1. Definition
2. Etiology and risk factors
3. Pathogenesis - step-by-step
4. Clinical features
5. Diagnosis and diagnostic criteria
6. Investigations
7. Management - acute, definitive, medical, and surgical where relevant
8. Complications
9. Differentials
10. High-yield exam points and common traps
11. Mnemonics
12. Reference images or diagrams when they genuinely help

Gynaecology study map

1. Basics and symptoms
   • Menstrual physiology and normal cycle
   • Abnormal uterine bleeding (AUB)
   • Pelvic pain, vaginal discharge, amenorrhea
2. Menstrual and endocrine disorders
   • PCOS
   • Primary and secondary amenorrhea
   • Dysmenorrhea and PMS
   • Hyperprolactinemia, thyroid-related menstrual disturbance
   • Premature ovarian insufficiency
3. Benign uterine and ovarian disease
   • Fibroids
   • Adenomyosis
   • Endometriosis
   • Ovarian cysts and benign ovarian tumors
   • Ovarian torsion
4. Infections
   • Vaginitis and cervicitis
   • Pelvic inflammatory disease
   • Tuberculosis of the female genital tract
   • Sexually transmitted infections
5. Infertility and reproductive medicine
   • Female infertility work-up
   • Ovulatory disorders
   • Tubal, uterine, and endometriosis-related infertility
   • Assisted reproduction basics
6. Gynecologic oncology
   • Cervical intraepithelial neoplasia and cervical cancer
   • Endometrial hyperplasia and cancer
   • Ovarian cancer
   • Vulvar and vaginal cancer
   • Screening and HPV vaccination
7. Urogynecology
   • Pelvic organ prolapse
   • Urinary incontinence
   • Urogenital fistulae
8. Contraception and menopause
   • Combined hormonal contraception
   • Progestin-only contraception
   • IUDs and emergency contraception
   • Menopausal symptoms and hormone therapy
9. Gynecologic emergencies
   • Ectopic pregnancy is technically obstetric but commonly tested with gynecology
   • Acute pelvic pain
   • Hemorrhage and shock in gynecologic conditions
   • Torsion, ruptured cyst, tubo-ovarian abscess

Pelvic Organ Prolapse (POP)

1. Definition

2. Etiology and risk factors

Major risk factors

1. Pregnancy and vaginal childbirth
   • Strongest common risk factor.
   • Risk rises with increasing parity.
   • Instrumental vaginal delivery, prolonged second stage, fetal macrosomia, and obstetric levator ani injury increase risk.
2. Increasing age and menopause
   • Aging causes weakening of connective tissue and muscle.
   • Reduced estrogen after menopause contributes to urogenital atrophy, although estrogen deficiency alone does not fully explain POP.
3. Raised intra-abdominal pressure
   • Obesity
   • Chronic cough, for example COPD
   • Chronic constipation and straining
   • Repeated heavy lifting
4. Prior pelvic surgery
   • Especially hysterectomy, which may predispose to vaginal vault prolapse if apical support is not restored.
   • Previous prolapse surgery increases recurrence risk.
5. Connective-tissue and neuromuscular factors
   • Family history
   • Ehlers-Danlos syndrome and other collagen disorders
   • Abnormal collagen metabolism
   • Pelvic floor denervation
6. Other associations
   • White ethnicity in epidemiologic studies
   • Smoking, partly through chronic cough and altered tissue healing

3. Pathogenesis - step by step

Normal pelvic support

• Levator ani muscles, especially pubococcygeus and puborectalis
• Endopelvic fascia
• Uterosacral-cardinal ligament complex
• Perineal membrane and perineal body
• Intact pudendal nerve supply

Stepwise development of prolapse

1. Childbirth trauma or chronic pressure damages support tissues
   • Vaginal delivery can stretch or avulse the levator ani.
   • Fascia, ligaments, and pudendal nerves can be injured.
2. Pelvic floor muscle weakness develops
   • The levator ani normally forms a supportive muscular “shelf.”
   • If it weakens, the genital hiatus widens.
3. Fascial and ligamentous supports stretch or fail
   • The vagina and pelvic organs lose their normal suspensory support.
4. Repeated rises in intra-abdominal pressure push organs downward
   • Coughing, straining, obesity, constipation, and lifting worsen descent.
5. The affected vaginal compartment bulges
   • Anterior defect causes cystocele.
   • Apical defect causes uterine or vault prolapse.
   • Posterior defect causes rectocele or enterocele.
6. Advanced prolapse may distort lower urinary and bowel anatomy
   • This can cause voiding difficulty, incomplete emptying, urinary retention, obstructed defecation, or the need for vaginal/perineal “splinting.”

