Gynaecology: Pelvic Organ Prolapse & Urinary Incontinence Flashcards
Define pelvic organ prolapse
Refers to the descent of pelvic organs into the vagina.
What is pelvic organ prolapse the result of?
Weakness and lengthening of the ligaments and muscles surrounding the uterus, rectum and bladder.
Define uterine prolapse
Uterine prolapse is where the uterus itself descends into the vagina.
Who does vault prolapse occur in?
Occurs in women that have had a hysterectomy, and no longer have a uterus
What happens in vault prolapse?
The top of the vagina (the vault) descends into the vagina.
What is a rectocele?
A rectocele is a type of prolapse where the supportive wall of tissue between a woman’s rectum and vaginal wall weakens. Without the support of these pelvic floor muscles and ligaments, the front wall of the rectum sags and bulges into the vagina, and in severe cases, protrudes out of the vaginal opening.
Cause of a rectocele?
Defect in posterior vaginal wall
What symptom are rectoceles particularly associated with?
Constipation
Symptoms of rectocele?
- Constipation
- Urinary retention
- Palpable lump in vagina
As a result of faecal loading
How can constipation be relieved in a rectocele?
Women may use their fingers to press the lump backwards, correcting the anatomical position of the rectum, and allowing them to open their bowels
What is a cystocele?
Cystoceles are caused by a defect in the anterior vaginal wall, allowing the bladder to prolapse backwards into the vagina. Prolapse of the urethra is also possible (urethrocele).
What is the prolapse of both the bladder and the urethra called?
Cystourethrocele
What is the result of a a defect in the ANTERIOR vaginal wall?
Cystocele
What is the result of a a defect in the POSTERIOR vaginal wall?
Rectocele
Risk factors for pelvic organ prolapse?
The result of weak and stretched muscles and ligaments:
- Multiple vaginal deliveries
- Instrumental, prolonged or traumatic delivery
- Advanced age and postmenopause status
- Obesity
- Chronic respiratory disease causing coughing
- Chronic constipation causing straining
Typical presenting symptoms of pelvic organ prolapse?
- A feeling of “something coming down” in the vagina
- A dragging or heavy sensation in the pelvis
- Urinary symptoms, such as incontinence, urgency, frequency, weak stream and retention
- Bowel symptoms, such as constipation, incontinence and urgency
- Sexual dysfunction, such as pain, altered sensation and reduced enjoyment
Women may have identified a lump or mass in the vagina, and often will already be pushing it back up themselves.
When will the pelvic organ prolapse become worse?
on straining or bearing down.
What should patients ideally do before examination of a prolapse?
They should empty their bladder and bowels before exam
What is used to assist examination in pelvic organ prolapse?
A Sim’s speculum is a U-shaped, single-bladed speculum that can be used to support the anterior or posterior vaginal wall while the other vaginal walls are examined.
Where is a Sim’s speculum held to examine a rectocele?
Held on the anterior wall
Where is a Sim’s speculum held to examine a cystocele?
Held on the posterior wall
What can you ask the patient to do to assess the full descent of the prolapse?
Cough or ‘bear down’
What system is used to grade uterine prolapses?
Pelvic organ prolapse quantification (POP-Q)
Describe grade 0 of the POP-Q
Normal
Describe grade 1 of the POP-Q
The lowest part is more than 1cm above the introitus
Describe grade 2 of the POP-Q
The lowest part is within 1cm of the introitus (above or below)
Describe grade 3 of the POP-Q
The lowest part is more than 1cm below the introitus, but not fully descended
Describe grade 4 of the POP-Q
Full descent with eversion of the vagina
What can a prolapse extending beyond the introitus be referred to as?
uterine procidentia.
What are the 3 management options for prolpse?
1) Conservative management
2) Vaginal pessary
3) Surgery
Who is conservative management appropriate for in prolapse?
For women that are able to cope with mild symptoms, do not tolerate pessaries or are not suitable for surgery.
What does conservative management in prolapse involve?
Physiotherapy (pelvic floor exercises)
Weight loss
Lifestyle changes for associated stress incontinence, such as reduced caffeine intake and incontinence pads
Treatment of related symptoms, such as treating stress incontinence with anticholinergic mediations
Vaginal oestrogen cream
What are vaginal pessaries?
Vaginal pessaries are inserted into the vagina to provide extra support to the pelvic organs.
Purpose of vaginal pessaries in prolapse?
They can create a significant improvement in symptoms and can easily be removed and replaced if they cause any problems.
Name some different types of vaginal pessaries
- Ring pessaries
- Shelf and Gellhorn pessaries
- Cube pessaries
- Donut pessaries
- Hodge pessaries
Where do ring pessaries sit?
Sit around the cervix holding the uterus up
Where do Shelf and Gellhorn pessaries sit?
Shelf and Gellhorn pessaries consist of a flat disc with a stem, that sits below the uterus with the stem pointing downwards
Where do Hodge pessaries sit?
Hodge pessaries are almost rectangular. One side is hooked around the posterior aspect of the cervix and the other extends into the vagina.
How to choose a vaginal pessary in prolapse?
Women often have to try a few types of pessary before finding the correct comfort and symptom relief
How to care for vaginal pessaries?
Pessaries should be removed and cleaned or changed periodically (e.g. every four months).
Vaginal pessaries can cause vaginal irritation and erosion over time.
What can be prescribed to help with this?
Oestrogen cream
What is the definitive management for prolapse?
Surgery e.g. hysterectomy