Pelvic Organ Prolapse

Question 1

What are the parts of the pelvic floor?

Answer 1

• Endopelvic fascia- fibromuscular connective type tissue
• Pelvic Diaphragm- striated muscle
• Urogenital Diaphragm- superficial and deep transverse perineal muscles

Question 2

What structures make up the endopelvic fascia?

Answer 2

• Uterosacral ligament
• Pubocervical fascia
• Rectovaginal fascia

Question 3

Risk factors for POP?

Answer 3

1- Pregnancy and vaginal birth 
- Forceps delivery
- Macrosomia= large baby
- Prolonged 2nd stage of labour
- Parity
2- Age
3- Obesity
4- Previous pelvic surgery: 
-hysterectomy -colposuspension
5-other 
- Constipation
- Heavy lifting
- Exercise
- Hormonal
- CT disease

Question 4

Traditionally how do we classify POP?

Answer 4

• Urethrocele
• Cystocele
• Uterovaginal prolapse
• Enterocele
• Rectocele

Question 5

Describe the vaginal symptoms of having a POP?

Answer 5

• Bulge/protrusion sensation
• Bulge/protrusion visible/palpable
• Pressure
• Heaviness
• Tampon insertion difficulties

Question 6

How can you score POP?

Answer 6

POPQ score is gold standard

Gives a staging from 0-6

Question 7

How can you investigate POP?

Answer 7

• No ultrasound required unlessvery large patient
• Examination to exclude pelvic mass

Due to associated problems:

• USS/ MRI: to look for fascial defects
• Urodynamics (for UI)
• IVU/Renal US (for ureteric obstruction)

Question 8

How do we prevent a POP?

Answer 8

• Avoid constipation
• Manage chest pathology e.g. COPD to avoid coughing/straining
• Less kids
• Pelvic floor muscle training antenatally and post-partum

Question 9

How can we treat POP?

Answer 9

• Pelvic Floor muscle Training (PFMT)
• Pessaries
• Surgery

Question 10

What is a urethrocele?

Answer 10

Prolapse of the urethra into ANTERIOR VAGINAL WALL

Question 11

What is a cystocele?

Answer 11

Prolapse of the bladder into ANTERIOR VAGINAL WALL

Question 12

What is a uterovaginal prolapse?

Answer 12

Prolapse of uterus, CERVIX and vagina

Question 13

What is a rectocele?

Answer 13

prolapse of the Rectum into the POSTERIOR VAGINAL wall

Question 14

What is an enterocele?

Answer 14

Prolapse of small loops of bowel into the POSTERIOR WALL of vagina

Question 15

What are the urinary symptoms of a prolapse

Answer 15

• Urinary Incontinence
• Frequency/ Urgency
• Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
• Manual reduction of prolapse to start or complete voiding- Need to more forwards/backawards to empty the bladder.

Question 16

What are the bowl symptoms of a prolapse?

Answer 16

• Incontinence of flatus, or liquid or solid stool
• Feeling of incomplete emptying/ Straining
• Urgency
• Digital evacuation to complete defecation
• Splinting, or pushing on or around the vagina or perineum, to start or complete defecation

Question 17

How does pelvic floor training work?

Answer 17

Increase the pelvic floor strength & bulk which relieve the tension on the ligaments

Question 18

What is the aim of surgery?

Answer 18

oRelieve symptoms,
oRestore/maintain bladder & bowel function and
oMaintain vaginal capacity for sexual function

OFTEN IT IS WISER TO USE PESSARIES

Question 19

What are the levels of endopelvic support?

Answer 19

Level I:
 Utero-sacral ligaments
 Cardinal ligaments

Level II:
 Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia

Level III:
 Urogenital Diaphragm
 Perineal body

Question 20

How common is it to be symptomatic in prolapse?

Answer 20

 Found asymptomatically in 50%

 Found Symptomatically in 2%