L1: Prolapse Flashcards
Relevant Anatomy to POP
- Cause of Uterovaginal Prolapse
Uterovaginal prolapse is caused by
- failure of the interaction between the levator ani muscles and the ligaments and fascia that support the pelvic organs.
Relevant Anatomy to POP
- Parts of Levator Ani
The levator ani muscles are
- Puborectalis
- Pubococcygeus
- Iliococcygeus.
They are attached on each side of the pelvic side wall from the pubic ramus anteriorly (pubococcygeus), over the obturator internus fascia to the ischial spine to form a bowl-shaped muscle filling the pelvic outlet and supporting the pelvic organs
Relevant Anatomy to POP
- gaps in Levator Ani
There is a gap between the fibers of the puborectalis on each side to allow passage
- of the urethra, vagina and rectum
Called the urogenital hiatus.
Relevant Anatomy to POP
- Func of levator Muscles
- The levator muscles support the pelvic organs and prevent excessive loading of the ligaments and fascia.
Relevant Anatomy to POP
- De Lancey’s three levels of vaginal support
De Lancey’s three levels of vaginal support
- Level 1
Is provided by
- uterosacral ligaments, suspending the uterus and attached vaginal vault.
De Lancey’s three levels of vaginal support
- Level 2
support is provided by
- the fascia lying between the vagina and the bladder or rectum that fuses laterally and runs to attach on the pelvic side wall.
De Lancey’s three levels of vaginal support
- Level 3
is provided by
- the perineal body, which has the posterior vaginal fascia fused to its upper surface
Levels of vaginal support & subsequent disorder
Def of Genital Displacement
Abnormal position of the genital organ (s) away from the normal anatomical level.
Common Types of Displacements
- The uterus is not central in the pelvis
- Prolapse
- RVF
- Inversion
Common Types of Displacements
- Non-Central Uterus
- Dextro-position = dextrorotation if deviated to the right.
- Levo-position = levorotation if deviated to the left.
- Ante-position: shifted anteriorly.
- Retro-position: shifted posteriorly.
Common Types of Displacements
- Prolapse
vertical downward descent of the genital organs below the anatomical level.
Common Types of Displacements
- RVF
loss of ante-version flexion and shifted to the back.
Common Types of Displacements
- Inversion
turning of the uterus from upside down.
Def of Pelvic Organ Prolapse
- Descent of the pelvic organ(s): bladder, rectum, vagina, uterus
- Below their normal anatomical position
- Due to distortion of their dynamic and integrated support
Anatomical Types of Pelvic Organ Prolapse
- May be vaginal, uterine or combined.
Anatomical Types of Pelvic Organ Prolapse
- vaginal
- Anterior wall (cystocele, urethrocele or combined)
- Posterior wall (rectocele, high or low)
- Vaginal vault prolapse
1. (in presence of the uterus —-> enterocele or hernia of Douglas’ pouch)
- (after hysterectomy —-> pos-hysterectomy vaginal vault prolapse).
Anatomical Types of Pelvic Organ Prolapse
- Uterine
- false —-> congenital elongation of portio vaginalis of the cervix
- True —-> actual decent due to distortion of support
Anatomical Types of Pelvic Organ Prolapse
- Combined
Utero-vaginal:
- if the uterus descends first, this occurs in congenital weakness of support ( congenital weakness of mesenchyme; virginal or nulliparous prolapse).
Vagino-uterine:
- if the vagina descends first, this occurs in acquired weakness or distortion of support e.g obstetric trauma.
Stages of Pelvic Organ Prolapse
- Old
- New (POP-Q)
Stages of Pelvic Organ Prolapse
- Old
Stages of Pelvic Organ Prolapse
- New
POP-Q System
- Aim
- This system aims to ‘quantify’ POP whatever the organ
- making 6 points & 3 measurements.
- After putting the measurements into the POP-Q grid staging is done
POP-Q System
- Points
POP-Q System
- Distances
POP-Q System
- Stages
Etiology of POP
CP of POP
CP of POP
- Intro
POP can cause symptoms
- directly due to the prolapsed organ
- indirectly due to organ dysfunction secondary to displacement from the anatomical position.
CP of POP
- Direct Symptoms
(1) a sensation of vaginal bulge,
(2) heaviness or a visible protrusion at or beyond the introitus.
(3) lower abdominal or back pain, or a dragging discomfort relieved by lying or sitting
CP of POP
- Indirect Symptoms
Signs of POP
- General
- Abdominal
- Gynecologic
Signs of POP
- General
- To exclude chronic disease or causes for increase intraabdominal pressure
Signs of POP
- Abdominal
- diagnose abdominal swellings, masses ascites, or hernia
Signs of POP
- Local
- Scheme
Local Signs in POP
- Inspection
- Masses protruding from the vulva at coughing or straining
- Escape of urine from the urethra, for any abnormality associated.
Local Signs in POP
- Palpatioon
- Mass whether reducible or not
- Size of the mass
- Measure the points and distances blotting in the POP-grid for staging
Local Signs in POP
- Bimanual Ex
- Evaluate the size, and position of the uterus as well as other pelvic masses.
Local Signs in POP
- Speculum
- Confirm diagnosis of enterocele (Malpas’ test)
- Detection of supra-vaginal elongation of the cervix by uterine sound in vagino-uterine prolapse.
