Overview

• Descent of pelvic organs into the vagina → a result of weakness of the ligaments and muscles (pelvic floor) surrounding the uterus, rectum and bladder. Affects around 40% of postmenopausal women.
  • Uterine Prolapse → uterus drops/sags into vagina.
  • Vault Prolapse → top of the vagina (the vault) descends into the vagina after hysterectomy.
  • Rectocele → defect in lower posterior vaginal wall, allowing rectum to prolapse forwards into the vagina.
    • Enterocele → defect in upper posterior vaginal wall, involving loops of bowel.
  • Cystocele → defect in the anterior vaginal wall, allowing bladder to prolapse backwards into the vagina.
• Risk Factors → multiple vaginal deliveries, instrumental/prolonged/traumatic delivery, advanced age/postmenopausal status, obesity, chronic respiratory disease causing chronic coughing, chronic constipation causing straining.

Making Diagnosis

Clinical Features

• Feeling of ‘something coming down’ in the vagina.
• A dragging or heavy sensation in the vagina.
• Urinary Symptoms → incontinence, urgency, frequency, weak stream, retention.
• Bowel Symptoms → consitpation, incontinence, urgency.
• Sexual Dysfunction → pain, altered sensation, reduced enjoyment.
• Prolapse may be worse on straining or bearing down.
• Pelvic organ prolapse quantification (POP-Q) grading

Investigations

• POP-Q Grading System (measures anatomical landmarks in relation to the hymen)
• Speculum (Sims’) → determine grade and severity.
• Urodynamic Tests → incontinence.
• MC&S → urine infections.