pelvic organ prolapse Flashcards
what is a prolapse
protrusion of an organ/structure beyond its normal anatomical confines
what is female POP
female pelvic organ prolapse
the descent of the pelvic organs towards or through the vagina
incidence of prolapse
difficult to determine
estimated to affect 12-30% of multiparous and 2% of nulliparous women
estimates vary from 2% for symptomatic prolapse to 50% for asympomatic prolapse
prevalence of prolapse
estimates vary from 2% for symptomatic prolapse to 50% for asympomatic prolapse
~50% of parous women will have some degree and only 10-20% of these seek medical help
POP accounts for 20% of women on the waiting list for major gynae surgery
what % of hysterectomies are indicated due to prolapse
7-14%
why must the pelvic cavity wall be flexible
to withstand changes in volume of these organs and also pressure changes within the cavity
what does the pelvic floor contain
all of the soft tissue structures that close the space between the pelvic bones
if the pelvic floor is normal, all the viscera will be maintained in their position at rest and during increased intra-abdo pressure
what are the 3 layers of the pelvic floor
endo-pelvic fascia
pelvic diaphragm
urogenital diaphragm
3 layers do not parallel each other and vary in strength and thickness from place to place
what does the pelvic floor act as
1 functional unit made from 3 layers
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
uterosacral ligaments/pubocervical fascia/rectovaginal fascia
what is the pelvic diaphragm
layer of striated muscles with its fascial coverings
levator ani and coccygeus
what is the urogenital diaphragm
superficial and deep transverse perineal muscles with their fascial coverings
how stretchy is the endo-pelvic fascia
fibro-muscular component can stretch
connective tissues doesn’t stretch or attenuate, instead it breaks
location of the uterosacral/cardinal complex
medially to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
laterally to the sacrum and fascia overlying the piriformis muscle
how can the uterosacral complex be palpated
down traction on the cervix and if intact allows limited side-side movement of the cervix
how does the utero-sacral complex tend to break
medially - around the cervix
what is the pubocervical fascia and what is its role
trapezoidal fibro-muscular tissue
provides the main support of the anterior vaginal wall
location of the pubocervical fascia
centrally - merge with the base of the cardinal ligaments and cervix
laterally - arcus tendineus fascia pelvis (white line)
distally - urogenital diaphragm (under SP)
how does the pubocervical fascia tend to break
3 supports = 3 defects
tends to break at lateral attachments of immediately in front of the cervix
what is the rectovaginal fascia and where is it located
fibro-musculo-elastic tissue
centrally - merge with the base of cardinal/uterosacral ligaments and peritoneum
laterally - fuses with fascia over levator ani
distally - firmly to the perineal body
where does the rectovaginal fascia tend to break
centrally
if upper defect = enterocele
describe the 3 levels of endopelvic support
I - uterosacral ligaments, cardinal ligaments
II - para-vagina to arcus tendineus fascia: pubocervical/rectovaginal fascia
III - urogenital diaphragm and perineal body
what levels of support do we aim for when repairing different types of prolapse
I - apical prolaps
II - vaginal prolapse
III - perineoplasty, perineorraphy
risk factors of POPP
PREGNANCY AND VAGINAL BIRTH advancing age obesity previous pelvic surgery other - hormonal factors quality of connective tissue, constipation, occupation with heavy lifting, exercise
risk factors with pregnancy and vaginal birth for POP
forceps delivery large baby (>4500g) prolonged 2nd stage
parity was the strongest risk factor for the development of prolapse
risk increases with increasing parity, rate of increase slows after 2 deliveries
previous pelvic surgery as a risk factor for POP
continence procedures
Burch colposuspension
hysterectomy
continence procedures and POP
while elevating the bladder neck, may lead to defects in other pelvic components
Burch colposuspension and POP
fixing the lateral vaginal fornices to the ipsilateral iliopectineal ligaments
leaves a potential defect in the posterior vaginal wall
presidposes to rectocele and enterocele formation –> 25% of women following Burch colposuspension required further surgery for prolapse
hysterectomy and POP
vaginal vault prolapse 9-13yrs after hysterectomy, in 11.6% of women who had the hysterectomy for prolapse and in 1.8% of women who had the hysterectomy for their benign disease
excercise and POP
weight lifting
high impact aerobics
long distance running
increased risk of urogenital prolapse
traditional classification of prolapse
