SOAP. – Pelvic Organ Prolapse – SỔ TAY LÂM SÀNG

Pelvic Organ Prolapse

Amy Hull

Definition

A.Many terms have been used to describe pelvic organ prolapse (POP), the protrusion or downward movement of the pelvic organs through the vaginal introitus. Frequently used descriptors include cystocele, urethrocele, rectocele, enterocele, vaginal prolapse, and uterine prolapse. Each term describes a specific organ that has been displaced and, while frequently used by clinicians, these descriptors do not accurately and completely describe the extent of what is actually occurring. Thus, it is recommended that when describing what is seen on exam, one may define prolapse by using anatomical definitions, such as anterior vaginal wall prolapse, apical prolapse, posterior vaginal wall prolapse, vault eversion, cervical prolapse, or rectal prolapse (see Table 17.8).

B.POP is also defined by stages of descent:

1.Stage 0: No evidence of descent.

TABLE 17.7 CDC Recommendations for Treating Pelvic Inflammatory Disease (PID)

Inpatient Therapy	Ambulatory Therapy
Regimen Aa	Regimen A
Cefotetan 2 g IV every 12 hours or cefoxitin 2 g plus doxycycline 100 mg IV or orally every 12 hours	Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg orally twice a day for 14 days
	With or Without
This regimen is continued for at least 48 hours after clinical improvement and followed by doxycycline 100 mg orally twice daily to complete 14-day total course.	Metronidazole 500 mg orally twice daily for 14 days
Regimen Ba	Or
Clindamycin 900 mg IV every 8 hours (15–40 mg/kg/d) PLUS gentamicin, loading dose 2.0 mg/kg IV, followed by maintenance 1.5 mg/kg IV every 8 hours. Single daily dosing at 3–5 mg/kg may be substituted.	Cefoxitin 2 g IM in a single dose and probenecid, 1 g orally administered concurrently in a single dose plus doxycycline 100 mg orally twice a day for 14 days with or without metronidazole 500 mg orally twice a day for 14 days
Plus	Or
This regimen is continued for at least 24 hours after significant clinical improvement is demonstrated, and it is followed by doxycycline 100 mg orally twice daily to complete a 14-day total course. Alternatively, clindamycin 450 mg orally four times daily may be given to complete a 14-day total course.	Other parenteral third-generation cephalosporin (e.g., ceftizoxime or cefotaxime) plus doxycycline 100 mg orally twice a day for 14 days
	With or Without
	Metronidazole 500 mg orally twice a day for 14 days

a When tubo-C is present, many clinicians use clindamycin because it provides more effective anaerobic coverage than doxycycline.

Note: For women or their partners who cannot tolerate doxycycline or tetracycline, erythromycin 500 mg orally four times daily may be used for 10 to 14 days.

2.Stage 1: Very minimal and usually asymptomatic descent.

3.Stage 2: Protruding to the vaginal hymen and slightly beyond.

4.Stage 3: Protruding well beyond the hymen.

5.Stage 4: Complete or almost complete descensus.

Incidence

A.POP is a common problem affecting women of all ages, races, and ethnicities.

B.Most authorities describe the incidence as somewhere between 10% and 30% of the female population, with increased incidence observed with advancing age. The Women’s Health Initiative (WHI) found a 41% incidence of POP among women aged 50 to 79, with the most commonly observed compartment being the anterior wall. Interestingly, researchers from the Pelvic Organ Support Study (POSST) saw that on routine gynecologic exams of asymptomatic women, 35% experienced stage 2 POP and 2% had descent that measured to stage 3.

C.It is believed that as the U.S. population continues to age and to expand, the incidence and prevalence of prolapse will continue to grow.

Pathogenesis

A.Though not fully understood, some logical pathologic factors may create the occurrence of POP.

