5 - Pelvic Organ Prolapse (+ anatomy of pelvic floor) Flashcards
define prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines
define female POP?
the descent of the pelvic organs towards or through the vagina
effect of prolapse on multiparous women? (%)
12-30%
effect of prolapse on nulliparous women? (%)
2%
% of parous women with degree of prolapse?
~50%
what % of gynaecological waiting lists is accounted for by POPs?
20%
what is indicated by prolapse at ~10%?
hysterectomies
which viscera is contained in abdomino-pelvic cavity?
abdominal and pelvic
why must the walls of the abdomino-pelvic be flexible?
to withstand changes in volumes of these organs & pressure changes
name 3 layers of pelvic floor?
endo-pelvic fascia
pelvic diaphragm
urogenital diaphragm
which layer of the pelvic floor is similar to a hammock structure?
endo-pelvic fascia
what type of tissue is present in the endo-pelvic fascia?
fibro-muscular connective-type tissue
which 3 structures are surrounded by the endo-pelvic fascia?
uterosacral ligaments
pubocervical fascia
rectovaginal fascia
describe flexibility of endo-pelvic fascia and the effects of this?
Fibro-muscular component can stretch (Uteroscarals)
Connective tissue does not stretch, therefore it breaks
describe the location of the utero-sacral complex MEDIALLY?
medially to uterus, cervix, lateral vaginal fornices and pubocervical & rectovaginal fascia
describe the location of the utero-sacral complex LATERALLY?
sacrum & fascia overlying the Piriforms muscle
where does utero-sacral complex tend to break?
medially - @ the cervix
what is the utero-sacral complex AKA?
Cardinal complex?
which tissue provides the main support of the anterior vaginal wall?
trapezoidal fibro-muscular tissue
where does the pubocervical fascia tend to break?
@ lateral attachments OR immediately in front of cervix
what does the pubocervical fascia merge with CENTRALLY?
base of cardinal ligaments and cervix
what is the pubocervical fascia associated with LATERALLY?
archus tendineus fascia pelvis
what is the pubocervical fascia associated with DISTALLY?
Urogenital diaphragm
which type of tissue makes up the rectovaginal fascia?
fibro-musculo-elastic tissue
what does the rectovaginal fascia merge with CENTRALLY?
base of cardinal ligaments and peritoneum
what is the rectovaginal fascia associated with LATERALLY?
fascia over the levator ani
what is the rectovaginal fascia associated with DISTALLY?
firmly stuck to the perineal body
where does the rectovaginal fascia tend to break?
centrally
where does the rectovaginal fascia tend to break if there is an upper defect?
enterocele
where does the rectovaginal fascia tend to break if there is a lower defect?
perineal body descent and retrocele
How many levels of endopelvic support are there?
3
components of level 1 of endopelvic support?
utero-sacral ligaments
cardinal ligaments
components of level 2 of endopelvic support?
para-vaginal to arcus tendineus fascia
pubocervical fascia
components of level 3 of endopelvic support?
Urogenital Diaphragm
Perineal body
3 common risk factors of POP?
parity (increases as parity increases)
advancing age
obesity
complication of Burch Colposuspension?
further surgery for prolapse
what is the Burch Colposuspension procedure for?
to improve continence
complication of hysterectomy?
vaginal vault prolapse
5 other risk factors of POP?
Hormonal factors
Quality’ of Connective Tissue
Constipation
Occupation with Heavy Lifting
Exercise
5 types of prolapse in traditional classification of prolapse?
urethrocele
cystocele
uterovaginal prolapse
enterocele
rectocele
describe urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethra only
describe cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder
(anterior wall prolapse)
describe uterovaginal prolapse?
prolapse of the uterus, cervix and upper vagina
describe enterocele?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
(apical prolapse)
describe rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
(posterior wall prolapse)
Typical symptoms of the vagina in women with pelvic organ prolapse?
Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
Typical urinary symptoms in women with pelvic organ prolapse?
Urinary Incontinence
Frequency/ Urgency
Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
Typical bowel symptoms in women with pelvic organ prolapse?
Incontinence of flatus, or liquid or solid stool
Feeling of incomplete emptying/ Straining
Urgency
Digital evacuation to complete defecation
Splinting, or pushing on or around the vagina or perineum, to start or complete defecation
3 aspects of assessment of POP?
Examination to exclude pelvic mass
Record the position of examination
Quality of Life
Grading for assessment of POP?
Baden-Walker-Halfawy
What is gold standard for assessment of POP?
POPQ score
4 investigations for POP?
USS/MRI (imaging)
urodynamics
IVU
Renal USS
4 methods of prevention of POP?
avoid constipation
effective management chronic chest pathology
smaller family size
improvements in antenatal and intra-partum care
3 possible treatments for POP?
physiotherapy
pessaries
surgery
in terms of pessaries, which material is advantageous and give 3 reasons why?
silicone:
long shelf-life
inertness
resistance to repeated cleaning
