GENITAL PROLAPSE Flashcards
What are the muscles of the pelvic floor?
Levator ani (pubococcygeus and iliococcygeus)
Internal obturator
Piriformis
Superficial and deep perineal muscle
What is the gap in the pelvic floor through which the urethra and vagina pass?
Urogenital aperture formed by the medical border of the levator ani.
What are the pelvic ligaments that act to support the uterus in the upper part of the vagina?
Transverse cervical or cardinal ligaments
Uterosacral ligaments
(Round ligaments)
What are the types of genital prolapse?
Cystourethrocoele Cystocoele Rectocoele Enterocoele Uterine descent Vault descent
What is the most common type of genital prolapse?
- Cystourethrocoele
- Uterine descent
- Rectocoele
What is a cystocoele?
This is when the bladder prolapses. There is prolapse of the anterior wall of the vagina, attached to bladder by fascia.
What is a cystourethrocoele?
This is when the bladder and urethra prolapse. It is basically a cystocoele that extends into the lower anterior vaginal wall, displacing the urethra downwards.
What is a rectocoele?
This is when the rectum prolapses. Weakness in the levator ani muscles cause a bulge in the mid posterior vaginal wall which incorporates the rectum.
What is an enterocoele?
This is a true hernia of the Pouch of Douglas. There is a prolapse of the upper third of the posterior vaginal wall and contains small bowel.
What is uterine descent?
This is when the uterus descends with the vagina and may even lie outside it. Often associated with a cystocoele and/or rectocoele.
How is uterine descent graded?
According to position of cervix on vaginal examination:
First degree - cervical descent within vagina
Second degree - Cervical descent to the opening of the vagina
Third degree - Cervical descent to outside the vagina
What is procidentia?
This is when the uterus descends so far that it actually lies outside of the vagina.
What is vaginal vault descent?
This is when the proximal end of the vagina prolapses within or outside the vagina, following hysterectomy.
What are the congenital conditions associated with genital prolapse?
Spina bifida
Connective tissue disorders such as Ehlers Danlos
What are the risk factors for genital prolapse?
Multiparity with normal vaginal deliveries
Giving birth to a large baby
High BMI
Increasing age - postmenopausal atrophy
Frequent heavy lifting
Chronic coughing
Prior pelvic surgery - eg colposuspension increases predisposition for rectocoele
Frequent straining during bowel movements
Hysterectomy (vaginal vault)
Being hispanic or white
What are the classic features of genital prolapse?
Discomfort Feeling of something coming down Dragging sensation Worse standing or straining (cough or defecation) Relieved by lying down Interferes with sexual function Backache Bloody purulent discharge Incontinence
What are the urinary symptoms associated with genital prolapse?
Frequency Incomplete emptying of the bladder Frequent UTI Overflow incontinence Stress incontinence
What are the bowel symptoms associated with rectocoele?
Tenesmus
What are the preventative factors that should be taken into account to avoid genital prolapse?
Appropriate management of labour - avoiding prolonged first and second stages
Caesarian section if risk factors or history
Postnatal pelvic floor exercises
What are the conservative/medical management options for someone suffering from genital prolapse?
Weight loss Stop smoking to reduce cough Treat constipation Pelvic floor exercises Hormone replacement therapy - increases skin collagen content Vaginal pessaries
What are the types of pessary used to treat genital prolapse?
Ring pessary
Shelf pessary
What are the indications for using a vaginal pessary rather than surgery?
Patient has not completed her family
Patient choice
Medically unfit for surgery
What are the main complications of a vaginal pessary?
Bleeding
Discharge
Discomfort if too large possibly leading to ulceration
Granulation tissue may develop, incarcerating the pessary if it is not changed regularly.
How often should a pessary be replaced?
Cleaned every 6 months
Replaced every 2 years
What are the main complications of surgical repair of genital prolapse?
Dyspareunia - vagina is narrowed and shortened
