Prolapse

Question 1

What is an Urethrocoele

Answer 1

Prolapse of lower anterior vaginal wall involving the urethra only

http://www.mdguidelines.com/images/Illustrations/urethroc.jpg

Question 2

What is a Cystocoele?

Answer 2

Prolapse of upper anterior vaginal wall involving the bladder

Often also involving urethra, ie cystourethrocoele

Question 3

What is an Apical Prolapse

Answer 3

Prolapse of uterus, cervix and upper vagina

aka Uterine prolapse

Question 4

What is an Enterocoele?

Answer 4

Small bowel prolapses into upper posterior vaginal wall

Question 5

What is a Rectocoele?

Answer 5

Rectum prolapses into lower posterior vaginal wall

Question 6

How do you grade a prolapse?

Answer 6

Pelvic Organ Prolapse (POP) scoring system of International Continence Society (ICS);

When straining

1. No descent
2. >1cm above Hymenal ring
3. <1cm above Hymenal ring & <1cm below Hymenal ring
4. >1cm below Hymenal ring
5. Vagina completely everted

Question 7

What is a complete Procidentia?

Answer 7

Grade 4 prolapse accordinint to ICS POP system.

Vagina completely everted

Question 8

Draw a picture of the major pelvic ligaments and muscles

Answer 8

Question 9

Outline the Epidemiology of Prolapse

Answer 9

Half of all parous women have some degree of prolapse

10-20% seek medical attention

Question 10

Outline the Aetioloy of prolapse

Answer 10

Increase intra-abdominal pressure;

• Pregnancy
• Obesity
• Chronic cough
• Constipation
• Heavt lifting
• Pelvic mass

Weakened pelvic floor;

• Congenital factors (collagen metabolism [eg Ehlers-Danlos syndrome])
• Menopause (deterioration of collagenous connective tissue following oestrogen withdrawal)
• Vaginal delivery (damage to pelvic floor)
• Iatrogenic (surgery predisposing)
  *

Question 11

Outline the clinical presentation of prolapse

Answer 11

• Asymptomatic
• Dragging/ lump sensation
  
  • Worse at end of the day or when standing
• Back pain usual
• Severe prolapse;
  
  • Interferes with intercourse
  • May ulcerate
  • Bleeding/ discharge
• Cystourethrocoele; freq/ urgency/ incontinence/ retention
• Rectocoele; problems defaecating
• O/E
  
  • Bear down to produce prolapse
  • Rectocoele can be confirmed by PR finger (compared to enterocoele)

Question 12

Outline the investigations for Prolapse

Answer 12

• Cause?
  
  • USS is pelvic mass suspected
  • Urodynamic testing if urinary incontinence is principle complaint

Question 13

How can you prevent Prevention?

Answer 13

• Recognition of obstructed labour
• Avoidance of long second stage
• Pelvic floor exercises

Question 14

Outline the conservatory (non-surgical) treatment for Prolapses

Answer 14

• Lifestyle
  
  • Weight reduction
  • Stop smoking
  • Physio & pelvic floor muscles
• Pessaries (unwilling/ unfit for surgery)
  
  • Artificial pelvic floor
  • Types include Ring (most common) & Shelf (for severe)
  • Changed every 6-9 months
  • Ulceration: Post-menopausal women may require oestrogen replacement (topical/ HRT)

Question 15

Outline the Surgical treatments for Uterine Prolapse

Answer 15

• Vaginal hysterectomy
  
  • Traditional treatment
  • Often re-presents with Vault prolapse..
• **Hysteropexy **[o/lap]
  
  • Uterus & cervix attahed to Sacrum using bifurcated non-absorbable mesh
  • Effective

Question 16

Outline the Surgical treatments for Vaginal Vault Prolapse

Answer 16

• **Sacrocolpopexy **[o/lap]
  
  • Fixed vault to sacrum using mech
  • Complications: Mesh erosion & haemorrhage
• Sacrospinous fixation [pv]
  
  • Suspends vault to sacrospinous ligament
  • Complications: nerve/ vessel injury, infection, buttock pain

Question 17

Outline the Surgical treatments for Vaginal Wall Prolapse

Answer 17

• Anterior and Posterior ‘repairs’ for relevent prolapse