Prolapse

Question 1

What is a Female pelvic organ prolapse?

Answer 1

The descent of the pelvic organs towards or through the vagina

Question 2

What are the 3 distinct layers of the pelvic floor?

Answer 2

• Endopelvic Fascia
  
  • Collective name for the fibro-muscular connective-type tissue that attaches the bladder, urethra, vagina and uterus to the pelvic walls
  • Can stretch due to fibro-muscular component
• Pelvic Diaphragm / floor
  
  • Layer of striated skeletal muscles
• Urogenital Diaphragm
  
  • The superficial & deep transverse perineal muscles with their fascial coverings.

Question 3

What is said to be the critical structure responsible for uterine and apical vaginal support?

Answer 3

The uterosacral-cardinal ligament complex (made up of the uterosacral ligament and the cardinal ligament)

• This tends to break medially (around the cervix)
• Attachments:
  
  • Medially to the uterux, cervix, pubocervical/rectovaginal fascia and lateral vaginal fornices
  • Laterally to the sacrum and fascia overlying the Piriformis muscle

Question 4

What is the Pubocervical Fascia and what is it’s function?

Answer 4

Trapezoidal fibro-muscular tissue.

• Function: provides the main support of the anterior vaginal wall
• Attachments:
  
  • Centrally - merge with the base of the cardinal ligaments and Cervix
  • Laterally - Arcus tendineus fascia pelvis (white in image)
  • Distally - urogenital diaphragm

Question 5

What is the rectovaginal fascia and how does it tend to break?

Answer 5

Fibro-musculo-elastic tissue that separates the rectum and vagina.

• Attachments:
  
  • Centrally - merges with the Base of cardinal/uterosacral ligaments and peritoneum
  • Laterally - fuses with fascia over the levator ani
  • Distally - firmly to the perineal body
• Tends to break centrally

Question 6

What results if there is an upper defect in the rectovaginal fascia?

Answer 6

Enterocele

• Descending of the small intestine into the lower pelvic cavity.
• When this occurs, the small intestine pushes on the top part of the vagina, creating a bulge
• Form of POP

Question 7

What results if there is a lower defect in the rectovaginal fascia?

Answer 7

Perineal body descent and rectocele

• a herniation (bulge) of the front wall of the rectum into the back wall of the vagina.

Question 8

What structures are involved in each level of Endopelvic support? (There are 3 levels in total)

Answer 8

• Level 1
  
  • Utero-sacral ligaments
  • Cardinal ligaments
• Level 2
  
  • Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia
• Level 3
  
  • Urogenital Diaphragm
  • Perineal body

Question 9

What is the strongest risk factor for the development of Pelvic organ prolapse?

Answer 9

Parity => pregnancy (over 24 weeks) i.e live born or still born

Question 10

Risk factors of Pelvic Organ Prolapse

Answer 10

• Parity
• Forceps Delivery
• Large baby (> 4500 gm)
• Prolonged Second Stage of Labour
• Advancing age
• Obesity
• Previous pelvic surgery
  
  • Continence procedures i.e Burch colposuspension
  • Hysterectomy
• Hormonal factors
• Quality of connective tissue
• Constipation
• Occupation with heavy lifting
• Exercise i.e weight lifting, high-impact aerobics and long-distance running

Question 11

Define urethrocele, cystocele and uterovaginal prolapse

Answer 11

• Urethrocele: Prolapse of the lower anterior vaginal wall involving the urethra only.
• Cystocele: Prolapse of the upper anterior vaginal wall involving the bladder.
• Uterovaginal prolapse. This term is used to describe prolapse of the uterus, cervix and upper vagina.

Question 12

Anterior wall prolapse

Answer 12

Anterior vaginal wall collapses and bladder descends because of this

Question 13

Posterior vaginal wall prolapse

Answer 13

Posterior vaginal wall collapses and rectum falls forwards

Question 14

What is apical prolapse/uterine prolapse/enterocele?

Answer 14

Where the uterus falls down the vaginal canal

Question 15

What are some typical vaginal symptoms in women with pelvic organ prolapse? (5)

Answer 15

• Sensation of a bulge or protrusion
• Seeing or feeling a bulge or protrusion
• Pressure
• Heaviness
• Difficulty in inserting tampons

Question 16

What are some typical urinary symptoms in women with pelvic organ prolapse? (4)

Answer 16

• Urinary incontinence
• Frequency/urgency
• Weak or prolonged urinary stream/hesitancy/feeling of incomplete emptying
• Manual reduction of prolapse to start or complete voiding

Question 17

What are some typical bowel symptoms in women with pelvic organ prolapse? (5)

Answer 17

• Incontinence of flatus, or liquid, or solid stool
• Feeling of incomplete emptying/ straining
• Urgency
• Digital evacuation to complete defecation - the use of fingers to aid in the removal of stool from the rectum.
• Splinting, or pushing on or around the vagina or perineum, to start or someplete defecation

Question 18

What is considered the ‘gold standard’ scoring tool for POP?

Answer 18

POPQ

• Used to assess the degree of prolapse of pelvic organs
• Score from 0-4
• Measures nine points in the vagina. The hymen is the reference point to which the other points are compared. The prolapsed organs are measured in centimeters to the hymen.
• The woman should be in the dorsal lithotomy position (as if giving birth) but may be standing or lying down flat - record this !

Question 19

Which investigations are done for POP? (5)

Answer 19

• USS/MRI - allow identification of fascial defects
• Urodynamics - concurrent urinary incontinence or to exclude occult Stress Incontinence (occult meaning it has no other recognisable associated signs/symptoms)
• IVU or Renal USS - if suspicion of ureteric obstruction

Question 20

How can you prevent POP?

Answer 20

• Avoid constipation
• Effective management of chronic chest pathology (COPD and asthma)
• Smaller family size
• Improvements in antenatal and intra-partum care - Antenatal and post-natal pelvic floor muscle training - thought to be protective

Question 21

Treatment of POP

Answer 21

• Physio
  
  • pelvic floor muscle training - increase the pelvic floor strength & bulk to relieve the tension on the ligaments
  • Used in cases of mild prolapse and in younger women who have not yet completed their family.
  • No role in advanced cases! Cannot treat fascial defects
• _​_May also be given things like:
  
  • Perineometer - instrument for measuring the strength of voluntary contractions of the pelvic floor muscles
  • Vaginal cones - weighted devices designed to increase the strength of the pelvic floor muscles
• Pessaries - non-surgical treatment - support or space filling pessaries - device inserted into vagina. At I year follow-up successful pessary treatment is as effective as surgery - it is the woman’s choice
• Surgery

Question 22

Aims of POP surgery

Answer 22

• Relieve symptoms
• Restore/maintain bladder and bowel function
• Maintain vaginal capacity for sexual function