Pelvic Organ Prolapse Flashcards
POP overal ideas
- clinically relevant only if symptomatic (pressure, bulge, sexual dysfunction, abnormal lower urinary or bowel function)
- usually occurs if reaches 0.5cm above the hymen
- 13% lifetime risk of surgery
- 30% risk of repeat surgery
POP staging
- Stage 0: no prolapse
- 1: higher than 1cm above hymen
- 2: at 1cm above to below hymen
- 3: more than 1cm below hymen
- 4: procidentia (complete prolapse or eversion)
Risk factos POP
Parity vaginal delivery age obesity connective tissue disease menopause chronic constipation
w/u POP
hx: symptoms, past medical, surgical hx exam: - vaginal epithelium looking for atrophy - do pelvic exam in standing position - POP-Q eval - assessment of muscle tone labs: - UA - PVR (if prolapsed stage 3 or 4) - urodynamic testing is stage 2 or worse
POP Treatment: non-surgical options
- high fiber diet
- osmotic laxatives
- local estrogen therapy
- vaginal pessary (change every 3-4 months, or more frequently if wall erosion occurs)
POP surgical treatment options for upper vaginal prolapse
Abdominal sacral colpopexy (with mesh)
- for pt with short vagina, other intra-abdominal pathology ad risk for POP recurrence
- can be laparoscopically/robotic
USLS
Sacrospinus ligament fixation
POP surgical management: anterior wall prolapse
Anterior colporrhaphy
POP surgical management: posterior wall prolapse
posterior colporrhaphya
POP surgical management: apical vaginal prolapse and/or anterior wall prolapse
repair with synthetic or biological graft
POP surgical management: Uterine prolaps
Hysterectomy with USLS and sacrospinous ligament suspension
hysteropexy comprising attachment of the cervix to the sacrospinous ligaments (less invasive and reduced morbidity compared to hysterectomy)
Mesh
Mesh with prolapse repair is associated with ~10% risk of erosion (with 10% of those patients needing re-operation)
Effective for anterior wall prolapse (not posterior wall), should only be considered in high risk pt such as those with recurrence or medical co-morbidities
Compared to natural tissue for anterior wall repair, polypropylene mesh provides better anatomic and subjective results, but higher morbidity
special surgical training required
anterior repair or apical compartment prolapse surgery
should get a cystoscopy always
Complications from mesh
- Bleeding, infections (especially UTI)
- Voiding dysfunction (typically transient)
- Structual anatomic breach (fistula, ureteral injury, diminished vaginal capacity which can cause dyspareunia)
- mesh erosion
- symptom recurrence with need for repeat surgery