Genitourinary Prolapses

Occurs when there is descent of one or more of the pelvic organs including the uterus, bladder, rectum, small or large bowel, or vaginal vault

Aetiology

Risk factors

• Sex - women are more likely than men to have pelvic organ prolapse
• Pregnancy, childbirth, giving birth to a large baby and menopause are risk factors which are exclusive to women

• Increasing age

• Obesity - being overweight increases the pressure on the pelvic floor

• Smoking - a chronic cough can cause episodes of high pressure in the abdomen or aggravate prolapse that has other causes

• Being Hispanic, Indian or White

• Prior pelvic surgery

• Others: heavy lifting, constipation, COPD, hereditary causes (family history of weakness in connective tissue e.g. Marfan's, Ehrlers-Danlos)

Pathophysiology

• The pelvic organs are normally supported by the levator ani muscles and the endopelvic fascia

Types of genitourinary prolapse

• Urethrocele: prolapse of the urethra into the vagina, frequently associated with urinary stress incontinence

• Cystocele: prolapse of the bladder into the vagina

• Cystourethrocele: prolapse of both urethra and bladder

• Uterine prolapse: descent of the uterus into the vagina

• Vaginal vault prolapse: descent of the vaginal vault in post-hysterectomy
• Often associated with cystocele, rectocele and enterocele

• Rectocele: prolapse of the rectum into the vagina

Classification of genitourinary prolapse

• 1st degree - in vagina

• 2nd degree - at interiotus

• 3rd degree - outside vagina

• Procidentia - entirely outside vagina

Clinical presentation

• Mild uterine prolapse generally doesn't cause signs or symptoms

• Signs and symptoms of moderate to severe uterine prolapse include:
• Sensation of heaviness or pulling in the pelvis
• Tissue protruding from the vagina
• Urinary problems, such as incontinence or urine retention (particularly in cystocele or vaginal vault prolapse)
• Trouble having a bowel movement (particularly in a rectocele)
• Feeling as if patient is sitting on a small ball or as if something is falling out of their vagina
• Sexual concerns, such as a sensation of looseness in the tone of the vaginal tissue

• Often symptoms are less bothersome in the morning and worsen as the day goes on

Investigations

• Usually clinical diagnosis

Management

Conservative

• Reassurance

• Lifestyle modification - avoid heavy lifting, loose weight, stop smoking, reduce constipation

• Pelvic floor muscle exercises
• Minimum 3-4 month trial supervised PFME

Vaginal pessary insertion

• Silicone or plastic structures which are inserted into the vagina to reduce the prolapse, provide support and relieve pressure on the bladder and bowel

• Ring pessary is usually the first choice

• Effective for short-term relief of prolapse prior to surgery, or in the long term if surgery is not wanted or is contra-indicated

Surgery

• Vaginal hysterectomy

• Manchester repair (cervix amputated, uterosacral ligaments shortened)

• Sacrospinous fixation

• Others - abdominal/laproscopic sacrocolpopexy, mesh techniques, colpocleisis