Pelvic Organ Prolapse Flashcards
What is female pelvic organ prolapse (POP)?
Descent of the pelvic organs towards or through the vagina
What are the 3 distinct layer of the pelvic floor?
- Endopelvic fascia
- Pelvic diaphragm
- Urogenital diaphragm
What is the endopelvic fascia?
fibro-muscular connective tissue that surrounds 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?
Superficical and deep transverse perineal muscles with their fasical coverings
What direction does the utero-sacral/cardinal complex tend to break in?
Medially (around the cervix)
What provides the main support of the anterior vaginal wall?
Pubocervical fascia
Where does the pubocervical fascia tend to break?
At lateral attachments or immediately infront of the cervix
How does the rectoaginal fascia tend to break?
- Usually breaks centrally
- If upper break it is called entrocele
What is included in level 1 of endopelvic support?
- Utero-sacral ligaments
- Cardinal ligaments
What is included in level 2 of endopelvic support?
- Para-vagina to arcus tendineus fascia
- Pubocervical/rectovaginal fascia
What is included in level 3 of endopelvic support?
- Uritogenital diaphragm
- Perineal body
Main risk factors for POP?
- Pregnancy and vaginal birth (forceps baby, large baby, prolonged second stage)
- Advancing age
- Obesity
- Previous pelvic surgery
Other risk factors for POP?
- Hormonal factors
- Quality of connective tissue
- Constipation
- Occupation with heavy lifting
- Exercise (weight lifting, high impact aerobics, long distance running)
What is an urethrocele?
Prolapse of lower anterior vaginal wall involving urethra only
What is a cystocele?
Prolapse of upper anterior vaginal wall involving the bladder
What is a uterovaginal prolapse?
Prolapse of uterus, cervix and upper vagina
What is an enterocele?
Prolapse of upper posterior wall of vagina usually containing loops of small bowel
What is a rectocele?
Prolapse of lower posterior vaginal wall involving rectum bulging forwards into the vagina
Symptoms of POP (vaginal)?
- Sensation of bulge or protrusion
- Seeing or feeling bulge or protrusion
- Pressure
- Heaviness
- Difficulty inserting tampons
Symptoms of POP (urinary)?
- Incontinence
- Frequency/urgency
- Weak or prolonged stream/hesitancy/incomplete emptying
- Manual reduction of prolapse to start or complete voiding
Symptoms of POP (bowel)?
- Incontinence of flatus/liquid/solid stool
- Incomplete emptying/straining
- Urgency
- Digital evacuation to complete defecation
- Splinting or push on or around vagina or perineum to start or complete defecation
How is POP assessed?
- Examination to exclude pelvic mass
- Record position of examination (left lateral vs lithotomy vs standing)
- QofL
What scoring tools are used to assess POP?
- POPQ
- Banden-walker
What investigations are done for a prolapse?
None it is a clinical diagnosis (investigations are done for associated symptoms)
How is POP prevented?
- Avoid constipation
- Effective management of chronic chest pathology (COPD + asthma)
- Smaller family size?
- Improvements in antenatal and intra-partum care
How and when prolapse managed through physiotherapy?
Pelvic floor muscle training in cases of mild prolapse
When can physiotherapy not be used for prolapse?
In advanced cases and/or fascial defects
What devices can be used for prolapse and what are their advantages?
Silicone pessaries
- long shelf life
- resistance to autoclaving and repeated cleaning
- non-absorbent to secretions and odors
- inertness
- hypoallergenic
What are the aims of surgery on prolapse?
- Relieve symptoms (not correct the anatomy)
- Restore/maintain bladder + bowel function
- Maintain vaginal capacity for sexual function
What types of surgery are used in anterior and posterior wall prolapses?
- Anterior vaginal wall repair
- Posterior vaginal wall repair
What types of surgery are used in apical prolapses?
- Vaginal hysterectomy/hysteropexy
- Sacrospinous fixation
- Adominal sacro-colpo-pexy / hysteropeyx
