Vaginal Prolapse

Question 1

If level 1 failure occurs, what falls?

Answer 1

The cervix

Question 2

If level 2 failure occurs, what falls?

Answer 2

Bladder

Question 3

What are the types of prolapse?

Answer 3

Anterior vaginal wall descent - cystocele
Apical descent - Uterine/vault prolapse, enterocele
Posterior vaginal wall descent - rectocele
Procidentia - uterus, bladder, rectum

Urethral prolapse
Rectal prolapse

Question 4

What is the role of the levator ani? What happens if it fails?

Answer 4

Reinforces support of endopelvic fascia

Not prolapse in of itself but worsening of prolapse in the presence of weakness in endopelvic fascia

Question 5

What is the most important factor leading to prolapse?

Answer 5

Mainly failure of endopelvic fascia

Question 6

What are aetiological factors of prolapse?

Answer 6

Parity/vaginal delivery - especially greater than 10p, instrumentation, more than 4 children, 2+ hour second phase
Age
Menopause
Previous surgery to correct pelvic organ support defects
Chronic cough, obesity, smoking, diabetes
Connective tissue disorder - Ehlers Danlos, Marfans
Tumour
Deinnervation
Heavy lifting, high impact activity

Question 7

What is the relationship between prolapse and incontinence?

Answer 7

Usually they’re both caused by pelvic floor weakness

Occasionally the prolapse directly causes the incontinence

Question 8

How do prolapses present?

Answer 8

Lump/bulge
Bladder - Stress incontinence, incomplete voiding, recurrent UTIs, complete urinary retention
Bowel - Incomplete/digitated defecation, faecal urgency
Sexual dysfunction due to obstruction

Question 9

When can prolapses be life threatening

Answer 9

Urinary retention/urethral kinking

Decubitus ulcer

Question 10

How do you exam in a prolapse?

Answer 10

Inspect
Speculum exam - Dorsal or left lateral position, with a full bladder if possible, Sims speculum best
Feel for cervical descent

Question 11

What is the best position to see the anterior wall?

Answer 11

Left lateral with Sims speculum

Question 12

What are the stages of prolapse?

Answer 12

0 - Normal
1 - Some bulge, not reached the hymen
2 - Reached the hymen
3 - Beyond the hymen
4 - Whole pelvic organ has prolapsed out

Question 13

What is the total vaginal length?

Answer 13

Distance from hymen to posterior fornix

Question 14

What are the non-surgical mx options?

Answer 14

No treatment

pelvic floor exercises
oestrogen replacement
lifestyle changes
pessary

Question 15

What evaluation system is used for prolapse examination?

Answer 15

POPQ

Question 16

What are the surgical management options?

Answer 16

Anterior or posterior vaginal wall repair (colporrhaphy) for cystoceles and rectocele respectively

Vaginal hysterectomy or hysteroplexy (mesh) for uterine prolapse

Abdominal sacral colpopexy, sacrospinatus fixation - vault fixation