INVx in POP
TTT of POP
- Conservative
1- pelvic floor muscle exercises and
2- the use of supportive vaginal pessaries.
For women with urinary or bowel symptoms as well, conservative treatment for these symptoms can be commenced at the same time as for the prolapse.
TTT of POP
- Conservative
- Pelvic Floor Exercise
- Vaginal Pessaries - Surgical
TTT of POP
- Pelvic floor Exercise
Pelvic floor Exercise in TTT of POP
- Advantages
- will reduce the symptoms of prolapse
Pelvic floor Exercise in TTT of POP
- Indications
women who are keen to avoid surgical treatment
Pelvic floor Exercise in TTT of POP
- Disadvantages
- Less evidence that pelvic floor exercise will reduce the anatomical extent of the prolapse
- Unlikely to be helpful for women whose prolapse is beyond the vaginal introitus.
TTT of POP
- Pessary
Pessary in TTT of POP
- Uses
- Reduce the prolapse, which leads to resolution of many of the symptoms.
Pessary in TTT of POP
- Advanatages
- Very effective at relieving symptoms
- Avoiding surgery and the associated risks, which can be extremely useful in the medically unfit and elderly
Pessary in TTT of POP
- Types
Pessary in TTT of POP
- Ring Pessary
- Ring pessaries are usually tried first, but an intact perineal body is necessary for these to be retained.
Pessary in TTT of POP
- Shelf Pessaries
- Shelf pessaries, Gellhorn pessaries and others are useful for women with deficient perineal bodies.
Pessary in TTT of POP
- Follow Up
- Replace a pessary every 6 months and to examine the patient for signs of vaginal ulceration
- Although this frequency is traditional and not based on any evidence.
Pessary in TTT of POP
- Complications
- Complications are uncommon and usually minor (bleeding, discharge)
- Although rarely the pessary can become incarcerated, requiring general anesthesia to remove, and rare cases of rectovaginal or vesicovaginal fistula formation have been reported.
Pessary in TTT of POP
- Sexual activity
- Sexual intercourse remains theoretically possible with a well-placed ring pessary, but not with the others, so would not generally be suitable for women who are sexually active.
- Motivated patients can be taught to insert and remove their own pessaries if they do wish to remain sexually active.
TTT of POP
- Surgery
Surgical TTT of POP
- Indication
- Surgical treatment for prolapse is common, and can be offered if conservative treatments have failed or if the patient chooses surgery from the outset.
Surgical TTT of POP
- procedure chosen depends on …..
(a). which compartment is affected,
(b). whether the woman wishes to retain her uterus and
(c). whether the vaginal or abdominal route of surgery is chosen.
Surgical TTT of POP
- Procedures
VIP Q
- Anterior vaginal repair (anterior colporrhaphy)
- Posterior vaginal repair (Posterior colporrhaphy)
- Vaginal repair with polypropylene mesh
- Fothergill (Manchester) operation
- Vaginal hysterectomy + Repair of the pelvic floor
- Partial colpocliesis (Le Forte operation)
Anterior vaginal repair (anterior colporrhaphy)
Anterior vaginal repair (anterior colporrhaphy)
- Key Points
- For anterior vaginal prolapse.
- NOT for stress incontinence
Anterior vaginal repair (anterior colporrhaphy)
- Short Desc
- Suture to reinforce fascia between vagina & bladder
Anterior vaginal repair (anterior colporrhaphy)
- Complications
- Bladder injury
- High recurrence
Posterior vaginal repair (Posterior colporrhaphy)
Posterior vaginal repair (Posterior colporrhaphy)
- Key Points
- For posterior vaginal prolapse
- Can improve obstructed defecation
- Risk of recurrence is low
Posterior vaginal repair (Posterior colporrhaphy)
- Short Description
Suture to reinforce fascia between vagina & rectum
Posterior vaginal repair (Posterior colporrhaphy)
- complications
- Risk of rectal injury
- Postoperative dyspareunia
Vaginal repair with polypropylene mesh
Vaginal repair with polypropylene mesh
- Key points
- Usually reserved for recurrent prolapse
- Surgical repair reinforced with mesh
- Very low recurrence rates
- Excellent anatomical results
Vaginal repair with polypropylene mesh
- Short Desc.
- Mesh can be inlay (not fixed), or fixed to the pelvic ligaments to mimic the native utrosacral ligaments and fascial attachments
Vaginal repair with polypropylene mesh
- Complications
- Mesh erosion through the
vagina (5%) - Mesh erosion through bladder or rectum (<5%)
- Dyspareunia
- Chronic pelvic pain
- Excision of mesh is difficult
Fothergill (Manchester) operation
- Description
Uterine preserving procedure, consists of:
- D&C
- anterior colporrhaphy
- shortening of the elongated cervix
- shortening of the cardinal ligaments
- posterior colpoperineorrhaphy.
Fothergill (Manchester) operation
- Indication
- indicated when there is supra-vaginal elongation of the cervix, and the patient wants to keep her uterus.
Vaginal hysterectomy + Repair of the pelvic floor
- Indications
- indicated in cases of POP when the uterus is to be removed
Partial colpocliesis (Le Forte operation)
- Indications
indicated in frail, non-sexually active women.
Principles of POP Surgery