depends on the site of the defect and the presumed pelvic viscera that are involved
urethrocele cystocele uterovaginal prolapse enterocele rectocele
implies a unrealistic certainty as to the structures on the other side of the vaginal bulge
this is often a false assumption, esp in women w/ prev prolapse surgery
what is a urethrocele
prolape of the lower anterior vaginal wall involving the urethra only
what is a cystocele
prolapse of the upper anterior vaginal wall involving the bladder
what is a uterovaginal prolapse
prolapse of the uterus, cervix and upper vagina
aka apical prolapse
what is an enterocele
prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
what is a rectocele
prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
what can be seen on this imaging
cystocele
anterior wall prolapse
what can be seen on this imaging
rectocele
posterior wall prolapse
what can be seen on this imaging
enterocele
apical prolapse
typical symptoms in women w/ POP - vaginal
sensation of a bulge/protrusion e.g. feels like sitting on a tennis ball etc seeing/feeling a bulge protrusion pressure heaviness difficulty in inserting tampons
typical symptoms in women w/ POP - urinary
urinary incontinence
frequency/urgency
weak/prolonger urinary stream, hesitancy, feeling of incomplete emptying
manual reduction of prolapse to start or complete voiding
typical symptoms in women w/ POP - bowel
incontinence of flatus or liquid/solid stool
feeling of incomplete emptying, straining
urgency
digital evacuation to complete defecation
splinting or pushing on/around the vagina/perineum to start/complete defecation
assessment of POP
mainly a clinical assessment:
examination to exclude pelvic mass
record the position of the examination e.g. L lateral vs lithotomy vs standing
QOL
objective assessment
objective assessment of POP
Baden- Walker-Halfawy Grading
POPQ score - gold standard
others
pelvic floor evaluation
investigations for POP
none as standard = clinical diagnosis
USS/MRI - allow identification of fascial defects/measurement of levator ani thickness (research only)
urodynamics - concurrent UI or exclude occult SI
IVU/renal USS - if suspicion of ureteric obstruction
prevention of POP
avoid constipation
effective management of chronic chest pathology - COAD, asthma (prevent coughing to prevent increase in intra-abdo pressure)
improvements in antenatal and intra-partum care
muscle training for prevention of POP
antenatal and post-natal pelvic floor muscle training has not yet been shown to conclusively reduce the incidence of prolapse, although there are logical reasons to think that it may be protective
treatment of POP
conservative
physiotherappy
physiotherapy for POP
pelvic floor muscle training (PFMT)
- increase pelvic floor strength and bulk - relieve tension on the ligaments
education re. pelvic floor exercises may be supplemented with the use of a perineometer and biofeedback, vaginal cones and electrical stimulation
when can physiotherapy be used for POP
mild prolapse
younger women who haven’t yet completed their family
no role in advanced cases
cannot treat fascial defects
pessaries for POP
silicone/rubber/plastic/ lucite based device
type of device depends on type of prolapse
helps place prolapse back into the vagina
patient can insert and remove them by themself to continue having sex - not for all pessaries
advantages of silicone for pessaries
long shelf life
resistance to autoclaving and repeated cleaning
non-absorbant towards secretions and odours
inertness
hypoallergenic
vaginal pessaries vs surgery
prospective observational study:
woman’s decision: surgery vs pessary
no sig difference in median parity, HRT, pre-op bowel, urinary, sexual symptoms
exclusions: prev POP surgery, unable to retain pessary for 2wks
results: no pessary related complications and no sig post-op morbidity
12 mths: no sig difference in bowel, urinary, sexual symptoms
at 1yr, follow-up successful pessary treatment is as effective as surgery §
general principles of surgical treatment
patient choice and informed decision
depends on age, sexual activity and patient expectations
usually indicated due to impact on QOL +/- exteriorised prolapse (stages 3/4)
aim of surgical treatment for POP
relieve symptoms
restore/maintain bladder and bowel function
maintain vaginal capacity for sexual function
what is surgical treatment of POP directed towards
the projecting compartments
anterior wall prolapse = anterior wall repair
posterior wall prolapse = posterior vaginal wall repair
apical prolapse = vaginal hysterectomy/hysteropexy, sacrospinous fixation, abdominal sacro-colpo-pexy/hysteropexy
usually combinations of the above
colpocleisis - vaginal closure, no penetrative intercourse
what is important to remember for surgical treatment of POP
prophylactic abx
thrombo-embolic prophylaxis
post-op urinary vs SPC
