pelvic organ prolapse Flashcards

1
Q

what does POP stand for?

A

pelvic organ prolapse

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2
Q

what is prolapse?

A

protrusion of an organ or structure beyond its normal anatomical confines

prevalence 12-30% multiparous woman, 2% nulliparous woman

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3
Q

what is female POP?

A

refers to the descent of the pelvic organ towards or through the vagina

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4
Q

what are the 3 layers of the pelvic floor?

A

endo-pelvic fascia
- network of fibro-muscular connective tissue

pelvic diaphragm
- layer of striated muscles with fascial coverings (levator ani & coccygeus)

urogenital diaphragm
- superficial and deep transverse perineal muscles with fascial coverings

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5
Q

what composes the endo-pelvic fascia?

A

uterosacral/cardinal complex: tends to break medially

pubocervical fascia: tends to break laterally

rectovaginal fascia: tend to break centrally

  • upper defect = enterocele
  • lower defect = perineal body descent and rectocele
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6
Q

what are the 3 levels of endopelvic support?

A

level 1

  • uterosacral ligaments
  • cardinal ligaments

level 2

  • pubocervical fascia
  • rectovaginal fascia

level 3

  • urogenital diaphragm
  • perineal body
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7
Q

what are risk factors for POP?

exam question

A

pregnancy and vaginal birth: forceps delivery, large baby (>4.5kg), prolonged second stage of labour, greater parity (parity is the amount of times a woman has been pregnant)

advancing age

obesity

previous pelvic surgery: continence procedures or hysterectomy

other: hormonal factors, constipation, heavy lifting, exercise (weight lifting, high impact aerobics and long distance running)

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8
Q

what are the different classifications of POP?

A

urethrocele: prolapse of lower anterior vaginal wall involving urethra only
cystocele: prolapse of upper anterior vaginal wall involving the bladder
uterovaginal: prolapse of uterus, cervix and upper vagina
enterocele: prolapse of the upper posterior wall of the vagina usually containing small loops of bowel
rectocele: prolapse of the lower posterior wall of vagina involving rectum bulging into vagina

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9
Q

what is the presentation of POP?

A

vaginal symptoms

  • bulging or protrusion
  • pressure
  • heaviness
  • difficulty in inserting tampons

urinary symptoms

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

bowel symptoms

  • incontinence of flatus, liquid or solid stool
  • feeling of incomplete emptying/straining
  • urgency
  • digital evacuation to complete defecation
  • splinting (pushing on or around vagina or perineum) to start or complete defecation)
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10
Q

what are different methods of measuring the severity of POP?

A

Baden-Walker-Halfaway grading

POPQ score – gold standard (image below)

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11
Q

what investigations are done for POP?

A

clinical diagnosis

investigations only for associative symptoms

  • USS/MRI: fascial defects/measurement of levator ani thickness
  • urodynamics: concurrent UI or to exclude occult SI
  • IVU or renal USS: ureteric obstruction
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12
Q

describe the management of POP?

A

prevention

  • avoid constipation
  • effective management of chronic chest pathology (COPD and asthma)
  • smaller family size
  • improvements in antenatal and intra-partum care

conservative

  • physiotherapy: Pelvic floor muscle training (PFMT)
  • pessaries: prosthetic device inserted into vagina

surgery

  • anterior vaginal wall repair
  • posterior vaginal wall repair
  • apical: vaginal hysterctomy/hysteropexy, sacrospinous fixation, abdominal sacro-colpo-pexy/hysteropexy
  • colpocleisis: vaginal disclosure

+ prophylactic antibiotics + thrombo-embolism prophylaxis

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