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A - MSRA Gynaecology > Genitourinary Prolapse > Flashcards

Genitourinary Prolapse Flashcards

1
Q

What is a uterine prolapse?

A

When the female pelvic organs fall from their normal position into or through the vagina

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2
Q

What % of parous women are affected by pelvic organ prolapse?

A

40-60%

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3
Q

Why is the exact incidence of pelvic organ prolapse difficult to determine?

A

Many do not receive medical advice

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4
Q

What is a woman’s lifetime risk of surgery for pelvic organ prolapse?

A

12-19%

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5
Q

What is the most common type of pelvic organ prolapse prolapse?

A

Prolapse of the anterior vaginal wall

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6
Q

What provides the main support for the pelvic organs?

A
  • Levator ani muscle

- Endopelvic fascia

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7
Q

What is the endopelvic fascia?

A

A connective tissue network connecting the organs to the pelvic muscles and bones

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8
Q

What organs can be involved in a pelvic organ prolapse?

A
  • Uterus
  • Bladder
  • Rectum
  • Small or large bowel
  • Vaginal vault
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9
Q

Where can the organs of a pelvic organ prolapse affect when they descend?

A

Anterior/posterior vaginal walls

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10
Q

What usually underlies most cases of pelvic organ prolapse?

A

Multifactorial causes

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11
Q

What can be involved in the multifactorial causes of pelvic organ prolapse?

A
  • Direct muscle trauma
  • Neuropathic injury
  • Disruption or stretching of support
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12
Q

What different compartments of the pelvis can be affected by pelvic organ prolapse?

A
  • Anterior
  • Middle
  • Posterior
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13
Q

What are the types of anterior compartment pelvic organ prolapse?

A
  • Urethrocele

- Cystocele

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14
Q

What are the types of middle compartment pelvic organ prolapse?

A
  • Uterine prolapse
  • Vaginal vault prolapse
  • Enterocele
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15
Q

What are the types of posterior compartment pelvic organ prolapse?

A
  • Rectocele
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16
Q

Why do crabs make good burglars?

A

They’re great at pinching things

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17
Q

What is a urethrocele?

A

Prolapse of the urethra into the vagina

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18
Q

What is a cystocele?

A

Prolapse of the bladder into the vagina

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19
Q

What is a uterine prolapse?

A

Descent of the uterus into the vagina

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20
Q

What is a vaginal vault prolapse?

A

Descent of the vaginal vault post-hysterectomy

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21
Q

What is an enterocele?

A

Herniation of the pouch of Douglas (including small intestine/omentum) into the vagina

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22
Q

What is a rectocele?

A

Prolapse of the rectum into the vagina

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23
Q

What system is used to grade pelvic organ prolapse?

A

POPQ system

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24
Q

What is the POPQ system?

A

Pelvic Organ Prolapse Quantification System

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25
Q

What is a Stage 0 POPQ pelvic organ prolapse?

A

No prolapse

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26
Q

What is a Stage 1 pelvic organ prolapse?

A

More than 1 cm above the hymen level

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27
Q

What is a Stage 2 pelvic organ prolapse?

A

Within 1 cm proximal/distal to the plane of the hymen

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28
Q

What is a Stage 3 pelvic organ prolapse?

A

More than 1cm below the plane of the hymen but no further than 2cm less than total length of the vagina

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29
Q

What is a Stage 4 pelvic organ prolapse?

A

Complete eversion of the vagina

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30
Q

What are the risk factors for pelvic organ prolapse?

A
  • Increasing age
  • Vaginal delivery
  • Increasing parity
  • Obesity
  • Previous hysterectomy
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31
Q

How do mild pelvic organ prolapses present?

A

Many are asymptomatic and are incidental findings

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32
Q

How severe can the symptoms of pelvic organ prolapse be?

A

Severe enough to affect quality of life

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33
Q

What are the symptoms of pelvic organ prolapse related to?

A

Site and type of prolapse

34
Q

What are the vaginal/general symptoms of pelvic organ prolapse?