B.Some evidence suggests that weakness of the pelvic floor muscles (PFMs) creates a more vertical angle for the vagina, thus no longer supporting the vagina and the pelvic organs in a slightly horizontal fashion:

1.This loss of a backboard increases the chance for the pelvic organs to be affected by gravity and descend downward through the canal.

2.Weakness of the muscles may also create an inability of the vaginal introitus to contract or close during periods of increased intra-abdominal pressure, such as during a cough.

3.Over time this can also allow the pelvic organs to descend through the widened opening.

C.Much research is ongoing into the role of connective tissue injuries that may occur to increase the risk of POP:

1.Direct injury to the muscles and connective tissue of the pelvic floor, such as during childbirth, may combine to encourage a herniation of the pelvic organs through the tear or tears in the fascia.

2.A more novel and very interesting theory involves the observation of possible familial or hereditary causes for prolapse.

3.Studies have indicated both structural and biochemical changes observed in the collagen of microscopically analyzed prolapsed tissue.

4.Other research has shown a weakening of collagen with increasing age. Over time the collagen becomes weaker, and faster degradation is observed, thus increasing the prevalence of POP. This raises the question regarding whether this is a normal process of aging versus an actual hereditary cause for the hastening of the collagen deprivation and resulting prolapse.

5.Research into all these theories of pathology continues to expand as we try to understand the root causes for prolapse and possible means for prevention.

Predisposing Factors

Many external and some potentially preventable risk factors can combine to create the risk for POP. Yet, it is not fully understood which of these factors creates the greatest risk:

TABLE 17.8 Anatomical Description of Pelvic Organ Prolapse (POP)

Previous Descriptors for POP	Current Anatomical Definitions
	Normal pelvic floor support with bladder located anteriorly. Uterus is located superior to the bladder.

Source: Goldwasser, S. (n.d.). Pelvic organ/vaginal prolapse. Retrieved from https://bladderdoc.com/condition/pelvic_organ. Used with permission from Steven Goldwasser, MD, Urogynecology Clinic, Jacksonville, FL.

A.Pregnancy and vaginal childbirth: Evidence supports the lack of consensus regarding pregnancy versus delivery as the predisposing risk factor. Other obstetric factors considered include the following:

1.Macrosomia.

2.Length of second stage of labor.

3.Midline episiotomy.

4.Forceps-assisted vaginal delivery.

5.Anal sphincter laceration.

6.Oxytocin use for labor initiation.

7.Epidural analgesia.

8.Higher gravidity.

B.Age and menopausal status:

1.The risk of POP doubles with each decade of life.

2.It is unclear how the loss of estrogen and the effects of age can be differentiated.

3.Questions remain regarding age, menopause, and collagen loss with aging.

C.Race:

1.African American and Asian women have the lowest risk for POP.

2.Hispanic women appear to have the highest risk, with White women directly following.

D.Hysterectomy:

1.Route of hysterectomy does not appear to influence risk, although some evidence exists regarding the benefit of keeping the cervix for prevention of POP after hysterectomy.

2.POP after a hysterectomy performed for the indication of prolapse appears to be a greater risk than hysterectomy for other causes.

E.Connective tissue disease:

1.Ehlers–Danlos syndrome.

2.Marfan syndrome.

F.Increases in intraabdominal pressure:

1.Obesity.

2.Chronic constipation.

3.Chronic lifting.

4.Chronic coughing.

5.Chronic obstructive pulmonary disease (COPD).

6.Cigarette smoking.

Common Complaints

Patients may experience a plethora of symptoms that may or may not be connected to the POP. Furthermore, research has shown a direct correlation between increased stage of prolapse and symptom occurrence. Many of the complaints are more noticeable to the patient as the prolapse advances beyond the hymen. It is also important to note that while many of these complaints may be identified by the patient as being caused by the POP, they may not be directly related to the problem at all. This is noted in the inconsistencies of prolapse symptoms in the literature.

A.Feeling of a bulge or ball in the vagina.

B.Vaginal or pelvic pressure.

