Pelvic floor disorders - prolapse

Question 1

Define what urogenital prolapse is

Answer 1

In urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls.

Question 2

How common is prolapse ?

Answer 2

Very - affects up to 50% of parous women

Question 3

What are the risk factors for developing a prolapse ?

Answer 3

• Pregnancy & birth
• Obesity
• Constipation, persistent coughing or prolonged heavy lifting
• Increasing age
• Following hysterectomy
• Family history (genetics)
• Connective tissue disorders - marfans, ehler danlos syndrome

Question 4

Describe the different types of urogenital prolapse

Answer 4

• Anterior wall prolapse (cystocele) = when the bladder bulges into the front wall of the vagina
• Posterior wall prolapse (rectocele) = when the rectum bulges into the back wall of the vagina

Middle or apical compartment prolapse causes:

1. Uterine prolapse = descent of the uterus into the vagina
2. Vaginal vault prolapse = descent of the vaginal vault post hysterectomy (upper portion of vagina prolapsing into vaginal canal or outside the vagina)
3. Enterocele = herniation of pouch of douglas into vagina

Note: >1 prolapse type may occur at the same time

Question 5

Describe the typical presentation of a urogenital prolapse

Answer 5

• Sensation of pressure, heaviness, bluging or ‘mass’
• Urinary symptoms: incontinence, frequency, urgency, incomplete emptying
• Difficult defacating or incomplete defacation
• Difficulty inserting tampon
• Sexual dysfunction - Dysparenuria

Question 6

State the classification of prolapses

Answer 6

• 1st degree (in vagina),
• 2nd degree (at interiotus),
• 3rd degree (outside vagina)
• Procidentia (entirely outside vagina)

Question 7

What should be done on examination of a patient with urogenital prolapse ?

Answer 7

• PR exam
• Vaginal exam using speculum
• Urodynamics may be done to exclude OAB & assess voiding

Question 8

How is diagnosis of urogenital prolapse made ?

Answer 8

On clinical examination

Question 9

What are the management of urogenital prolapse ?

Answer 9

For mild prolapse/ no symptoms:

• Conservative management (stop smoking, decrease weight, avoid heavy lifting, reduce constipation) + physio pelvic floor exercises
• If atrophic vaginitis add in topical oestrogens
• Consider a vaginal pessary for women with symptomatic pelvic organ prolapse, alone or in conjunction with supervised pelvic floor muscle training.

For severe prolapse or prolapse not manged conservatively:

• Surgery is the best treatment but pessaries may be used if surgery not appropriate

Question 10

What are the indications for pessary use ovary surgery for urogenital prolapse ?

Answer 10

• Women unfit for surgery
• Relief symptoms whilst awaiting surgery
• Further pregnancies planned or pregnant
• As diagnostic test for prolapse/ensure correction of large cystourethrocele not cause SUI
• Patient request

Question 11

How often do pessaries need to be changed ?

Answer 11

Every 6 months (or at least cleaned)

Question 12

What can be given when changing a pessary to help with the pain ?

Answer 12

Topical oestrogen

Question 13

What is the surgical treatment of anterior or posterior wall prolapses ?

Answer 13

Pelvic floor repair (vaginal repair)

Question 14

What is the surgical treatment of middle/apical prolapses ?

Answer 14

• Marked uterine prolapse is best treated with hysterectomy. There are lots of fixation options - sacrospinous fixation, Sacralcolpopexy, mesh techniques
• Colpoclesis is done if others have failed & they arent or wont become sexually active (vagina stitched closed)

Question 15

What should be done prior to surgical repair of prolapse and why?

Answer 15

Urodyanmic studies to determine if they have any incontinence as may need to repair this at the same time

Question 16

What are the complications of pessaries ?

Answer 16

• Discharge
• Ulcerations (leading to fistula)
• FIbrous bands

(hence may need to leave a pessary out for 2-3 weeks after the 6monthly change to allow things to heal before new one inserted)