A
  • Sensation of pressure/fullness/heaviness
  • Sensation of bulge or ‘something coming down’
  • Seeing/feeling a bulge/protrusion
  • Difficulty retaining tampons
  • Spotting
35
Q

What can cause spotting in a pelvic organ prolapse?

A

Ulceration of the prolapse

36
Q

What are the potential urinary symptoms of pelvic organ prolapse?

A
  • Incontinence
  • Frequency
  • Urgency
  • Feeling of incomplete bladder emptying
  • Weak or prolonged urinary stream
  • Need to reduce prolapse manually before voiding
  • Need to change position to start voiding
37
Q

What are the symptoms of coital difficulty that may present in pelvic organ prolapse?

A
  • Dyspareunia
  • Loss of vaginal sensation
  • Vaginal flatus
  • Loss of arousal
38
Q

What are the potential bowel symptoms in pelvic organ prolapse?

A
  • Constipation/straining
  • Urgency of stool
  • Incontinence of flatus or stool
  • Incomplete evacuation
  • Need to apply digital pressure to perineum or posterior vaginal wall to enable defecation
  • Digital evacuation necessary
39
Q

In what positions should patients presenting with pelvic organ prolapse be examined?

A
  • Standing

- Left lateral position

40
Q

What should the patient be asked to do whilst examining for prolapse?

41
Q

How should the vagina be examined when assessing pelvic organ prolapse?

A

With a speculum

42
Q

What may be noticed on pelvic organ prolapse examination?

A
  • Ulceration
  • Hypertrophy
  • Bleeding
43
Q

When are abnormalities of the mucosa likely to occur in pelvic organ prolapse?

A

When the prolapse protrudes beyond the hymen level

44
Q

How is pelvic organ prolapse usually diagnosed?

A

Based on history and examination

45
Q

What tests should be considered if urinary symptoms are present in pelvic organ prolapse?

A
  • Urinalysis/MSU
  • Post-void residual urine volume testing using catheter or bladder USS
  • Urodynamic investigations
  • Urea and creatinine
  • Renal USS
46
Q

What tests can be considered if bowel symptoms are present in pelvic organ prolapse?

A
  • Anal manometry
  • Defecography
  • Endo-anal USS
47
Q

When is treatment of a prolapse not necessary?

A

In mild and/or asymptomatic prolapse

48
Q

What are the broad management options for pelvic organ prolapse?

A
  • Conservative
  • Vaginal pessary
  • Surgery
49
Q

Who is conservative management of pelvic organ prolapse particularly helpful for?

A
  • Mild prolapse
  • Want further pregnancies
  • Frail or elderly
  • High anaesthetic risk
  • Don’t want surgery
50
Q

What are the approaches to conservative management of pelvic organ prolapse?

A
  • Watchful waiting
  • Lifestyle modification
  • Pelvic floor muscle exercises
  • Vaginal oestrogen creams
51
Q

When may further treatment be required for pelvic organ prolapse following watchful waiting?

A

If symptoms become troublesome or complications develop

52
Q

What lifestyle modifications can conservatively treat pelvic organ prolapse?

A
  • Weight loss
  • Minimising heavy lifting
  • Preventing or treating constipation
53
Q

Who can vaginal oestrogen creams be useful for treating pelvic organ prolapse in?

A

Women with signs of vaginal atrophy

54
Q

What is the function of a vaginal pessary in pelvic organ prolapse?

A

It is inserted in the vagina to reduce the prolapse and provide support and relieve pressure on the bladder and bowel

55
Q

What can vaginal pessaries be used in combination with to treat pelvic organ prolapse?

A

Pelvic floor muscle exercises

56
Q

How long can vaginal pessaries for prolapse be used for?

A
  • Short-term prior to surgery

- Long-term if surgery is not an option

57
Q

What should patients wanting vaginal pessary for prolapse be made aware of?

A
  • More than one fitting may be necessary
  • May affect sexual intercourse
  • Should be changed every 6 months
  • Complications
58
Q

What are the potential complications of a vaginal pessary for pelvic organ prolapse?