C.Rubbing of bulge against undergarments and/or vaginal bleeding.

D.Concurrent urinary incontinence (UI).

E.Urinary urgency or frequency.

F.Urinary hesitancy.

G.Constipation and/or anal incontinence (AI).

H.Incomplete rectal evacuation/stool trapping.

I.Low back pain.

J.Sexual dysfunction/dyspareunia.

K.Pelvic pain.

When determining the severity of symptoms, the clinician may find it helpful to use validated prolapse symptom questionnaires, including the Pelvic Floor Distress Inventory (PFDI), Urinary Distress Inventory 6 (UDI-6), Colorectal-Anal Distress Inventory 8 (CRADI-8), the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6), and the Pelvic Floor Impact Questionnaire (PFIQ; see Table 17.9).

Potential Complications

Most prolapse complications center around the impact on the woman’s quality of life. However, some researchers and clinicians believe some direct, serious complications may occur as a result of increasing stages of POP, including the following:

A.Urinary retention, with resulting increased risk for hydronephrosis and hydroureter.

B.Vaginal ulcers/sores/infection and vaginal bleeding.

C.Recurrent urinary tract infection (UTI).

Subjective Data

A.Ask the patient if she feels a bulge or a feeling of pressure in the vagina.

B.Does the patient feel as if she is sitting on something, much like a ball?

C.Ask the patient if she feels something rubbing against her undergarments.

D.Have the patient describe whether symptoms worsen when standing.

E.Ask patient to describe if she needs to manually assist herself to empty her bowel or bladder. Does she need to maneuver on the toilet?

F.Determine if the patient has had any prior treatments for the prolapse, surgical or conservative.

G.Ask about progression of the bulge; has it become more pronounced over time?

H.Is it difficult to have sex, as if something is blocking the opening of the vagina?

I.Review her full obstetric history specifically for factors as noted earlier.

J.Review her medical history with specific queries about COPD and smoking.

K.Review all medications, including over-the-counter (OTC) and herbal products. Evaluate problems such as chronic cough secondary to angiotensin-converting enzyme (ACE) inhibitors.

Physical Examination

As patients with POP may have other conditions caused by pelvic floor dysfunction, it is important for the clinician to perform a thorough examination to evaluate the full spectrum of problems and the resulting impact on function and quality of life:

A.General inspection of external genitalia performed with patient in lithotomy position:

1.Evaluate the perineal area for skin rash, such as with changes consistent with atrophy, as well as bowel or bladder incontinence.

2.Evaluate for other skin changes indicative of vulvar dermatoses or yeast infections.

3.Evaluate for allodynia—a positive pain response to light touch.

4.Evaluate the urethra for discharge, masses, or atrophy.

5.Perform a cough stress test (CST) to evaluate for stress urinary incontinence (SUI):

a.This test is positive if leakage is noted during the cough.

b.A positive result may indicate a significant weakness of the urethral sphincter or a poorly supported urethra.

c.While performing the test, look to see if the urethra is hypermobile as this may indicate SUI, even if the CST is negative for leakage.

B.Neurologic exam of sacral reflexes:

1.Evaluate S2 to S4 dermatomes:

a.Evaluate for symmetry of sensation.

b.Evaluate soft sensation with cotton-tipped end of Q-tip.

c.Evaluate sharp sensation with wooden end of Q-tip.

2.Bulbocavernosus reflex:

a.Elicit the reflex response by using a cotton swab; gently stroke the bilateral labia majora looking for a positive reflex response by observing subtle contraction or movement of the labial tissue (see Figure 17.1).

b.No movement of the tissue is a negative response, which may indicate nerve damage to the pelvic floor.

c.Up to 20% of normal patients may have a negative response.

d.Neurologic testing for the bulbocavernosus reflex is also useful in evaluating a cauda equina lesion.

