Gynaecology - Pelvic organ prolapse Flashcards
Mechanism of pelvic organ support
Delancey’s levels of uterovaginal support
Types of prolapse caused by damage to levels of uterovaginal support
Types of pelvic organ prolapse
Cystocele
Cause
Symptoms
Urethrocele
Cause
Symptoms
Uterine/ vault prolapse
Cause
Symptoms
Rectocele
Cause
Symptoms
Enterocele
Cause
Symptoms
Pelvic organ prolapse
Epidemiology
Risk factors
POP
Classification
POP-Q
Measurements
6 points: Aa, Ba, C, D, Ap, Bp
- A = anterior (distal) half of vagina;
- B = posterior (proximal) half of vagina;
- C = cervix;
- D = posterior fornix (Pouch of Douglas)
- a = anterior; p = posterior
3 measurements: gh (genital hiatus), pb (perineal body), tvl (total vaginal length)
- gh = middle of external urethral meatus to posterior hymen
- pb = posterior margin of genital hiatus to middle of anal opening
- tvl = greatest depth of vagina without straining
POP
History taking question
POP
P/E
POP
Conservative management
Ring pessaries
Types
Complications
Management of erosions
Other types of pessaries
- Hodge pessary: rigid elongated curved ovoid inserted same way as ring pessary; Used in retroverted uterus
- Gellhorn pessary: shaped like a collar stud; Used in severe prolapse
- Shelf pessary: shaped like a coat hook Used in uterine or vault prolapse
POP
Surgical treatment options
- for cystocele, enterocele, rectocele, vault prolapse and perineal body deficiency
Surgical management: more definitive
Aim: restore vaginal anatomy/function
Pre-operative preparation:
- local estrogen for 2-4 weeks
- prophylactic Cefazolin 1g IV at induction
Route: usu done transvaginal, can be done under RA
Choice: exact procedure depend on type of prolapse
- anterior colporrhaphy for cystocele alone
- McCall culdoplasty for enterocele
- posterior colporrhaphy for rectocele
- perineorrhaphy for deficient perineal body
- pelvic floor repair procedures for vault prolapse: sacrospinous colpopexy, abdominal sacrocolpopexy, olpocleisis
- vaginal hysterectomy with pelvic floor repair vs uterus-sparing procedures for apical prolapse
Apical prolapse
Surgical treatment options
Procedures with hysterectomy
- Vaginal hysterectomy with high uterosacral ligament suspension: recommended in protocol
- Total abdominal/laparoscopic hysterectomy with sacrocolpopexy (or sacrocervicopexy)
Uterus-sparing procedures
- Manchester (Fothergill) repair: vaginal, rarely used nowadays
- Hysterosacropexy: open or laparoscopic transabdominal
- Sacrospinous hysteropexy: vaginal
- Total mesh technique: PERIGEE, APOGEE, Anterior and Posterior Elevate
