Pelvic Organ Prolapse Flashcards
Define Prolapse:
Is described by the compartment of the vagina in which it occurs:
- Apical
- Anterior vaginal wall prolapse
- Posterior vaginal wall prolapse
- Perineal descent syndrome
- Rectal prolapse
Apical prolapse details
loss of support at the apex of the vagina:
- Uterine/cervix prolapse = procidentia (Uterocele) is the term used to describe complete protusion of the Uterus and vaginal walls outside the body
- Vaginal vault prolapse = complete or partial inversion of the vaginal apex, found in individuals who have had a hysterectomy
- Enterocele = due to herniation of the peritoneal sac and small intestines pushing at the vaginal apex, can also be posterior vaginal wall prolapse
Anterior vaginal wall prolapse:
- Cystocele = bladder descent into anterior vaginal wall, most common location of prolapse (hendrix, 2002)
- Cystourethrocele = descent of the bladder and urethra into the anterior vaginal wall, hypermobility of the urethrovesical junction
Posterior vaginal wall prolapse:
- rectocele = prolapse of the rectum into the posterior vaginal wall
- Enterocele = prolapse of the small bowel into the cul-de-sac or posterior vaginal wall
Types of Enterocele:
- Traction enterocele = posterior cul-de-sac protrusion pulled into the vaginal wall by prolapse of the cervix or vaginal cuff
- Pulsion enterocele = posterior cul-de-sac protrusion into the vaginal wall caused by chronically increased intra-abdominal pressure
Perineal descent syndrome:
- descent of the rectovaginal septum with the perineal body
- perineum “balloons” downward during increases intra-abdominal pressure
- perineum lies below the ischial tuberosities at rest or with bearing down
Rectal prolapse:
Telescoping of the rectum through the anal sphincter
Burden of POP
- significant public health impact
- financial burden includes both direct (routine care, medical care) and indirect (loss of productivity) costs
- MC data = direct care for ambulatory care for PFD in 2006 was estimated to be $412 million, expected to double in the future
- in 1997, > 225,000 IP procedures for POP were performed in the USA at the cost of over $1 billion (subek, 2001)
- significant impact on the patient QOL and self-perception of body image, decreased activity levels and exercise (Lowder, 2011)
Etiology/Pathophysiology
multiple mechanisms have been hypothesized and described as contributors to the development of POP although none have fully explained the oigin or natural history of this process - there is little doubt that POP is multifactorial in etiology
Risk Factors for POP:
- female gender
- vaginal childbirth
- increasing age
- increased intra-abdominal pressure
- increased body mass index
- CT disorders
- a combination of any of the above
Urogenital Hiatus (UGH) is also called:
Levator hiatus - the opening between the left and right LA
What passes through the UGH?
Urethra and Vagina
LA contraction compresses…
the pelvic structures anteriorly against the pubic bones and closes the UGH
What is the UGH measured by?
- MRI
- Transperineal US imaging
- palpation
UGH is increased in
POP patients
- 9.5cm^2
vs normal = 5.25cm^2
Andrew 2013 study suggests that excessive UGH distensibility
is a cause rather than effect of POP
What is the common site of POP injury?
pubococcygeus or pubovisceral muscles - which may lead to a more vertical inclination to the levator plate increasing strain on the CT (Corton 2009)
What nerve injury may denervate the LA leading to POP?
pudendal nerve injury
Geometric models have predicted the pudendal nerve and branches may reach
35% maximum strain during vaginal birth
- 15% strain threshold is known to cause permanent damage in nerves
Structural and Postural factors associated with POP
- increased diameter of the bony pelvis and changes in other bony dimensions, such as pelvis inlet/outlet may facilitate POP
- thoracic kyphosis is associated with uterine POP (lind, 1996)
- decreased lumbar lordosis is associated with POP (Nguyen 2000, Mattox 2000)
Connective Tissue (CT) factors associated with POP
genetic CT abnormalities - mutations that result in collagen metabolism
- in a large multicenter study, hispanic race was shown to be a risk factor for POP development
- collagen and elastin have been shown to be decreased or disordered in women with POP compared to controls
Reproductive factors can lead POP:
Pregnancy and vaginal delivery:
- stretching, tearing, and avulsion of perineal tissues
- pudendal neuropathy
- prolonged second stage = starts after the cervix is completely dilated and the fetal head begins to touch the PF, Normal is approx. 90 minutes duration
- larger baby weight =
- shoulder dystocia and occiput posterior fetal presentations
- instrumented delivery (forceps, vaccuum extraction)
T/F elective C-section to avoid vaginal delivery is protective for POP
False. Not necessarily
Increased risk of POP with parity:
- 4x increase in primiparous women
- 8x increase in women having 2 children
- 9-10x increase in women having 3 or 4 children
