7 - Gynae - Prolapse of the Uterus and Vagina - Prolapse Flashcards
How are prolapses classified?
5 types?
anatomically by site of defect and viscera involved
cystocoele, rectocoele, enterocoele, urethrocoele, apical prolapse
What is a urethrocoele? a cystocoele? what is common?
u - prolapse of lower ant vaginal wall, inv urethra only
c - prolapse of upper ant vag wall, inv bladder
often ass w eachother - cystourethrocoele
What is an apical prolapse? what is an enterocoele? what is a rectocoele?
a - uterus, cergix and upper vagina prolapse - vault (top of vagina) can prolapse if uterus removed
e - prolapse of upper post wall of vag - small bowel pouch
r - lower post vag wall - inv ant wall of rectum
how is prolapse graded?
POP (pelvic organ prolapse) score - 0-4 depending on descent (0=no descent during straining, 4=vagina completely everted)
Epidemiology - % of parous women? % that seek medical help?
aetiology - 5 main causes?
50% to some degree
20-30% seek med attention
vag delivery + pregnancy congenital factors menopause chronic predisposing factors iatrogenic factors
Aetiology -
vag del and preg
-delivery may cause ? injury and ? of pelvic floor
-incr risk with ? infants, prolonged ? stage and ? delivery
what congenital factors may predispose?
how does menopause contribute ?
mechanical denervation large second instrumental
abnormal collagen metab eg ehlers danlos syndrome
deterioration of collagenous conn tissue following oestrogen withdrawal
Aetiology - name a few chronic predisposing factors?
-iatrogenic - what ass w subsequent vault prolapse? what may cause defects in other pelvic compartments?
chronic incr in intra abdo pressure -> obesity, heavy lifting, pelvic mass, constipation, cough
hysterectomy
continence procedures
S+S
Hx points.
-often ?
-what is common and usually worse at end of day/when standing?
-severe prolapse interferes with what? they may ulcerate to give ? or ?
-what is common but also may be incidental ?
-rectocoele common Sxs?
-c-u-ocoele common Sxs?
some must reduce prolapse before passing u/f…
aSx dragging sensation/sensation of lump intercourse bleeding / discharge stress incontinence normally aSx - possibly difficulty in defaecating urinary freq and incontinence
S+S
Ex points.
-what two simple Ex to do to exclude something (what?)?
-large prolapses are visible where?
-what allows inspection of ant and post vag walls?
-what may be mistaken for rectocoele? how to confirm?
-what 2 things may be mistaken for prolapse?
-how to test for stress incontinence?
abdo + VE -> exclude pelvic mass outside sim's speculum enterocoele do a PR large polyps and vaginal cysts temp reduce prolapse and ask pt to strain/cough
Ix
- look for cause with what if mass suspected?
- what is done if incontinence is 1’ complaint?
- 4 things to ass fitness for surgery?
Prevention
- recognition of ? ? and avoidance of ? ? ? stage
- what are encouraged after birth?
pelvic USS
urodynamic testing
ECG, CXR, FBC, Ren Fx
-obstructed labour
excessively long 2nd stage
-pelvic floor exercises
MGMT - what is often appropriate? what to stop? how may physio help? what other part of body may you trt?
wt reduction
smoking
reduce stress incontinence + mild-mod degree prolapses
MGMT - pessaries
- used in who?
- placed in vagina to stay behind ?? and in front of ?.
- more commonly which type? what is more effective in severe cases?
- how often changed?
- what might postmen women need to prevent vaginal ulceration?
- 4 complx?
- women unwilling/unfit for surgery
- pubic symph - sacrum
- ring - shelf
- 6-9m
- oestrogen replacement (either topical or standard HRT)
pain, retention, infection, fall out
MGMT - surgery
-what to think about regarding stress incontinence when counselling for surgery?
prolapse may kink urethra - masking stress incontinence - repair could cause incontinence so concomitant surgery for stress incont may be needed
Uterine prolapse - 2 surgical trts? complx/con of one?
vaginal hysterectomy (complx = vaginal vault prolapse) or Hysteropexy (uterus and cervix attached to sacrum
Vaginal vault prolapse - 2 surgeries? complx for each?
sarocolppexy - fix vault to sacrum w mesh - complx = mesh erosion and haemorrhage
sacrospinous fixation =- suspend vault to sacrospinous ligament - complx = nerve/vessel injury, infection, buttock pain
