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Y3 repro > pelvic organ prolapse > Flashcards

pelvic organ prolapse Flashcards

1
Q

what is a prolapse

A

protrusion of an organ/structure beyond its normal anatomical confines

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2
Q

what is female POP

A

female pelvic organ prolapse

the descent of the pelvic organs towards or through the vagina

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3
Q

incidence of prolapse

A

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

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4
Q

prevalence of prolapse

A

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

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5
Q

what % of hysterectomies are indicated due to prolapse

A

7-14%

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6
Q

why must the pelvic cavity wall be flexible

A

to withstand changes in volume of these organs and also pressure changes within the cavity

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7
Q

what does the pelvic floor contain

A

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

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8
Q

what are the 3 layers of the pelvic floor

A

endo-pelvic fascia
pelvic diaphragm
urogenital diaphragm

3 layers do not parallel each other and vary in strength and thickness from place to place

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9
Q

what does the pelvic floor act as

A

1 functional unit made from 3 layers

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10
Q

what is the endo-pelvic fascia

A

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

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11
Q

what is the pelvic diaphragm

A

layer of striated muscles with its fascial coverings

levator ani and coccygeus

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12
Q

what is the urogenital diaphragm

A

superficial and deep transverse perineal muscles with their fascial coverings

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13
Q

how stretchy is the endo-pelvic fascia

A

fibro-muscular component can stretch

connective tissues doesn’t stretch or attenuate, instead it breaks

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14
Q

location of the uterosacral/cardinal complex

A

medially to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia

laterally to the sacrum and fascia overlying the piriformis muscle

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15
Q

how can the uterosacral complex be palpated

A

down traction on the cervix and if intact allows limited side-side movement of the cervix

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16
Q

how does the utero-sacral complex tend to break

A

medially - around the cervix

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17
Q

what is the pubocervical fascia and what is its role

A

trapezoidal fibro-muscular tissue

provides the main support of the anterior vaginal wall

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18
Q

location of the pubocervical fascia

A

centrally - merge with the base of the cardinal ligaments and cervix
laterally - arcus tendineus fascia pelvis (white line)
distally - urogenital diaphragm (under SP)

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19
Q

how does the pubocervical fascia tend to break

A

3 supports = 3 defects

tends to break at lateral attachments of immediately in front of the cervix

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20
Q

what is the rectovaginal fascia and where is it located

A

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

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21
Q

where does the rectovaginal fascia tend to break

A

centrally

if upper defect = enterocele

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22
Q

describe the 3 levels of endopelvic support

A

I - uterosacral ligaments, cardinal ligaments

II - para-vagina to arcus tendineus fascia: pubocervical/rectovaginal fascia

III - urogenital diaphragm and perineal body

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23
Q

what levels of support do we aim for when repairing different types of prolapse

A

I - apical prolaps
II - vaginal prolapse
III - perineoplasty, perineorraphy

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24
Q

risk factors of POPP

A 
PREGNANCY AND VAGINAL BIRTH
advancing age 
obesity
previous pelvic surgery
other - hormonal factors quality of connective tissue, constipation, occupation with heavy lifting, exercise
25
Q

risk factors with pregnancy and vaginal birth for POP

A 
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

26
Q

previous pelvic surgery as a risk factor for POP

A

continence procedures
Burch colposuspension
hysterectomy

27
Q

continence procedures and POP

A

while elevating the bladder neck, may lead to defects in other pelvic components

28
Q

Burch colposuspension and POP

A

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

29
Q

hysterectomy and POP

A

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

30
Q

excercise and POP

A

weight lifting
high impact aerobics
long distance running

increased risk of urogenital prolapse

31
Q

traditional classification of prolapse

A

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

32
Q

what is a urethrocele

A

prolape of the lower anterior vaginal wall involving the urethra only

33
Q

what is a cystocele

A

prolapse of the upper anterior vaginal wall involving the bladder

34
Q

what is a uterovaginal prolapse

A

prolapse of the uterus, cervix and upper vagina

aka apical prolapse

35
Q

what is an enterocele

A

prolapse of the upper posterior wall of the vagina usually containing loops of small bowel

36
Q

what is a rectocele

A

prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina

37
Q

what can be seen on this imaging

A

cystocele

anterior wall prolapse

38
Q

what can be seen on this imaging

A

rectocele

posterior wall prolapse

39
Q

what can be seen on this imaging

A

enterocele

apical prolapse

40
Q

typical symptoms in women w/ POP - vaginal

A 
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
41
Q

typical symptoms in women w/ POP - urinary

A

urinary incontinence
frequency/urgency
weak/prolonger urinary stream, hesitancy, feeling of incomplete emptying
manual reduction of prolapse to start or complete voiding

42
Q

typical symptoms in women w/ POP - bowel

A

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

43
Q

assessment of POP

A

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

44
Q

objective assessment of POP

A

Baden- Walker-Halfawy Grading
POPQ score - gold standard
others

45
Q

pelvic floor evaluation

A
46
Q

investigations for POP

A

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

47
Q

prevention of POP

A

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

48
Q

muscle training for prevention of POP

A

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

49
Q

treatment of POP

A

conservative

physiotherappy

50
Q

physiotherapy for POP

A

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

51
Q

when can physiotherapy be used for POP

A

mild prolapse
younger women who haven’t yet completed their family
no role in advanced cases
cannot treat fascial defects

52
Q

pessaries for POP

A

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

53
Q

advantages of silicone for pessaries

A

long shelf life
resistance to autoclaving and repeated cleaning
non-absorbant towards secretions and odours
inertness
hypoallergenic

54
Q

vaginal pessaries vs surgery

A

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 §

55
Q

general principles of surgical treatment

A

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)

56
Q

aim of surgical treatment for POP

A

relieve symptoms
restore/maintain bladder and bowel function
maintain vaginal capacity for sexual function

57
Q

what is surgical treatment of POP directed towards

A

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

58
Q

what is important to remember for surgical treatment of POP

A

prophylactic abx
thrombo-embolic prophylaxis
post-op urinary vs SPC

Y3 repro (47 decks)

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