Gynae: Urinary Incontinence & Prolapse Flashcards
What do we mean by pelvic organ prolapse?
Why does pelvic organ prolapse occur?
- Descent of pelvic organs (uterus, bladder or rectum) from normal position into the vagina
- Due to weakness of ligaments & muscles surrounding pelvic organ (uterus, rectum & bladder)
What is a uterine prolapse?
Uterus descends from it’s normal position into vagina
What is a vault prolapse?
Occurs in women who have had hysterectomy; top of vagina (vault) descends from normal position into the vagina
What is rectocele?
What is rectocele associated with?
- Rectum prolpases/descends/moves forward into the vagina due to defect in posterior vaginal wall
- Associated with constipation. Women may get faecal loading in part of rectum that has prolapsed; this can lead to constipation, urinary retention if compressing urethra and a palpable lump in vagina.
*NOTE: women may use their fingers to push lump backwards- correcting position of rectum- allowing them to open bowels
What is cystocele?
- Bladder prolapses/descends/moves backwards into vagina due to defect in anterior vaginal warll
- Urethrocele= prolapse of urethra
- Cystourethrocele= prolapse of bladder & urethra
State some risk factors for pelvic organ prolapse
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Increasing age
- Post-menopausal
- Obesity
- Chronic respiratory disease (leading to chronic cough)
- Chronic constipation leading to straining
Describe typical presentation of pelvic organ prolapse
- Feeling of something coming down in the vagina
- Dragging or heavy sensation in pelvis
- Urinary symptoms:
- Urgency
- Frequency
- Weak stream
- Retention
- Incontinence
- Bowel symptoms:
- Constipation
- Urgency
- Incontinence
- Sexual dysfunction
- Dyspareunia
- Altered sensation
*
Discuss how you should examine a woman with suspected pelvic organ prolapse
- Pt should ideally empty bladder & bowel
- Examine in multiple positions including dorsal & left lateral position
- Use Sim’s speculum to support anterior & posterior vaginal wall in turn whilst examining other vaginal walls (hold on anterior wall to look for rectocele and hold on posterior wall to look for cystocele)
- Ask women to cough or bear down to assess full extent of prolapse
Uterine prolapses can be graded using the POP-Q (pelvic organ prolapse quantification) system; describe this grading system
- Grade 0: Normal
- Grade 1: The lowest part is more than 1cm above the introitus
- Grade 2: The lowest part is within 1cm of the introitus (above or below)
- Grade 3: The lowest part is more than 1cm below the introitus, but not fully descended
- Grade 4: Full descent with eversion of the vagina
*Introitus: opening to the vagina
What is uterine procidentia?
Uterus lies entirely outside the introitus (same as grade 4 on POP-Q)
Management for pelvic organ prolapses can be split into 3 categories: state these
- Conservative management
- Vaginal pessary
- Surgery
Discuss the conservative management of pelvic organ prolapse
Can help all women. Women with mild symptoms, who don’t tolerate pessaries or are not suitable for surgery may also benefit:
- Weight loss
- Pelvic floor exercises
- Vaginal oestrogen cream
- If have associated stress incontinence
- Decrease caffeine
- Not drinking too much
- Anticholinergic medications
For pessaries, discuss:
- How they work
- Different types
- How to use pessaries
- Risks & how to reduce
- Inserted into vagina to provide extra support to pelvic organs
- Types:
- Ring: sit around cervix holding uterus up
- Shelf & Gellhorn: flat disc with stem that sits below uterus (with stem pointing down)
- Cube: cube shaped
- Donut: thick ring
- Hodge: one side hooked around posterior aspect of cervix and other side extends into vagina
- Often have to try multiple types. Remove and clean or change periodically (e.g. every 4 months)
- Can cause vaginal irritation & erosion over time so oestrogen cream can be used to help protect vagina from irritation
Surgery is only definitive treatment option for pelvic organ prolapse; state some surgical options available for pelvic organ prolapse
- Uterine prolapse → hysterectomy, sacrohysteropexy (**lift the uterus back into its normal position)
- Vault prolapse → sacrocolpopexy
- Cystocele/Cystourethrocele → colposuspension (lift neck of bladder and hold in place with stitches), anterior colporrhaphy (push bladder back to normal position and strengthen anterior vaginal wall using stitches)
- Rectocele → posterior colporrhaphy
.State some potential complications of surgery for pelvic organ prolapse
- Usual surgical complications:
- Pain
- Bleeding
- Infection
- DVT
- Risk of anaesthetic
- Damage to surrounding structures e.g. bladder, bowel
- Recurrence of prolapse
- Altered sexual experience
Discuss how you should examine a woman presenting with urinary incontinence
Assess for:
- Pelvic organ prolapse
- Atrophic vaginitis
- Urethral diverticulum
- Pelvic masses
- Leakage of urine when pt asked to cough
- Strength of pelvic muscle contractions during bimanual pelvic examination
Discuss how urodynamic tests are done- including what measurements are taken
