Prolapse and Incontinence

1. Prolapse and Incontinence Craig Dyson Sioned Griffiths October 2013

2. Contents • Normal Anatomy • Causes of prolapse • Types of Prolapse • Investigation • Management

3. Anatomy

4. Anatomy

5. Anatomy

6. Prolapse • “To fall out” • Protrusion of an organ or structure beyond its normal confines and with an epithelial surface • Genitourinary prolapse – Descent of one or more of pelvic organs. • 41% of 50-79 year old’s but uncertain • Uterocoele, Cystocoele, Rectocoele, Enterocoele

7. Pathophysiology • Levator Ani/Endopelvic Fascia important • Damage to these structures can occur through: • Trauma • Neuropathic Injury • Disruption/Stretching • Multifactorial – Orientation of bones may be a factor.

8. Risk Factors • Increasing Age (Double risk with every decade) • Vaginal Delivery • Increasing parity • Obesity • Spina Bifida • Pregnancy Variables • Macrosomia • Prolonged 2nd stage • Episiotomy • Use of forceps/oxytocin • FH of prolapse • Constipation • Connective Tissue Disorder • Occupation

9. Types • Anterior • Urethrocoele • Urinary Stress Incontinence • Rare • Cystocoele • Increased frequency • UTI • Sensation of mass • No Symptoms • Both • Most Common

10. Types • Middle • Uterine Prolapse • Vaginal Vault Prolapse • Post Hysterectomy • Assoc with cystocoele, rectocoele and enterocoele. • Retention • Enterocoele • Pouch of Douglas • Cough Impulse

11. Types • Posterior • Rectocoele

12. POPQ System • Pelvic Organ Prolapse Quantification System • Valsalva - ? Left Lateral • Stage 0 • Stage 1 – 1cm above hymen • Stage 2 - Within 1 cm of hymen • Stage 3 - >1cm below plane of hymen but <2cm of total length of vagina • Stage 4 – Complete eversion of vagina

13. Symptoms • General • Fullness • Sensation of bulge • Backache • Urinary • Incontinence • Frequency • Coital • Dypareunia • Flatus • Bowel • Constipation/Incontinence • Need to apply digital pressure

14. Investigations • History and Examination • Urinalysis • Post-Voidal Urine volume testing • Urodynamics • US • Urea/Creatinine

15. Management • Conservative • Watchful Waiting • Lifestyle Modification • Pelvic Floor Exercises • Evidence? • Vaginal Oestrogen Creams • Pessary

16. Pessary • Inserted into vagina to reduce prolapse • Made of silicon or plastic or Soaked in wine… • Good short term option

17. Management • Surgical • Effective • Re-operation required in 29% of cases • Fitness of patient • Sexually Active • Surgeons Advice

18. Surgery • Anterior Colporrhaphy • Involves plication of anterior vaginal wall to reinforce. • Hysterectomy • Sacrospinous Fixation • Unilateral or bilateral fixation of uterus to sacrospinous ligament • Sacocolpoplexy • Mesh used to attach top of vagina to sacrum.

19. Summary • Prolapse is increasingly common with age. • Can be classified according to compartment or level of prolapse • Can be clear on examination • Good conservative and surgical options available • Good prognosis

20. References • Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Lamers BH, Broekman BM, Milani AL - Int Urogynecol J (2011) • Rev Urol. 2004; 6(Suppl 5): S2–S10. PMCID: PMC1472875. Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Sender Herschorn • Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092–1139. • Rectocele | Vaginal Surgery & Urogynecology Institute .vaginalsurgeryandurogynecologyinstitute.com • Int J Med Sci 2012; 9(10):894-900. doi:10.7150/ijms.4829. Three-dimensional Ultrasound Appearance of Pelvic Floor in Nulliparous Women and Pelvic Organ Prolapse Women. Tao Ying Corresponding address, Qin Li, Lian Xu, Feifei Liu, Bing Hu • http://www.patient.co.uk/health/Genitourinary-GU-Prolapse.htm • www.pelvicfloor.com/knowledge/imagelibrary/1/img/1.jpg • www.bristolsurgery.com/images/Preop%20Rectocele.jpg