12. Pelvic prolapse Flashcards
Name types of female GU prolapse (5)
- Cystocele
- Uterine prolapse
- Vaginal vault prolapse
- Rectocele
- Enterocele
Describe: Cystocele (1)
Herniation of the bladder with associated descent of the anterior vaginal segment
Describe: Uterine prolapse (1)
Descent of the uterus and cervix
Describe: Vaginal vault prolapse (1)
Descent of the vaginal apex (posthysterectomy)
Describe: Rectocele (1)
Herniation of the rectum with associated descent of the posterior vaginal segment
Describe: Enterocele (1)
Herniation of the small bowel with associated descent of the posterior vaginal segment
Pelvic organs are supported by what? (3)
- the pelvic floor musculature
- fascial supports
- nervous system.
The muscular pelvic floor is composed of what? (2)
- of the levator ani (combination of puborectalis, pubococcygeus, and iliococcygeus)
- the coccygeus muscles attached to elements of the bony pelvis, coccyx, and sacrum.
The majority of women with clinically significant prolapse will have at least two RFs. Name them (7)
- Damage to support
- Obstetric causes: pregnancy (multiparity), delivery (vacuum/forceps), fetal macrosomia, perineal laceration (third- and fourth-degree tears)
- Surgical causes: hysterectomy
- Estrogen deficiency
- Chronically ↑ abdo pressure: obesity, smoking, pulmonary disease (chronic cough), constipation (chronic strain), recreational/occupational activities (weight lifting), ascites
- Pelvic masses
- Neuromuscular/connective tissue disorders
- Genetics
Name stages of prolapse (5)
- Stage 0: no prolapse
- Stage I: most distal prolapse is 1 cm above the hymen.
- Stage II: most distal prolapse between 1 cm above or below the hymen
- Stage III: most distal prolapse > 1 cm distal to the hymen
- Stage IV: total prolapse (“procidentia”)
Describe link between parity and prolapse (1)
Although ↑ parity is a RF for prolapse, nulliparity does not provide absolute protection against prolapse.
Describe: Occult/latent incontinence (2)
- Many women with anterior vaginal prolapse are continent either due to a competent urethral sphincter (despite lack of support) or an incompetent sphincter kinked by the prolapse, which when repaired results in new onset of stress incontinence known as occult/ latent stress incontinence.
- Stress incontinence is not a Sx of prolapse, rather a coincident Sx.
Describe Post Void Residual Volume cut-off normal values (3)
- There is no consensus on PVR cut-off normal values.
- If the initial voided volume is > 1 5 0 mL, a PVR of < 100 mL is indicative of appropriate bladder emptying.
- A PVR of > 100 mL indicates impaired bladder emptying, which may or may not be due to prolapse.
Describe: Pelvic Organ Prolapse Quantification System (POP–Q) (3)
- Standard system approved by the International Continence Society is the POP-Q.
- Measures nine locations on the vagina and vulva in centimeters relative to hymen
- More detailed than necessary for clinical care, but used routinely in studies
Describe HX: Evaluation of pelvic prolapse (12)
- Pelvic pressure/heaviness
- Protrusion of tissue from vagina
- Inability to wear tampons
- Incontinence, including urge or stress
- Defecatory dysfunction
- Excessive straining
- Difficult or incomplete emptying of bladder or bowel
- Digitation to aid in urination or defecation (“splinting”)
- ↓ Sexual activity (due to fear/ embarrassment/incontinence)
- Vaginal bleeding (due to mucosal irritation)
- Screen for prolapse risk factors
- PMH, Sx, Hx, meds, social Hx
Describe Physical Exam: Evaluation of pelvic prolapse (7)
- Inspect vulva and vagina for erosions/ ulcerations and estrogen status
- Examine all aspects of vaginal support:
- a. In dorsal lithotomy position without pessary
- b. Using single-bladed speculum to retract an- terior/posterior/lateral vaginal walls
- Standing straining exam to assess maximal prolapse
- Examine for stress incontinence
- Digital assessment of pelvic muscle/anal sphincter baseline and voluntary contraction tone (strength, duration, symmetry)
- ± Rectovaginal exam to detect enterocele
- Neuro exam: lower extremity neuromuscular exam
Describe Investigations: Evaluation of pelvic prolapse (5)
- No specific tests for prolapse
- Imaging not usually necessary (unless procidentia to R/O urinary retention)
- Biopsy all suspicious persistent vulvovaginal lesions
- Cystocele evaluation:
- a. UTI screen
- b. Postvoid residual (PVR)
- ± Refer to gynecologist for urodynamic testing
Name: Relative CI to pessary
- Inability to comply with pessary maintenance → risk rectovaginal or vesicovaginal fistulae
- Persistent vaginal erosions (consider local E, change size of pessary or potential vaginal neoplasm)
- Active genital infection or neoplasm
All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.
All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.
All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.
All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.
Name different managements of Pelvic prolapse (5)
- Conservative
- Nonsurgical
- Pelvic Floor Muscle Training
- Pessaries
- Surgical
Describe nonsurgical management: Pelvic prolapse (2)
- Sx relief and prevention of worsening prolapse
- Reasonable choice when observation not suitable but surgery high-risk or refused by patient
Describe Pelvic Floor Muscle Training management: Pelvic prolapse (3)
- Improving support to pelvic organs with ↑ strength and endurance of pelvic muscles
- No evidence for treating or preventing prolapse, but may benefit
- Is effective for urinary and fecal incontinence
Describe pessaries: Pelvic prolapse (5)
- Device placed in vagina to provide support and/or fill space
- Support pessaries (the ring) for earlier stages (II and III)
- Space-filling pessaries (Gellhorn) for more advanced prolapse
- Ideally changed and rinsed weekly with F/U q3mo
- Lubricants or vaginal E (if atrophy) is often employed with pessaries in postmenopausal women