A
  • Bleeding
  • Discharge
  • Difficulty removing pessary
  • Expulsion
  • Vesicovaginal and rectovaginal fistulas
  • Faecal impaction
  • Hydronephrosis
  • Urosepsis
59
Q

What are the indications for surgical intervention for pelvic organ prolapse?

A
  • Failure of conservative management
  • Presence of voiding problems or obstructed defecation
  • Recurrence of prolapse
  • Ulceration
  • Irreducible prolapse
  • Woman prefers surgery
60
Q

What are the goals of surgical intervention for pelvic organ prolapse?

A
  • Restore anatomy
  • Improve symptoms
  • Return bladder, bowel and sexual function
61
Q

What does the choice of surgical procedure for pelvic organ prolapse depend upon?

A
  • If woman is sexually active
  • If family is complete
  • General fitness
  • Whether has had a hysterectomy
  • Nature of prolapse
62
Q

What is a controversial surgery for pelvic organ prolapse?

A

Mesh repair

63
Q

Why is mesh repair for pelvic organ prolapse a topic of controversy?

A

Concerns of long-term health problems

64
Q

What are the long-term complications of mesh repair for pelvic organ prolapse?

A
  • Extrusion
  • Erosion
  • Bleeding
  • Pain
  • Dyspareunia
  • Bladder/bowel dysfunction
65
Q

What are the surgical options for bladder/urethral prolapse?

A
  • Anterior colporrhaphy

- Colposuspension

66
Q

What happens in an anterior colporrhaphy?

A

Folds the fibromuscular layer of the anterior vaginal wall

67
Q

What are the intraoperative complications of anterior colporrhaphy?

A
  • Haemorrhage
  • Haematoma
  • Cystotomy
68
Q

When can a colposuspension be considered for treatment of pelvic organ prolapse?

A

For urethral sphincter incontinence associated with cystourethrocele

69
Q

How is a colposuspension performed?

A

Paravaginal fascia on either side of the bladder neck and base of the bladder are approximated to pelvic side wall by sutures through ipsilateral iliopectineal ligament

70
Q

What are the surgical options for a uterine prolapse?

A
  • Hysterectomy
  • Sacrocolpoplexy
  • Sacrospinus fixation
71
Q

What is a sacrocolpoplexy?

A

The uterus is attached to the longitudinal ligament over the sacrum

72
Q

What are the ways a sacrocolpoplexy can be performed?

A
  • Laparoscopic

- Open

73
Q

What is an advantage of a sacrocolpoplexy for uterine prolapse?

A

Woman can retain her uterus

74
Q

What is a sacrospinus fixation of uterine prolapse?

A

Unilateral or bilateral fixation of the uterus to the sacrospinus ligamnet

75
Q

What are the risks of sacrospinus fixation for uterine prolapse?

A

Injury to the pudendal nerve and vessels and the sciatic nerve

76
Q

What are the surgical options for a vault prolapse?

A
  • Sacrospinus fixation

- Sacrocolpoplexy

77
Q

What is the surgical option for a recto/enterocele?

A

Posterior colporrhaphy

78
Q

What is obliterative surgery for pelvic organ prolapse?

A

The prolapse is corrected by moving the pelvic viscera back into the pelvis and closing off the vaginal canal

79
Q

What are the advantages of obliterative surgery for pelvic organ prolapse?

A
  • Almost 100% effective
  • Reduced peri-operative morbidity
  • Safe for those who are frail
80
Q

What is the main disadvantage of obliterative surgery for pelvic organ prolapse?

A

Vaginal intercourse is no longer possible

81
Q

What are the potential complications of pelvic organ prolapse?

A
  • Ulceration and infection of prolapsed organs outside introitus
  • Urinary tract complications
  • Bowel dysfunction
82
Q

What are the urinary complications that can occur with pelvic organ prolapse?

A
  • Stress incontinence
  • Chronic retention and overflow incontinence
  • Recurrent UTIs

A - MSRA Gynaecology (52 decks)

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