KIMS COLLEGE OF NURSING

LESSON PLAN
ON
Pelvic organ prolapse (pop)

Prepared By
Mrs. Gopika Krishnan. G
Lecturer
KIMS COLLEGE OF NURSING

Name of the teacher: - Mrs. Gopika Krishnan. G date: -

Subject- Obstetrics and gynaecological nursing time: -
Unit: - VI (Mechanical disturbances and injuries to female genital tract) duration: -

Topic: -Pelvic organ prolapse (POP) venue: - IV Year B.Sc. classroom

Method of teaching: - Lecture cum discussion Group: - 4th year B.Sc. Nursing

Av aids: - Slides showing with the help of LCD, White board, OHP. Number of students: -

Previous knowledge: - Students may have knowledge from textbooks and medias.

Central objective: - At the end of the class students will be able to gain adequate knowledge regarding pelvic organ prolapse and apply this
knowledge in clinical setting with a positive attitude.
Specific objective: - Students will be able to,

 define pelvic organ prolapse (POP)

 enumerate the predisposing factors of POP
 enlist the clinical types of POP
 explain the classification of POP
 describe the degrees of POP
 explain the quantitative grading of POP
 enlist the symptoms of POP
 describe the diagnosis of POP
 explain the management of POP
 describe about the surgical management of POP
 Teacher’s /
time Specific Content Learner’s Av Aids Evaluation
objectives activity

Define POP PELVIC ORGAN PROLAPSE Teacher explains What is pelvic

the content and organ prolapse?
Definition students actively LCD
Pelvic organ prolapse occurs when a pelvic organ drops from listens
its normal position and pushes against the walls of the vagina.
Etiology
• Predisposing factors
• Aggravating factors
Predisposing factors:
What are the
Enumerate the • Acquired
predisposing
predisposing • Congenital
factors of pelvic
factors of POP Acquired Teacher explains
organ prolapse?
• Overstretching of the Mackenrodt’s and uterosacral ligament the content and LCD
due to students actively
• Premature bear down efforts prior to full dilatation of listens
the cervix
• Deliver with forceps/ventouse
• Prolonged second stage of labour
• Downward pressure on the uterine fundus
• Precipitate labour
• Overstretching and breaks in the endopelvic fascial sheath
• Overstretching of the perineum
• Imperfect repair of the perineal injuries
• Loss of levator function
• Neuromuscular damage of levator ani during child birth
• Subinvolution of the supporting structures
 Congenital
• Congenital weakness
Aggravating factors
• Post-menopausal atrophy
• Race
• Hereditary
• Intra-abdominal pressure (obesity, cough, constipation,
lifting etc)
• Iatrogenic
• Frequent heavy lifting
• Increased age
• Multiple vaginal birth
Enlist the Clinical type
clinical types Teacher explains
of POP the content and
students actively LCD What are the
listens clinical types of
pelvic organ
prolapse?
VAGINAL PROLAPSE What are the
• Anterior wall: varieties of
• Cystocele: the cystocele is formed by laxity and vaginal prolapse?
descent of the upper two-thirds of the anterior
vaginal wall
• Urethrocele: When there is laxity of the lower third
of the anterior vaginal wall, the urethra herniates
through it. This may independently or usually along
with cystocele and is called cysto-urethrocele
• Posterior wall:
• Relaxed perineum: torn perineal body produces
gaping introitus with bulge of the lower part of the
posterior vaginal wall.
• Rectocele: there is laxity of the middle-third of the
posterior vaginal wall and the adjacent rectovaginal
septum
• Vault Prolapse:
• Enterocele: laxity of the upper third of the posterior
vaginal wall results in herniation of the pouch of
Douglas. It may contain omentum /even loop of
small bowel and hence called enterocele
• Secondary vault prolapses: This may occur
following either vaginal or abdominal hysterectomy.
Undetected enterocele during initial operation or
inadequate primary repair usually results in
secondary vault prolapse.

UTERINE PROLAPSE
• Uterovaginal prolapse: is the prolapse of the uterus, cervix What are the
and upper vagina. varieties of
uterine prolapse?
 • Congenital prolapse: the cause is congenital weakness of the
supporting structures holding the uterus in position.
Explain the
classification
Classification of POP according to compartment:
of POP Teacher explains What are the
the content and LCD classification of
students actively POP?
Anterior Middle Posterior listens

Bladder Uterus Pouch of Douglas

Urethra Vaginal vault Rectum
Perineum
Describe the Degrees of uterine prolapse
degrees of What are the
POP • First degree: the uterus descends down from its normal degrees of uterine
anatomical position (external OS at the level of ischial spine) Teacher explains prolapse?
but the external OS still remains inside the vagina the content and LCD
students actively
• Second degree: the external OS protrudes outside the listens
vaginal introitus but the uterine body still remains inside the
vagina.

