Uterine Prolapse and Pelvic Relaxation

Introduction to Pelvic Organ Prolapse (POP)

Pelvic Organ Prolapse (POP) is a highly prevalent condition in the Canadian population, particularly among aging women. It involves the descent of one or more aspects of the vagina and uterus: the anterior vaginal wall, the posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy).

For MCCQE1 preparation, it is crucial to understand that while POP is rarely life-threatening, it significantly impacts the Quality of Life (QoL). The management approach in the Canadian context emphasizes a stepwise progression from conservative measures to surgical intervention, adhering to CanMEDS roles of Health Advocate and Communicator.

MCCQE1 Objectives

Candidates should be able to:

1. Identify risk factors (e.g., parity, obesity, connective tissue disorders).
2. Diagnose the type and degree of prolapse through history and physical exam.
3. Manage the condition using a patient-centered approach (expectant, conservative, surgical).
4. Counsel patients on lifestyle modifications (Health Promotion).

Anatomy and Classification

Understanding the specific anatomical defect is essential for diagnosis and surgical planning.

POP-Q Classification (Simplified)

While the Pelvic Organ Prolapse Quantification (POP-Q) system is the standard for research and specialists in Canada, the MCCQE1 expects a general understanding of staging based on the hymen as a landmark.

Etiology and Risk Factors

The etiology is multifactorial. In Canada, with rising rates of obesity and an aging demographic, the prevalence is increasing.

Clinical Presentation

History

• Bulge symptoms: “Sitting on a ball,” vaginal fullness, heaviness.
• Urinary: Stress incontinence, urgency, incomplete emptying, manual reduction needed to void.
• Bowel: Constipation, need for digital splinting (pressing on the vagina/perineum) to defecate.
• Sexual: Dyspareunia, decreased sensation.

Physical Examination

A thorough pelvic examination is required.

Management Strategies

Management is driven by symptoms and the impact on Quality of Life. Asymptomatic prolapse generally does not require treatment (Expectant Management).

1. Conservative Management (First-Line)

In line with SOGC Guidelines, conservative options should be offered to all patients.

• Lifestyle Modifications: Weight loss, smoking cessation (reduces coughing), treating constipation.
• Pelvic Floor Muscle Training (PFMT): Kegel exercises, often with a specialized pelvic floor physiotherapist. Effective for Stage I-II and preventing progression.
• Pessaries:
  • Intravaginal devices (silicone) that support pelvic organs.
  • Indications: Patients wishing to avoid surgery, poor surgical candidates, or those needing temporary relief before surgery.
  • Maintenance: Must be removed and cleaned regularly to prevent erosion or infection. Estrogen cream is often co-prescribed.

2. Surgical Management

Indicated when conservative management fails or is declined by the patient.

• Reconstructive Surgery:
  • Anterior/Posterior Colporrhaphy: Repair of cystocele/rectocele.
  • Sacrocolpopexy: Suspension of the vaginal vault to the sacrum (Gold standard for apical prolapse).
  • Sacrospinous Ligament Fixation: Vaginal approach to suspend the vault.
• Obliterative Surgery:
  • Colpocleisis: Closure of the vagina.
  • Indication: Elderly patients with significant comorbidities who are no longer sexually active. Less invasive, high success rate.

Canadian Guidelines (SOGC)

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides the framework for care:

1. Assessment: Mandatory to screen for occult stress incontinence. When the prolapse is reduced (e.g., with a pessary or swab), does the patient leak? If yes, they may need an anti-incontinence procedure (e.g., mid-urethral sling) concomitant with prolapse repair.
2. Topical Estrogen: Strongly recommended for post-menopausal women with POP to improve tissue quality before and after pessary use or surgery.
3. Referral: Refer to a Urogynecologist for Stage III/IV or recurrent prolapse.

// Common Abbreviations in Canadian Gynecology
SOGC  : Society of Obstetricians and Gynaecologists of Canada
POP-Q : Pelvic Organ Prolapse Quantification
SUI   : Stress Urinary Incontinence
PFMT  : Pelvic Floor Muscle Training
TVT   : Tension-free Vaginal Tape

Key Points to Remember for MCCQE1

• Asymptomatic Prolapse: Observation is the correct answer. Do not treat “numbers” or “stages,” treat the patient.
• First-line Treatment: Conservative (Pessary/PFMT) is almost always the correct initial step before surgery.
• Pessary Care: Neglected pessaries can cause fistulas. Regular follow-up is mandatory.
• Occult Incontinence: Reducing a prolapse can unmask stress incontinence (kinking of the urethra is relieved).
• Emergency: Procidentia (Stage IV) can lead to ureteral obstruction and hydronephrosis. While rare, keep this complication in mind.

Study Checklist

• Review pelvic anatomy (DeLancey levels).
• Memorize the “4 Ps” risk factors.
• Understand the difference between Cystocele, Rectocele, and Enterocele.
• Review contraindications for pessary use (e.g., active infection, latex allergy - though most are silicone).
• Read the SOGC guideline summary on Conservative Management of POP.

Sample Question

Clinical Scenario

A 68-year-old female presents to her family physician with a complaint of a “bulge” coming out of her vagina. She reports a sensation of pelvic pressure that worsens by the end of the day. She denies urinary leakage but notes she sometimes has to push the bulge up with her fingers to initiate urination. She has a history of 3 vaginal deliveries. Her BMI is 32. On examination, with Valsalva, the cervix descends 2 cm past the hymen. The vaginal mucosa appears thin and pale. She is sexually active and wishes to avoid major surgery if possible.

Question

Which one of the following is the most appropriate initial management for this patient?

• A. Abdominal sacrocolpopexy
• B. Ring pessary with topical estrogen
• C. Colpocleisis
• D. Reassurance and observation only
• E. Oral systemic hormone replacement therapy

Explanation

The correct answer is:

• B. Ring pessary with topical estrogen

Detailed Analysis

• Diagnosis: The patient has symptomatic uterine prolapse (likely Stage III given descent >1cm past hymen) with voiding dysfunction (splinting) and vaginal atrophy.
• Reasoning:
  • Option B (Correct): This patient is symptomatic, so Option D (Observation) is incorrect. She wishes to avoid surgery, making conservative management the first line. A pessary is highly effective for symptomatic relief. Topical estrogen is indicated to treat the vaginal atrophy (thin, pale mucosa), which improves comfort and reduces the risk of pessary-induced erosion.
  • Option A (Incorrect): While sacrocolpopexy is a gold-standard surgical repair, the patient explicitly requested to avoid surgery as an initial step.
  • Option C (Incorrect): Colpocleisis is an obliterative procedure that closes the vaginal canal. It is contraindicated in patients who are sexually active, as this patient is.
  • Option E (Incorrect): Systemic HRT is not the first-line treatment for local vaginal atrophy or structural prolapse. Local (topical) estrogen is safer and more effective for vaginal tissue quality.

References

1. Society of Obstetricians and Gynaecologists of Canada (SOGC). (2021). Clinical Practice Guideline: Conservative Management of Pelvic Organ Prolapse in Women.
2. Berek, J. S., & Berek, D. L. (2020). Berek & Novak’s Gynecology (16th ed.). Wolters Kluwer.
3. Medical Council of Canada. (2023). MCCQE Part I Clinical Decision-Making and Multiple-Choice Questions Objectives.
4. Health Canada. (2019). Surgical Mesh - Complications associated with transvaginal implantation for the treatment of Stress Urinary Incontinence (SUI) and Pelvic Organ Prolapse (POP).