Pelvic organ prolapse

• Overview:

  • Descent of one or more of the pelvic organs into the vagina
  • Anterior vagina - bladder
  • Posterior vagina - bowel
  • Apical - uterus/cervix or vault if the women has previous had a hysterectomy
  • Typically more than one compartment will be involved e.g. bladder and uterine prolapse co-existing
  • Caused by injury to the pelvic floor
  • Stress urinary incontinence has the same aetiology and can co-exist
• Anterior compartment prolapse:

  • Bladder = cystocele
  • Urethra = urethrocele
  • Both = cystourethrocele
• Posterior compartment prolapse:

  • Rectum = rectocele
  • Particularly associated with constipation - can develop faecal loading in the part of the rectum that has prolapsed into the vagina
  • Can result in urinary retention due to compression of the urethra
  • Small bowel = enterocele (loop of bowel in the rectovaginal space)
  • Rectovaginal space = Pouch of Douglas
• Apical compartment prolapse:

  • Uterine prolapse
  • Vault prolapse - occurs in women that have had a hysterectomy and no longer have a uterus. The top of the vagina (vault) descends into the vagina
• Risk factors:

  • Increasing age
  • Pregnancy and childbirth - risk increases with number of vaginal deliveries
  • Congenital
  • Menopause - oestrogen deficiency
  • Chronic increased intra-abdominal pressure e.g. constipation, cough, obesity, heavy lifting
  • Iatrogenic - pelvic surgery e.g. hysterectomy
• Typical presenting symptoms:

  • A feeling of "something coming down" in the vagina
  • A dragging or heavy sensation in the pelvis - can also cause back pain due to traction on uterosacral ligaments
  • Urinary symptoms - incontinence, urgency, frequency, weak stream and retention
  • Bowel symptoms - constipation, incontinence and urgency
  • Large prolapses that protrude outside the vagina - ulceration and bleeding (rule out malignancy)
  • Sexual dysfunction - pain, reduced enjoyment
  • Most women have already identified the lump and are pushing it back up themselves
• Assessment:

  • History of symptoms of prolapse, urinary, bowel and sexual function
  • Examination - rule out pelvic mass, visualise prolapse with Sim's speculum
  • Use pelvic floor symptom questionnaire
  • Pelvic organ prolapse quantification (POP-Q)
  • Do not routinely perform imaging if prolapse if detected by physical examination
• Clinical exam:

  • General health including BMI
  • Abdominal exam - scars, masses, palpable bladder (prolapsed kinked urethra)
  • PV - atrophy, leakage of urine on coughing, ulceration
  • Sims speculum exam (left lateral) - Sim's speculum is applied against the anterior then the posterior vaginal walls to assess the extent of prolapse on the other wall - ask patient to bare down/Valsava
  • Classify prolapse - POP-Q
• Conservative management:

  • For women that are able to cope with mild symptoms, do not tolerate pessaries or not suitable for surgery
  • Physiotherapy - supervised pelvic floor exercises
  • Weight loss
  • Lifestyle changes for associated stress incontinence - reduce caffeine and alcohol, incontinence pads
  • Consider anticholinergic medications for stress incontinence
  • Vaginal oestrogen for vaginal atrophy
• Vaginal pessaries:

  • For symptomatic pelvic organ prolapse, alone or in combination with supervised pelvic floor exercises
  • Combine with vaginal oestrogen to treat atrophy and prevent irritation
  • Most common types - ring and shelf (gellhorn)
  • Ring - sit around the cervix holding the uterus up
  • Shelf - flat disc with a stem that sits below the uterus with the stem pointing downwards
  • Must be removed and cleaned at least every 6 months (should be seen in pessary clinic if high risk of complications)
• Surgical options:

  • Uterine prolapse:
  • Vaginal hysterectomy, with or without vaginal sacrospinous fixation with sutures
  • Vaginal sacrospinous hysteropexy with sutures
  • Manchester repair
  • Vault prolapse:
  • Vaginal sacrospinous fixation with sutures
  • Anterior prolapse - anterior repair without mesh
  • Posterior prolapse - posterior repair without mesh
• Vaginal sacrospinous fixation:

  • In women who had a hysterectomy
  • Via incision in the vagina
  • Stiches are placed into sacrospinous ligament and then to the cervix or vaginal vault
• Vaginal sacrospinous hysteropexy:

  • For uterine prolapse
  • Cervix stitched to sacrospinous ligament
  • resuspension of the prolapsed uterus using mesh to lift it and hold it in place
• Manchester repair:

  • Cervix is shortened
  • Strengthen cervix with sutures to ligament
• Anterior/posterior repair:

  • Fascia is folded and stitched
  • Done via vaginal incision
• Complications of mesh repairs:

  • Chronic pain
  • Altered sensation
  • Dyspareunia (painful sex) for women and partner
  • Abnormal bleeding
  • Urinary or bowel problems