• Third degree: (Syn: Procidentia, complete prolapse): the

uterine body descends to lie outside the introitus.
Explain the Quantitative gradings of POP
quantitative Teacher explains LCD
the content and What are the
grading of
students actively stages of POP?
POP listens
 Morbid changes

• Vaginal mucosa: the mucosa becomes stretched and if

exposed to air becomes thickened and dry with surface
keratinisation. There may be pigmentation.
• Decubitus ulcer: it is a trophic ulcer found in the prolapsed
mass outside the introitus. There is initial surface
keratinisation – cracks – infection – sloughing – ulceration
• Cervix: there will be chronic congestion in the vaginal part.
The addition of infection leads to purulent or at times blood
stained discharges. And, the supra-vaginal part becomes
elongated
• Urinary symptoms:
• Bladder: incomplete emptying
• Ureters: hydroureters and pyelonephritis
• Incarceration: At times, the infection of the paravaginal
and cervical tissue makes the entire prolapsed mass
oedematous and congested.
• Peritonitis: peritoneal infection may occur through posterior
vaginal wall
• Carcinoma: rarely develops in decubitus ulcer

Symptoms Teacher explains What are the

Enlist the • Feeling of something coming down per vagina the content and LCD symptoms of
symptoms of • Backache or dragging pain in the pelvis students actively POP?
POP • Dyspareunia listens
• Urinary symptoms (in presence of cystocele)
• Difficulty in passing urine
• Incomplete evacuation may lead frequency of
micturition
• Urgency and frequency of micturition
 • Painful micturition is due to infection
• Stress incontinence
• Retention of urine may occur
• Bowel symptom (in presence of rectocele)
• Difficulty in passing stool. The patient has to push
back the posterior vaginal wall in position to
complete the evacuation of faeces.
• Excessive white or blood-stained discharge per vagina is due
to associated vaginitis or decubitus ulcer. What are the
Describe the Clinical examination & Diagnosis of POP Teacher explains LCD diagnosis of
diagnosis of • A composite examination: inspection and palpation of the content and POP?
vagina, rectum, rectovaginal/even under anaesthesia may be students actively
POP
required to arrive at a correct diagnosis listens
• Pelvic examination: done in dorsal and standing positions.
The patient is asked to strain as to perform a Valsalva
manoeuvre during examination
• Cystocele: on clinical examination, there will be bulge of
varying degree of anterior vaginal wall which increases
when the patient is asked to strain. If it is not seen on
inspection then in order to elicit this, one may have to
separate the labia/ depress the posterior vaginal wall with
fingers/using Sims speculum by placing the patient in lateral
position.
• Cysto-urethrocele: bulging in the anterior wall involves the
lower –third also. One may find the urine to escape out when
patient is asked to cough – stress incontinence. To elicit the
test, the bladder should be full.
• Rectocele and enterocele: identified by means of rectal or
recto- vaginal examination (when the 2 findings exist
together, there is bulging of the posterior vaginal wall with a
transverse sulcus between the two
• Uterine prolapse: by inspection and bimanual examination
 Teacher explains LCD
Explain the Management the content and
 Preventive students actively What are the
management
 Conservative listens preventive
of POP  Surgery measures of POP?

PREVENTIVE
 Adequate antenatal and intra-natal care
To avoid injury to the supporting structures during the time
of vaginal delivery either spontaneous or instrumental
 Adequate postnatal care
• To encourage early ambulance
• To encourage pelvic floor exercises by squeezing the pelvic
floor muscles in the puerperium
 General measures
• To avoid strenuous activities, chronic cough, constipation,
and heavy weight lifting What are the
• To avoid future pregnancy too soon and too many by curative measures
contraceptive practice of POP?
CURATIVE
• Improvement of general measures
• Oestrogen replacement therapy may improve minor degree
prolapsed in postmenopausal women
• Pelvic floor exercises in an attempt to strengthen the muscles What are the
(Kegel exercises) advantages of
PESSARY TREATMENT pessary
Advantages in selected cases such as; treatment?
• Early pregnancy: The pessary should be placed inside up to
18 weeks when the uterus becomes sufficiently enlarged to
sit on the brim of the pelvis
• Puerperium: To facilitate involution
 • Patients absolutely unfit for surgery specially with short life
expectancy
• Patients unwillingness for operation
• While waiting for operation Teacher explains LCD What are the
the content and surgical treatment
Describe about SURGICAL TREATMENT students actively for POP?
the surgical listens
management
of POP

CONCLUSION
POP is common particularly in parous women. It is the
descent of one or more of the genital organs below their normal
anatomical position.
RECAPITUALTION

 What is pelvic organ prolapse?

 What are the predisposing factors of pelvic organ prolapse
 What are the degrees of uterine prolapse?
 What are the symptoms of POP?
 What is the diagnosis of POP?
 What is the surgical treatment for POP?

REFERENCE
 Hiralal Konar, D.C Dutta’s textbook of gynecology, 7th edition, Jaypee publication, Newdelhi.

 Diane. M. Fraser, Margret. A. Cooper, Myle’s textbook for midwives, 15th edition, Elsvier publication.

 Annamma Jacob, Comprehensive text book of midwifery, Jaypee brothers, New Delhi.

 Saritha Shamsunder, Manual of Gynaecology,1st edition, CBS Publishers, Bangalore.