Delancey levels of vaginal support - very high yield

4. Types and terminology

Anterior compartment

• Cystocele: bladder bulges into anterior vaginal wall.
• Urethrocele: urethra descends with anterior vaginal wall.
• Usually associated with urinary symptoms, but symptoms and severity do not always correlate.

Apical compartment

• Uterine prolapse: uterus/cervix descends.
• Vaginal vault prolapse: vaginal apex descends after hysterectomy.
• Procidentia: complete uterovaginal prolapse, with the uterus protruding beyond the vaginal introitus.

Posterior compartment

• Rectocele: rectal wall bulges into posterior vaginal wall.
• Enterocele: peritoneal sac, often containing small bowel, protrudes between rectum and vagina, commonly after hysterectomy.
• Symptoms can include obstructed defecation and vaginal splinting.

5. Clinical features

Typical symptom

“A feeling or sight of a lump/bulge coming down from the vagina.”

Other symptoms

Vaginal or pelvic symptoms

• Vaginal pressure, heaviness, dragging discomfort
• Something “coming out” per vagina
• Symptoms worse after standing, lifting, straining, or later in the day
• Vaginal irritation, discharge, bleeding, ulceration in severe external prolapse

Urinary symptoms

• Stress urinary incontinence
• Urgency, frequency, urge incontinence
• Hesitancy, poor stream, straining to void
• Feeling of incomplete emptying
• Recurrent UTI
• Urinary retention in advanced prolapse

Bowel symptoms

• Constipation
• Incomplete evacuation
• Obstructed defecation
• Need to press on posterior vaginal wall or perineum to defecate: splinting
• Fecal urgency or incontinence in some patients

Sexual symptoms

• Dyspareunia
• Reduced sexual satisfaction
• Body-image concerns

Important point

6. Diagnosis

History

• Vaginal bulge or pressure
• Urinary incontinence, voiding symptoms, recurrent UTIs
• Constipation, splinting, fecal incontinence
• Sexual function and dyspareunia
• Obstetric history: parity, mode of delivery, instrumental birth, obstetric trauma
• Previous hysterectomy or prolapse/incontinence surgery
• Chronic cough, constipation, obesity, heavy lifting
• Impact on activities and quality of life
• Fertility wishes, future pregnancy plans, and sexual activity

Examination

1. Inspect external genitalia for atrophy, ulceration, discharge, or exposed prolapse.
2. Perform speculum examination.
3. Ask the patient to Valsalva/strain.
4. Assess each compartment separately:
   • Anterior
   • Apical
   • Posterior
5. Assess pelvic floor muscle contraction.
6. Perform bimanual examination to exclude pelvic mass.
7. Consider rectal examination when posterior compartment symptoms exist.
8. If prolapse is not apparent but symptoms are suggestive, repeat examination while the patient is standing or squatting.

7. POP-Q classification

Easy memory aid

8. Investigations

Usually required

• Urinalysis and urine culture if UTI symptoms are present.
• Post-void residual urine volume if there is poor stream, incomplete emptying, recurrent UTI, or advanced anterior/apical prolapse.
• Validated pelvic-floor symptom questionnaires can help quantify impact and follow response.

Selective investigations

9. Management

• Symptoms and their impact
• POP compartment and stage
• Age, comorbidities, and surgical fitness
• Desire for future sexual intercourse
• Desire for uterine preservation/future fertility
• Previous treatments
• Patient preference

A. Expectant and lifestyle management

• Reassure: POP is benign and not always progressive.
• Weight reduction if overweight.
• Treat chronic cough.
• Treat constipation and avoid chronic straining.
• Avoid heavy repetitive lifting where possible.
• Smoking cessation.
• Vaginal moisturizers or topical estrogen for postmenopausal atrophy.

B. Pelvic-floor muscle training (PFMT)

• First-line for symptomatic stage I or II POP.
• Should be supervised, ideally by a pelvic-floor physiotherapist.
• NICE recommends a supervised program for at least 16 weeks for symptomatic POP-Q stage I or II prolapse, then continued exercise if beneficial. See NICE recommendations.

C. Vaginal pessary

Indications

• Symptomatic POP in a woman wishing to avoid or delay surgery
• Poor surgical candidate
• Wants future pregnancy
• Awaiting surgery
• Temporary symptom relief
• Recurrent prolapse

Common types

• Ring pessary with or without support: common first option, relatively easy to insert/remove.
• Gellhorn pessary: useful for more advanced prolapse but often harder for the patient to manage.
• Cube and shelf pessaries are other options.

