Uterovaginal Prolapse

Question 1

Definition of a uterogenital prolapse

Answer 1

When a defect in the pelvic floor allows one or more of the pelvic viscera to fall through it
20% of all gynae surgery
Not life threatening but has a severe impact on the quality of life

Question 2

Structures of the pelvic floor (5)

Answer 2

Pelvic bones Levator Ani
Endopelvic fascia Viscera
Perineal Body

Question 3

Anterior Compartment

Answer 3

Urethrocele - involves the lower part of the anterior vaginal wall
Cystocele - prolapse of the upper vaginal wall and bladder

Question 4

Middle compartment

Answer 4

Uterovaginal prolapse - descent of the uterus and cervix through the vagina
Vault prolapse - after hysterectomies the vault can prolapse usually with small bowel and omentum

Question 5

Posterior compartment prolapses

Answer 5

Enterocele - involves the upper part of the posterior vagina and can bowel loops and the POD - true herniation through the pelvic outlet
Rectocele - prolapse of the posterior vaginal wall containing the rectum

Question 6

Urethrocele

Answer 6

Prolapse of the anterior vaginal wall including the urethra

Question 7

Causes of Cystocele

Answer 7

Due to a defect in the pubovesical and pubocervial fascia - usually presents with a urethral prolapse

Question 8

Causes of Uterovaginal prolapse

Answer 8

Usually related to damage of genital structures during childbirth

Question 9

Vault prolapse

Answer 9

Mainly occur after hysterectomies

Similar symptoms to uterine prolapse but instead of uterus they have enterocele

Question 10

Symptoms of Enterocele

Answer 10

Can cause lower abdominal pain and pelvic pressure which is relieved by lying down - worsening through the day
May only be palpable when supine if the patient bares down

Question 11

Causes of Rectocele

Answer 11

Caused by a defect in the recto-vaginal fascia with separation of the levator ani musculature

Question 12

Bladder dysfunction in Cystocele

Answer 12

Can compromise bladder emptying leading to higher residuals and recurrent UTIs - large cystoceles can kink the urethra causing retention, but incontinence if the posterior urethro-vesical angle is increased - makes pt vulnerable to acute increases in pressure

Question 13

Complications of Uterovaginal prolapse (2)

Answer 13

Can impair bladder emptying

Cervical protrusion can predispose to mucosal dryness and infections

Question 14

Procidentia

Answer 14

Total eversion of the vagina

Question 15

Contents of the posterior compartment

Answer 15

Rectovaginal septum Puborectalis muscle
Uterosacral ligaments Perineal body
Perineal membrane Anal sphincters

Question 16

Symptoms of Rectocele

Answer 16

Feelings of pressure in the perineum with defecation or difficulty defecating - pts can improve symptoms by pushing on the posterior vaginal wall to empty the rectum

Question 17

POP classification of prolapses

Answer 17

Stage 0 - no descent of structures when straining
Stage 1 - descent up to 1cm above the hymenal ring
Stage 2 - from 1cm above or below the hymenal ring
Stage 3 -more than 1cm beyond the hymenal ring but no vaginal eversion
Stage 4 - Full vaginal eversion

Question 18

Risk factors for pelvic prolapses

Answer 18

Age Oestrogen deficency or post-menopausal
Striated muscle weakness/neuromuscular disease
SVD, hysterectomy or collagen disorders (marfans or ehlers-danlos
Increased intra-abdominal pressure (chronic cough, heavy lifting, constipation, obesity
Long term steroid use

Question 19

General symptoms of prolapse

Answer 19

At first can be asymptomatic - worsen over the day or activities which increase abdominal pressure
Backache or urinary symptoms
Dysparenuria

Question 20

Examination for Prolapses

Answer 20

Lithotomy position using a speculum and bimanual or left lateral position using a simms speculum
Look for signs of decreased estrogens - vaginal atrophy etc

Question 21

Physical Signs of reduced estrogens

Answer 21

Loss of rugae in the vaginal mucosa
Decreased secretions
Thin perineal skin
Easy perineal tearing

Question 22

Prevention of pelvic floor damage

Answer 22

Minimizing trauma during labour - post natal pelvic floor exercises
Ensure adequate support of the vaginal vault at hysterectomy

Question 23

Conservative Treatment

Answer 23

Small prolapses can be treated with reassurance and pelvic floor exercises
Avoid heavy lifting and straining
Ring (1st line) or shelf pessary as support - effective in 60% of women. Largest pessary which is comfortable. change every 6-12months.

Question 24

Use of Pessaries vs surgery

Answer 24

Surgery is definitive treatment
Use pessaries if: during or after pregnancy if further pregnancies are planned.
to confirm benefit from surgery or while awaiting surgery - if unfit for surgery

Question 25

Complications of Pessaries

Answer 25

Fall out or do not provide adequate support
Can cause vaginal ulceration causing bleeding or discharge - managed by removal and prescribing vaginal estrogens
Can replace ring pessaries with a shelf pessary

Question 26

Considerations of surgery

Answer 26

Intended to correct prolapse, maintain continence and preserve sexual function - should take full Sexual Hx as over repair can cause dysparenuria - avoid sex for 6-8wks
Depending on the location of the prolapse use anterior or posterior colporraphy
Vault prolapse can be treated with a sacrospinous fixation

Question 27

Conservative treatment of prolapse - if no symptoms

Answer 27

watch and wait
Lifestyle modifications - treat cough and lose weight
Pelvic floor exercises may help
Topical oestrogens are not useful in most cases

Question 28

Anterior Colporrhaphy

Answer 28

Transvaginal op to plicate the fibromuscular layer of the anterior vaginal wall used for bladder/urethral prolapse

Question 29

Colposuspension

Answer 29

Performed for urethral sphincter incontinence due to cystourethrocele. sutures are placed through the ipsilateral iliopectineal ligament.

Question 30

Sacrospinous fixation

Answer 30

Uni or bilateral fixation of the vault to the sacrospinous ligament. Lower success rate but low risk than sacrocolpopexy

Question 31

Posterior colporrhaphy

Answer 31

levator ani pilcation or repair of fascial defects. used for rectoceles or enteroceles.

Question 32

Sacrophysteropexy

Answer 32

If there is uterine prolapse and the women wants to keep her uterus then it can be attached to the longitudinal ligament over the sacrum.
A sacrocolpopexy can also be used to treat vault prolapse by attaching the top of the vagina to the sacrum.