B17. Pelvic organ prolapse; symptoms and diagnosis

Definition and epidemiology

Pelvic organ prolapse (POP) is the protrusion or herniation of bladder, rectum, intestines, uterus, cervix, or vaginal apex into the vaginal vault due to decreased pelvic floor support.

The prolapse is measured relative to the hymen according to POP-Q system or the Baden-Walker Halfway system.

It’s a common disorder. Women have an 11% lifetime risk of undergoing POP repair.

Risk factors

  • Obstetric-related risks
    • Pregnancy – the weight of the pregnancy puts stress on the pelvic floor
    • Multiparity
    • Vaginal childbirth
      • Macrosomia
      • Prolonged second stage of labour
      • Episiotomy
      • Forceps use
      • Perianal injuries
  • Menopause
    • Due to old age, hypoestrogenism
  • Connective tissue disease
  • White ethnicities
  • Chronically increased intraabdominal pressure (COPD, constipation, obesity)
  • Pelvic floor trauma

Pathomechanism

One theory is that the levator ani muscle is important in the pathomechanism, which is either directly damaged or suffers denervation or ischaemic injury.

Another theory is that connective tissue failure is important.

DeLancey has distinguished three levels of vaginal support:

  • Level I support – apical suspension
    • Damage results in apical compartment prolapse
  • Level II support – midvaginal lateral attachment
    • Damage results in anterior compartment prolapse
  • Level III support – distal perineal fusion
    • Damage results in posterior compartment prolapse or perineal deficiency

Classification

The Baden-Walker Halfway system is used for evaluation of the severity of POP during physical examination:

  • Grade 0 – no prolapse
  • Grade 1 – descent halfway to the hymen
  • Grade 2 – descent to the hymen
  • Grade 3 – descent halfway past the hymen
  • Grade 4 – maximum descent

It’s also classified according to the specific site of prolapse:

  • Anterior compartment prolapse (urethrocoele)
  • Middle compartment prolapse (cystocoele)
    • Traction cystocoele
    • Pulsion cystocoele
  • Posterior compartment prolapse (rectocoele)
  • Apical compartment prolapse (uterine prolapse)
  • Enterocoele

Clinical features

These are the most important symptoms the patient can experience:

  • Bulge symptoms
    • Sensation of vaginal bulging or protrusion
    • Pelvic or vaginal pressure or heaviness
  • Urinary symptoms
    • Urinary incontinence
    • Frequency
    • Urgency
    • Feeling of incomplete emptying
    • Hesitency
  • Bowel symptoms
    • Faecal incontinence
    • Feeling of incomplete emptying
    • Hard straining to defecate
  • Sexual symptoms
    • Dyspareunia
    • Decreased lubrication
    • Decreased sensation
  • Pain (lower abdominal or back)

Manual reduction of the prolapse by the patient may be required to start voiding or defecating.

Diagnosis and evaluation

The patient should be physically examined in the lithotomy position with a full bladder. The patient is asked to perform the Valsalva manoeuvre or to cough. This triggers the prolapse.

Then the patient is examined with vaginal retractors (and not the Cusco speculum). This allows us to assess each of the compartments of the vagina, the anterior vaginal wall, the posterior vaginal wall, and the apical compartment. This is required to assess the POP-Q and the severity of the prolapse.

Transvaginal or transperineal ultrasound can be used to evaluate the pelvic floor. It’s also important to look for the rugae vaginales.

The Q tip test can be used to assess urethral hypermobility and urinary incontinence. A Q tip is inserted to the urethra-vesicular junction, and the patient is asked to perform Valsalva. If the Q tip lifts more than 35 degrees, the test is positive.


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B18. Pelvic organ prolapse; therapy

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