3.Anal reflex, wink:

a.Using the cotton-tipped end of Q-tip, strike bilateral sides of the anal meatus, observing for contraction (see Figure 17.1).

b.Up to 25% of normal patients may have absent response.

C.Pelvic organ prolapse quantification (POPq) exam:

1.System of measurement of prolapse defined by the International Continence Society (ICS).

2.The prolapse is measured in specific segments or sections, with all measured points in relation to the hymen.

3.Exam is performed with the patient in either lithotomy or standing positions.

4.A split speculum and measuring stick are used to visualize and measure the extent of the prolapse (see Figure 17.2).

5.All points of measurement are performed during Valsalva with exception of one: Total vaginal length (TVL), which is a resting measurement.

6.Measured points are plotted on a Tic-Tac-Toe grid (see Figure 17.3).

a.Point Aa: Anterior wall; this point can be 3 cm from the hymen to its fullest extent, +3 cm beyond the hymen.

b.Point Ba: This is the more proximal or deeper portion of measurement of the anterior wall located from the vaginal cuff/cervix or anterior vaginal fornix to point Aa. In the absence of prolapse, the value would be −3 cm from point Aa and with prolapse it can fall anywhere from −2 cm from the hymen to a positive value that can be equal to the cuff’s length. For example, point Ba can be −3 to +10, depending on the length of the anterior wall to the cuff.

c.Point C: This point represents the most distal edge of the cervix or vaginal cuff if no uterus is present.

d.Point D: This measurement is not included in the POPq measurement if the patient has had a hysterectomy; this point differentiates a well-supported uterus from true uterine prolapse, and measurement is taken from the posterior fornix in the patient with a cervix. This point represents the level of the uterosacral ligament. Point D can be −10 to as much as +10.

e.Point Ap: This point is a measurement of the posterior wall, and, like the anterior wall, this point can be from the hymen to +3 cm beyond the hymen.

FIGURE 17.1Pelvic floor neurologic testing—bulbocavernosus and anal wink reflexes.

FIGURE 17.2Split speculum and measuring stick.

FIGURE 17.3Tic-Tac-Toe grid for plotting prolapse.

f.Point Bp: This is the more proximal or deeper portion of measurement of the posterior wall located from the vaginal cuff or posterior fornix to point Ap. In the absence of prolapse, the value would be −3 cm from point Ap and with prolapse it can fall anywhere from −2 cm from the hymen to a positive value that can be equal to the cuff’s length. For example, point Bp can be −3 to +10, depending on the length of the posterior wall to the cuff/fornix.

FIGURE 17.4 Complete prolapse.

Source: Used with permission of Barry Jernigan, MD, Center for Pelvic Health. http://www.centerforpelvichealth.org.

D.Stages of prolapse:

1.Stage 0: No prolapse.

2.Stage 1: Leading edge of POP comes to within 2 cm of hymen.

3.Stage 2: Leading edge of POP moves from −1 cm above to +1 cm beyond hymen.

4.Stage 3: Leading edge of POP is +2 cm beyond the hymen but is still 2 cm less than the TVL.

5.Stage 4: Complete prolapse (see Figure 17.4)

Diagnostic Tests

A.Obtain a clean catch urinalysis to screen the urine for clarity, hematuria, and infection:

1.Send the urine for culture and sensitivity to evaluate for the presence of infection.

2.Urine for cytology is recommended for evaluation of hematuria.

B.Immediately after void, obtain a post-void residual (PVR) by inserting a catheter into the bladder or use a bladder scanner.

C.Blood urea nitrogen (BUN), creatinine, for evaluation of kidney function.

D.Pelvic ultrasound for evaluation of uterus and ovaries if there is vaginal bleeding. Consider an endometrial biopsy if ultrasound shows an abnormal endometrium.

E.Pap smear.

F.Urodynamic testing for evaluation of bladder function and UI.

G.Cystoscopy for evaluation of bladder structure and hematuria. CT scan to evaluate for hydronephrosis and hydroureter (important to assess if patient is experiencing increased PVRs).