Advantages

• Non-surgical
• Often gives rapid bulge symptom relief
• Can be used with PFMT
• Can be removed if poorly tolerated

Complications

• Vaginal discharge
• Odor
• Bleeding
• Vaginal erosion/ulceration
• Infection
• Rarely fistula or incarceration if neglected

D. Surgical management

Surgical principles

1. Identify all compartment defects.
2. Restore apical support when needed.
3. Choose reconstructive versus obliterative surgery.
4. Discuss recurrence, dyspareunia, urinary symptoms, bowel symptoms, mesh-related risks, and possible future surgery.
5. If hysterectomy is performed for prolapse, the vaginal apex must be suspended to reduce post-hysterectomy vault prolapse risk.

Reconstructive surgery

Uterus-preserving surgery

• Sacrohysteropexy
• Vaginal sacrospinous hysteropexy
• Other hysteropexy procedures, depending on local expertise

Sacrocolpopexy

• Usually abdominal or laparoscopic.
• Mesh is attached to the vaginal apex and anchored to the sacrum.
• Often considered durable for apical/vault prolapse.
• Risks include mesh exposure/erosion, bowel injury, vascular injury, ileus, and rare sacral osteomyelitis.

Obliterative surgery

• Suitable for frail patients with severe prolapse who no longer desire penetrative vaginal intercourse.
• Effective and relatively lower operative burden.
• Irreversible loss of vaginal intercourse must be explicitly discussed.

Mesh: an exam-safe answer

10. Complications of POP

Complications of untreated advanced prolapse

• Vaginal/cervical ulceration and bleeding
• Infection and discharge
• Voiding difficulty and urinary retention
• Recurrent UTI
• Hydroureter/hydronephrosis and, rarely, renal impairment
• Obstructed defecation
• Sexual dysfunction and impaired quality of life

Complications of pessary treatment

• Discharge, odor
• Erosion and bleeding
• Infection
• Rare fistula or impaction with neglected pessary

Surgical complications

• Hemorrhage
• Bladder, ureteric, bowel, or vascular injury
• UTI, wound infection, venous thromboembolism
• Urinary retention
• De novo stress urinary incontinence
• Dyspareunia
• Recurrence or prolapse in another compartment
• Mesh exposure/erosion where mesh is used

11. Differential diagnosis of a vaginal mass/bulge

• Prolapsed submucosal fibroid
• Cervical polyp
• Vaginal wall cyst
• Urethral diverticulum
• Vaginal or cervical malignancy
• Bartholin cyst, usually posterolateral and at the introitus rather than a true vaginal-wall prolapse
• Rectal prolapse

12. High-yield exam points

1. Most specific symptom: a vaginal bulge or the feeling that “something is coming down.”
2. POP involves anterior, apical, and posterior compartments.
3. Most important risk factor: pregnancy and vaginal childbirth.
4. Posterior vaginal wall prolapse = rectocele.
5. Complete uterovaginal prolapse = procidentia.
6. Post-hysterectomy apical prolapse = vaginal vault prolapse.
7. POP-Q is the standard objective staging system.
8. Routine imaging is not required if physical examination clearly demonstrates POP.
9. Consider post-void residual in voiding difficulty or advanced prolapse.
10. First-line for symptomatic stage I-II: supervised PFMT for at least 16 weeks.
11. Pessary is a good non-surgical option and can be combined with PFMT.
12. Surgical planning should be multicompartmental. Correct apical support when it is deficient.
13. In a woman undergoing hysterectomy for prolapse, perform apical suspension to reduce later vault prolapse.
14. Colpocleisis is for women who do not want future penetrative vaginal intercourse.
15. Do not present transvaginal mesh as routine first-line treatment.

13. Mnemonics

Risk factors: “PUSH DOWN”

• P - Parity and pregnancy
• U - Uterine/pelvic surgery, especially hysterectomy
• S - Straining from constipation
• H - Heavy lifting
• D - Delivery trauma, especially instrumental delivery
• O - Obesity
• W - Weak connective tissue/levator ani
• N - New age: aging and menopause

Compartments: “A-A-P”

• Anterior: cystocele
• Apical: uterine or vault prolapse
• Posterior: rectocele/enterocele

POP-Q stages: “Above, At, Beyond, Out”

• Stage I: above hymen
• Stage II: at hymen
• Stage III: beyond hymen
• Stage IV: out, near-total/total eversion

14. Short exam answer template