Uterine Prolapse and Pelvic Relaxation

Introduction

Uterine prolapse and pelvic relaxation are significant women's health issues that Canadian medical students must understand for the MCCQE1 exam. This comprehensive guide covers key concepts, Canadian guidelines, and MCCQE1-specific information to help you prepare effectively.

Definitions and Classifications

Uterine Prolapse

Uterine prolapse is the descent of the uterus into or through the vagina due to weakening of the pelvic floor support structures.

Pelvic Organ Prolapse (POP) Classification

The Pelvic Organ Prolapse Quantification (POP-Q) system is used in Canada and internationally to classify the severity of prolapse:

Epidemiology in Canada

• Prevalence: Approximately 50% of parous women in Canada have some degree of prolapse
• Risk increases with age, with peak incidence in the 60-69 age group
• First Nations women in Canada have a higher risk due to higher parity rates

Risk Factors

1. Obstetric factors:

   • Vaginal delivery (especially multiple)
   • Prolonged second stage of labor
   • Forceps delivery
   • Large baby (>4kg)

2. Non-obstetric factors:

   • Age
   • Obesity (BMI >30)
   • Chronic cough (e.g., COPD)
   • Chronic constipation
   • Heavy lifting
   • Family history
   • Connective tissue disorders (e.g., Ehlers-Danlos syndrome)

Clinical Presentation

Common symptoms include:

• Sensation of pelvic pressure or fullness
• Seeing or feeling a bulge in the vagina
• Lower back pain
• Dyspareunia
• Urinary symptoms (e.g., incontinence, retention)
• Bowel symptoms (e.g., constipation, fecal incontinence)

Diagnosis

Management

Management depends on the severity of symptoms and the patient's preferences. Options include:

1. Conservative Management:

   • Pelvic floor muscle training (PFMT)
   • Lifestyle modifications (weight loss, smoking cessation)
   • Pessary use

2. Surgical Management:

   • Vaginal approaches (e.g., anterior colporrhaphy, posterior colporrhaphy)
   • Abdominal approaches (e.g., sacrocolpopexy)
   • Obliterative procedures (e.g., colpocleisis) for women who no longer desire sexual function

Canadian Guidelines

The Society of Obstetricians and Gynaecologists of Canada (SOGC) provides guidelines for the management of pelvic organ prolapse:

1. Conservative management should be first-line treatment for most women with symptomatic prolapse.
2. Pessaries are an effective treatment option and should be offered to all women with symptomatic prolapse.
3. Surgical management should be considered for women who have failed or declined conservative management.
4. The choice of surgical approach should be individualized based on the patient's anatomy, symptoms, and preferences.

Key Points to Remember for MCCQE1

• 🇨🇦 Understand the POP-Q classification system and its clinical application
• 🇨🇦 Know the risk factors specific to Canadian populations (e.g., higher risk in First Nations women)
• 🇨🇦 Familiarize yourself with SOGC guidelines for management
• 🇨🇦 Recognize the importance of quality of life assessment in treatment decisions
• 🇨🇦 Be aware of both conservative and surgical management options available in the Canadian healthcare system

Sample MCCQE1-Style Question

A 65-year-old G3P3 woman presents to her family physician with a 6-month history of pelvic pressure and the sensation of a vaginal bulge. She has no urinary or bowel symptoms. On examination, the anterior vaginal wall protrudes 1 cm beyond the hymen during Valsalva maneuver. Which of the following is the most appropriate initial management for this patient?

• A. Anterior colporrhaphy
• B. Sacrocolpopexy
• C. Pelvic floor muscle training
• D. Vaginal hysterectomy
• E. Colpocleisis

Explanation

The correct answer is:

• C. Pelvic floor muscle training

Explanation: This patient has stage 2 pelvic organ prolapse based on the POP-Q classification (protrusion ≤1 cm beyond the hymen). According to Canadian guidelines (SOGC), conservative management should be the first-line treatment for most women with symptomatic prolapse. Pelvic floor muscle training (PFMT) is a non-invasive, low-risk option that can improve symptoms and potentially prevent progression. Surgical options (A, B, D, E) should be considered only if conservative management fails or is declined by the patient. This question tests the MCCQE1 candidate's knowledge of appropriate initial management strategies for pelvic organ prolapse in the Canadian healthcare context.

References

1. Hagen S, Stark D. Conservative prevention and management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2011;(12):CD003882.

2. Society of Obstetricians and Gynaecologists of Canada. SOGC clinical practice guideline: Pelvic organ prolapse. J Obstet Gynaecol Can. 2019;41(11):1611-1625.

3. Bump RC, Mattiasson A, Bø K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol. 1996;175(1):10-17.

4. Wu JM, Vaughan CP, Goode PS, et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet Gynecol. 2014;123(1):141-148.

5. Rortveit G, Brown JS, Thom DH, et al. Symptomatic pelvic organ prolapse: prevalence and risk factors in a population-based, racially diverse cohort. Obstet Gynecol. 2007;109(6):1396-1403.