Pelvic organ prolapse Flashcards
What are the main presenting complaints in urogynaecology?
incontinence
vaginal prolapse
(+interstitial cystitis)
List the supporting structures for utero-vaginal
Ligaments:
pubocervical ligamenets, cardinal ligaments, uterosacral ligaments
Muscle: levator ani muscles
How is the pelvic floor damaged?
increase in abdominal pressure
- parity
- obesity
- smoking, coughing, constipation, weight lifting
- occupation
- increase weight of the uterus (e.g. fibroid)
What are the symptoms of prolapse?
lump, urinary, bowels, sex, pain
What are the background/key questions to ask in gynae history?
Background: age parity menstrual history contraception smears STIs sexual history
What are the types of prolapse?
cystocele- anterior/front (bladder)
rectocoele- posterior
uterine- top
enterocoele- upper vagina, descent of vagina and peritoneal sac
What is the management of prolapse?
watch and wait
conservative
trial of pessary
surgery
What is POP-Q?
quantitative assessment for prolapse- grading system for severity of prolapse, based on position of most distal portion of prolapse during straining
What is the conservative management?
eliminate precipitating factors
pelvic floor exercise (physio)
lifestyle modifications (weight and smoking)
estrogen vaginal cream (most patients are post-menopausal therefore vagina is dry, worsening symptoms)
For how long can you leave pessary in?
must take out every night
What is the absolute contraindications for colpocleisis?
sexually active
List three risk factors for prolapse
Increasing age/menopause
vaginal delivery
increasing parity
raised intra abdo pressure
List two causes of raised intra abdo pressure
obesity
chronic cough
chronic constipation
Why does menopause render you more prone to prolapse?
loss of oestrogen and connective tissue strength reduction
How can vaginal delivery result in prolapse
direct trauma with forceps- avulsion of the levator ani or ligaments
pudendal nerve damage
List three vaginal symptoms of prolapse
pressure, fullness, heaviness
bulge- something coming down, worse at end of day better when lying down
bleeding/discharge
backache
List two urinary symptoms of prolapse
incontinence, frequency,, urgency
need to manually reduce prolapse prior to voiding
List two bowel symptoms of prolapse
constipation/straining
faecal incontinence or urgency of stool
incomplete evacuation
Why is the hymenal ring important?
marker for grading of prolapse POP-Q
Which is the most common type of prolapse?
cystocele
In which group of patients is vaginal vault prolapse observed?
post hysterectomy
Name two factors which will influence the management of prolapse
severity + QoL Age + wish for further pregnancies Sexual acitivity Urinary symptoms Smoking and obesity
List two complications of pessaries
sexual intercourse interference
ulceration
infection
difficulty and discomfort when removed
Where are pessaries placed?
between posterior aspect of symphysis pubis and post fornix of vagina
What are the stages of prolapse
stage 1-2= inside vagina
stage 3-4= outside vagina
hymenal ring!!
Why should you be cautious when treating incontinence in elderly population?
elderly more susceptible to antimuscarinic cognitive side effects due to pre-existing cognitive impairment