Differential Diagnosis

A.Prolapsed uterine fibroid.

B.Anterior or posterior vaginal wall cyst.

C.Ureterocele.

D.Rectal prolapse.

Plan

A.Patient teaching:

1.Educate patient about proper body mechanics and avoidance of repetitive, chronic strain.

2.Smoking cessation.

3.Discuss perineal hygiene to avoid irritation to the vulva and prolapsing vagina.

B.Treatment options:

1.Observation.

2.Pelvic floor muscle exercises (PFME):

a.Little research exists to indicate that Kegel exercises can reduce prolapse stage.

b.Primary goals for pelvic floor physical therapy (PFPT) serve to improve symptoms of prolapse, enhance proper body mechanics, and serve as a potential prevention for increasing prolapse stage.

3.Pessary (see Figures 17.5 to 17.8):

a.Offered as an option for management of the prolapse; not curative.

b.Pessary is used for the patient who desires nonsurgical treatment or is unable to achieve surgical clearance.

c.Can be for temporary or long-term use.

d.Patient must undergo a pessary-fitting session. See Section II: Procedure for Pessary Insertion and Management.

e.Follow-up schedule is dependent on patient’s willingness to manage the pessary.

f.Clinician must be aware of potential complications with pessary use:

i.Pain may occur if pessary is too large.

ii.Pessary may fall out if it is too small.

iii.Vaginal bleeding.

iv.Erosion or ulcer.

g.Reasons patients discontinued use of pessaries:

i.Unsuccessful, especially in patients with posterior prolapse.

ii.Difficulty removing.

iii.Inability to void.

iv.Patient desires surgery.

4.Surgery: Surgical correction techniques will not be discussed in this chapter and require the evaluation of a subspecialist physician.

Individual Considerations

A.Pregnancy and reproductive-age women:

1.Pregnancy is not a contraindication for pessary use.

2.Practice of PFME is acceptable during pregnancy.

3.In the absence of large prolapse, no treatment is necessary during pregnancy if the patient and baby are stable.

FIGURE 17.5Ring with support pessary.

Source: Used with permission from CooperSurgical. coopersurgical.com.

FIGURE 17.6Gellhorn pessary.

Source: Used with permission from CooperSurgical. coopersurgical.com.

FIGURE 17.7Donut pessary.

Source: Used with permission from CooperSurgical. coopersurgical.com.

FIGURE 17.8Cube pessary.

Source: Used with permission from Cooper Surgical. (2018). Milex cube pessary. Retrieved from https://www.coopersurgical.com/Medical-Devices/Detail/milex-cube-pessary

4.If the patient has not completed childbearing, surgical correction is not recommended. Offer a pessary or PFME to this patient until she is past this stage.

B.Geriatrics:

1.Physical examination in the elderly:

a.The pelvic examination may be more difficult related to the lack of hip mobility, arthritis, or spinal deformities.

b.The examination may need to be performed on the patient turned to her left side.

c.Allow extra time to explain each step of the examination and for positioning. An assistant can help the patient onto the exam table and may help gently support the patient’s legs if necessary.

2.Must consider the geriatric patient’s ability to manage her pessary:

a.Frailty and decreased mobility may prevent the patient’s personal management of a pessary.

b.Dementia may inhibit the geriatric patient’s ability to perform a regimen of PFME.

c.Close family involvement is important to ensure proper management and follow-up for the geriatric patient with dementia.

d.If surgical correction is desired in this patient, preoperative clearance must be obtained. In cases of dementia, family members must provide consent.

Pelvic Organ Prolapse

Definition

TABLE 17.7 CDC Recommendations for Treating Pelvic Inflammatory Disease (PID)

Incidence

Pathogenesis

Predisposing Factors

TABLE 17.8 Anatomical Description of Pelvic Organ Prolapse (POP)

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