Pelvic Organ Prolapse Flashcards
Prolapse
Protrusion of an organ or structure beyond its normal anatomical confines.
Female pelvic organ prolapse
Refers to the descent of the pelvic organs towards or through the vagina.
What is the epidemiology of pelvic organ prolapse?
- 12–30% of multiparous and 2% of nulliparous women.
- Prevalence estimates varying from 2% for symptomatic prolapse to 50% for asymptomatic prolapse.
- Accounts for 20% of women on gynaecological surgery waiting list
- Approximately 50% of parous women will have some degree and only 10–20% of these seek medical help
- The indication of 7-14% of hysterectomies is PROLAPSE
What is the pelvic flood?
All of the soft tissue structures that close the space between the pelvic bones
What is the function of a normal pelvic floor?
Maintain the pelvic viscera at rest and in periods of increased intra-abdominal pressure
What must be true of the walls of the abdomino-pelvic cavity?
Must be of sufficient flexibility to withstand changes in volumes of these organs & also pressure changes within the cavity
What are the 3 distinct layers of the pelvic floor?
- Endo-pelvic fascia
- Pelvic diaphragm
- Urogenital diaphragm
What is the endo-pelvic fascia?
- Network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
- Fibro-muscular component can stretch but the connective tissue des not (it breaks)
What is the pelvic diaphragm?
Layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
What is the urogenital diaphragm?
The superficial & deep transverse perineal muscles with their fascial coverings.
How do the 3 layers of the pelvic floor form a functional unit?
They do not parallel each other and vary in strength and thickness from place to place
What is medial to the uterosacral ligament?
- Uterus
- Cervix
- Lateral vaginal fornices
- Pubocervical fascia
- Rectovaginal fascia
What is lateral to the uterosacral ligament?
- Sacrum
- Fascia overlying piriformis muscle
How is the uterosacral ligament easily palpated?
By down traction on the Cervix and if intact allows limited side-side movement of the cervix.
Where does the uterosacral ligament tend to break?
Medially (around the cervix)
What is the pubocervical fascia?
Trapezoidal fibro-muscular tissue
What does the pubocervical fascia do?
Provides the main support of the anterior vaginal wall
What does the pubocervical ligament merge with centrally?
Base of the cardinal ligaments and cervix
What does the pubocervical ligament merge with laterally?
Arcus tendineus fascia pelvis
What does the pubocervical fascia merge with distally?
Urogenital diaphragm
Where does the pubocervical fascia tend to break?
Tend to break at lateral attachments or immediately in front of the cervix.
What is the rectovaginal fascia?
Fibro-musculo- elastic tissue.
What does the rectovaginal fascia merge with centrally?
Base of Cardinal/ uterosacral ligaments & peritoneum.
What does the rectovaginal fascia fuse with laterally?
Fascia over the levator ani
What is the rectovaginal fascia firmly attached to distally?
Perineal body
Where does the rectovaginal fascia tend to break?
Centrally
- If upper defect: Enterocele.
- If lower defect: perineal body descent & Rectocele.
What are the 3 levels of endopelvic support?
Level I:
- Utero-sacral ligaments
- Cardinal ligaments
Level II:
-Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia
Level III:
- Urogenital Diaphragm
- Perineal body
What are the risk factors for POP?
-Pregnancy and vaginal birth
-Advancing age
-Obesity
-Previous pelvic surgery
-Hormonal factors
-Quality of connective tissue
-Constipation
Occupation with heavy lifting
-Exercise ( weight lifting, high impact aerobics and long distance running)
What features associated with pregnancy and vaginal birth increase the risk of POP?
- Forceps Delivery
- Large baby (> 4500 gm)
- Prolonged Second Stage
- Parity (strongest risk factor)
How can continence procedures increase the risk of POP?
While elevating the bladder neck, may lead to defects in other pelvic compartments:
How can Burch colposuspension increase the risk of POP?
- By fixing the lateral vaginal fornices to the ipsilateral iliopectineal ligaments, leaves a potential defect in the posterior vaginal wall, which predisposes to rectocele and enterocele formation
- Overall 25% of women following Burch colposuspension required further surgery for prolapse.
What does the classification of prolapse depend on?
Site of defect and the presumed pelvic viscera involved
Urethrocele
Prolapse of the lower anterior vaginal wall involving the urethra only.
Cystocele
- Prolapse of the upper anterior vaginal wall involving the bladder
- Anterior wall prolapse
Uterovaginal prolapse
Prolapse of the uterus, cervix and upper vagina
Enterocele
- Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
- Apical prolapse
Rectocele
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
-Posterior wall prolapse
What is an apical prolapse?
Does not involve anterior/posterior wall, the cervix simply comes down
What vaginal symptoms can POP present with?
- Sensation of a bulge or protrusion
- Seeing or feeling a bulge or protrusion
- Pressure
- Heaviness
- Difficulty in inserting tampons
What urinary symptoms can POP present with?
- Urinary Incontinence
- Frequency/ Urgency
- Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
- Manual reduction of prolapse to start or complete voiding
What bowel symptoms can POP present with?
-Incontinence of flatus, or liquid or solid stool
-Feeling of incomplete emptying/ Straining
Urgency
-Digital evacuation to complete defecation (Splinting, or pushing on or around the vagina or perineum, to start or complete defecation)
How is POP assessed?
- Examination to exclude pelvic mass
- Record the position of examination: left lateral Vs Lithotomy Vs Standing.
- Quality of Life
Objective assessment
- Baden- Walker- Halfawy Grading
- POPQ Score
- Others
What is the gold standard assessment for POP?
POPQ score
How is POP investigated?
USS / MRI: Allow identification of fascial defects/ measurement of Levator ani thickness (research only).
Urodynamics: concurrent UI or to exclude Occult SI.
IVU or Renal USS (if suspicion of ureteric Obstruction).
How is POP prevented?
- Avoid constipation.
- Effective management chronic chest pathology (COAD & asthma).
- Smaller family size.
- Improvements in antenatal and intra-partum care (muscle training?)
How can POP be treated?
- Physiotherapy
- Pessaries
- Surgery
What phsyiotherpay can be used for POP?
Pelvic floor muscle training (PFMT):
-Increase the pelvic floor strength & bulk to relieve the tension
Who is physiotherapy used in?
- Cases of mild prolapse
- Younger women who have not yet completed their family.
- No role in advanced cases.
- Cannot treat fascial defects.
How can pelvic floor exercises be supplemented?
By the use of a perineometer and biofeedback, vaginal cones and electrical stimulation.
What are pessaries usually made from?
Today, pessaries are generally made from a variety of materials including silicone, Lucite, rubber or plastic.
What are the advantages of silicone pessaries?
- Long Shelf-life
- Resistance to autoclaving and repeated cleaning
- Non-absorbent towards secretions and odors
- Inertness
- Hypoallergenic nature.
What is the aim of surgery?
- Relieve symptoms,
- Restore/maintain bladder & bowel function and
- Maintain vaginal capacity for sexual function.
What further management should patients undergoing surgery receive?
- Prophylactic Antibiotics.
- Thrombo-embolic prophylaxis.
- Postoperative Urinary Vs supra-pubic catheter
Which treatment is more effective? Vaginal pessary or surgery?
Both as effective as each other
