartum care
  
  • Avoid unnecessary instrumental trauma
  • Avoid prolonged labour