12. Pelvic prolapse Flashcards

1
Q

Name types of female GU prolapse (5)

A
  • Cystocele
  • Uterine prolapse
  • Vaginal vault prolapse
  • Rectocele
  • Enterocele
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2
Q

Describe: Cystocele (1)

A

Herniation of the bladder with associated descent of the anterior vaginal segment

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3
Q

Describe: Uterine prolapse (1)

A

Descent of the uterus and cervix

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4
Q

Describe: Vaginal vault prolapse (1)

A

Descent of the vaginal apex (posthysterectomy)

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5
Q

Describe: Rectocele (1)

A

Herniation of the rectum with associated descent of the posterior vaginal segment

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6
Q

Describe: Enterocele (1)

A

Herniation of the small bowel with associated descent of the posterior vaginal segment

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7
Q

Pelvic organs are supported by what? (3)

A
  • the pelvic floor musculature
  • fascial supports
  • nervous system.
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8
Q

The muscular pelvic floor is composed of what? (2)

A
  • of the levator ani (combination of puborectalis, pubococcygeus, and iliococcygeus)
  • the coccygeus muscles attached to elements of the bony pelvis, coccyx, and sacrum.
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9
Q

The majority of women with clinically significant prolapse will have at least two RFs. Name them (7)

A
  • 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
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10
Q

Name stages of prolapse (5)

A
  • 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”)
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11
Q

Describe link between parity and prolapse (1)

A

Although ↑ parity is a RF for prolapse, nulliparity does not provide absolute protection against prolapse.

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12
Q

Describe: Occult/latent incontinence (2)

A
  • 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.
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13
Q

Describe Post Void Residual Volume cut-off normal values (3)

A
  • 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.
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14
Q

Describe: Pelvic Organ Prolapse Quantification System (POP–Q) (3)

A
  • 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
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15
Q

Describe HX: Evaluation of pelvic prolapse (12)

A
  • 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
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16
Q

Describe Physical Exam: Evaluation of pelvic prolapse (7)

A
  • 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
17
Q

Describe Investigations: Evaluation of pelvic prolapse (5)

A
  • 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
18
Q

Name: Relative CI to pessary

A
  • 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
19
Q

All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.

A

All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.

20
Q

All patients with defecatory dysfunction should be evaluated from a ___ perspective and receive age-appropriate screening for ___.

A

All patients with defecatory dysfunction should be evaluated from a GI perspective and receive age-appropriate screening for colorectal CA.

21
Q

Name different managements of Pelvic prolapse (5)

A
  • Conservative
  • Nonsurgical
  • Pelvic Floor Muscle Training
  • Pessaries
  • Surgical
22
Q

Describe nonsurgical management: Pelvic prolapse (2)

A
  • Sx relief and prevention of worsening prolapse
  • Reasonable choice when observation not suitable but surgery high-risk or refused by patient
23
Q

Describe Pelvic Floor Muscle Training management: Pelvic prolapse (3)

A
  • 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
24
Q

Describe pessaries: Pelvic prolapse (5)

A
  • 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
25
Q

Describe surgical management: Pelvic prolapse (2)

A
  • An attempt to improve prolapse Sx and concomitant Sx (GI, urinary, and sexual) through techniques to restore normal anatomy or obliterate the vagina
  • Surgery may combine repairs to anterior vagina, vaginal apex, posterior vagina, and perineum, as well as concomitant bladder neck or anal sphincter repair
26
Q

Name indications for surgery in pelvic prolapse (4)

A
  • Surgery not recommended in woman with asymptomatic prolapse
  • If advanced prolapse and asymptomatic: must assess efficiency of bladder emptying due to risk for complications of urinary retention (recurrent UTI, urosepsis) and assess exposed vaginal epithelium for erosions at risk for infection
  • More frequent F/U (q3 mo) if decided against surgery
  • Patient fails conservative management, is unable or unwilling to use pessary, or desires surgical management