38 Questions
What is splinting used to improve?
Defecation
Why may surgery be necessary in cases of obstructed defecation?
To resolve symptoms of obstructed defecation
What is the primary purpose of taking a comprehensive history in patients with POP?
To identify the most worrisome symptoms
Why is it essential to evaluate the patient's symptoms thoroughly?
To identify the underlying cause of bladder or bowel symptoms
What is the common consequence of treating prolapse in isolation?
Disappointment with treatment outcomes
What percentage of women undergoing routine gynecological care will show loss of vaginal or uterine support on examination?
30-70%
Why is it important to evaluate patients with POP thoroughly?
To manage patient expectations
What symptoms are often misattributed to POP?
Backache and pelvic pain syndrome
Which type of prolapse is the least common?
Apical prolapse
What is the ideal position for the patient during the pelvic examination?
Dorsal lithotomy position
What is the approximate number of women undergoing surgery for pelvic organ prolapse in the USA each year?
300 000
What percentage of women in the UK report symptoms of pelvic organ prolapse?
5-8%
What is the lifetime risk of surgery for pelvic organ prolapse?
12-19%
What is the most common type of prolapse?
Cystocele
What is the most common cause of avulsion injury to the levator ani during childbirth?
Vaginal childbirth
What is the term for the prolapse of the vaginal vault after the removal of the uterus?
Vaginal vault prolapse
What is the most significant contributor to the development of prolapse?
Age
What is the term for the prolapse of the anterior vaginal compartment wall?
Cystocele
What is the term for the prolapse of the posterior vaginal compartment wall?
Rectocele
What is the effect of instrumental delivery on the risk of developing prolapse?
It has no effect on the risk of developing prolapse
What is the term for the prolapse of the uterus?
Procidentia
What is the condition that may contribute to the development of prolapse besides vaginal childbirth and age?
All of the above
What is the more common approach for performing sacrocolpopexy nowadays?
Laparoscopic sacrocolpopexy
What is the main advantage of abdominal supporting procedures over vaginal procedures?
Reduced recurrent vault prolapse
What is the primary concern when evaluating apical support in anterior compartment prolapse?
Supporting the vaginal apex
What is the main reason for reserving abdominal procedures for younger, fitter patients?
They are better suited for the longer operating time and greater expense
What is a common complication associated with uterosacral colpopexy?
Ureteric injury
What is the typical approach for sacrospinous fixation?
Unilateral extraperitoneal
What is the primary reason for performing a detailed examination under anaesthesia?
To decide whether to repair other anatomic sites
What is a common feature of anterior compartment prolapse?
It is often accompanied by descent of the vaginal apex
What is the primary goal of adding apical support procedures to anterior repair?
To improve success rates of anterior wall surgery
What is the typical success rate of posterior repair?
80-95%
What is the primary indication for obliterative surgical procedures?
Failed conservative therapy in women with significant comorbidities
What is the name of the most common obliterative procedure?
Colpocleisis
What is the role of mesh in posterior repair?
The use of mesh has been shown to have no advantages over native tissue repair
What is the primary advantage of performing anterior repair concurrently with apical support repair?
Improved success rates of anterior wall surgery
What is the typical outcome of anterior colporrhaphy in terms of bowel symptoms?
Improvement in bowel symptoms in the majority of women
What is the primary reason for performing lateral wall defect correction in anterior repair?
To correct anatomical defects in the lateral wall
Study Notes
Pelvic Organ Prolapse (POP)
- Defined as the downward displacement of pelvic organs from their original position into or beyond the vagina
- Affects a substantial number of women, with a lifetime risk of surgery of 12-19% and approximately 300,000 women undergoing surgery annually in the USA
- Symptoms can have a major impact on quality of life, but skillful assessment and management are required to ensure appropriate treatment and improved outcomes
Incidence and Epidemiology
- 8% of women in the UK report symptoms of prolapse
- 30-70% of women who present for routine gynecological care have loss of vaginal or uterine support
- Only 3-6% of these women have descent beyond the hymenal margin and are symptomatic
Types of Prolapse
- Anterior vaginal wall prolapse (cystocele): most common form
- Posterior vaginal wall prolapse (rectocele): less frequent
- Apical prolapse (descent of the uterus or vaginal vault): least common
Aetiology
- Poorly understood, but predisposing risk factors include:
- Vaginal childbirth
- Obesity
- Previous hysterectomy
- Age (incidence doubles with every decade of life)
Evaluation
- Comprehensive history taking, including urinary, bowel, and sexual history
- Patients presenting with primary bladder or bowel dysfunction may be referred for management of prolapse due to mistaken belief that their symptoms are the result of the prolapse
Treatment
- Surgery: laparoscopic sacrocolpopexy, robotically assisted sacrocolpopexy, or transvaginal apical support with sacrospinous fixation
- Abdominal supporting procedures reserved for younger, fitter, and more active patients
- Vaginal procedures reserved for older and frailer patients
Surgery for Anterior Compartment Prolapse
- Rarely occurs in isolation, often accompanied by descent of the vaginal apex or posterior wall
- Apical support must be carefully evaluated
- Anterior repair involves midline plication of the vaginal fascia, excision of redundant vaginal wall epithelium, and suture of the epithelium
- Success rates in the range of 40-60%
Surgery for Posterior Compartment Prolapse
- Associated with higher rates of anatomical success (80-95%)
- Operation involves midline plication of the rectovaginal fascia, excision of redundant epithelium, and reconstruction of the epithelium
- Improvement in bowel symptoms demonstrated in the majority of women after posterior colporrhaphy
Obliterative Surgical Procedures
- Reserved for women who have failed conservative therapy, have significant comorbidities, and are not candidates for extensive surgery
- Most common procedure: colpocleisis, which can be done in women who have had a hysterectomy and those who have not
This quiz covers the definition, impact, assessment, and management of pelvic organ prolapse (POP) in women, a benign condition affecting quality of life.
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