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OBGYN > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

What is the definition of utero vagina prolapse?

A

Descent of the uterus and/or vaginal walls beyond normal anatomical confines

Type of herniation

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2
Q

What is the epidemiology of uterovaginal prolapse?

A

40-60% of porous women have some degree of prolapse on examination (due to loss pelvic wall support)

6-8% report a bulging mass

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3
Q

What makes up the pelvic floor?

A
  • muscular and fascial structures
  • transverse cervical (cardinal) ligaments
  • uerosacral ligaments
  • endopelvic fascia
  • Levator ani/ perineal muscles
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4
Q

What is the role of the pelvic floor?

A

Support pelvic organs and external openings

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5
Q

What are the uterus and vagina suspended from the pelvic side walls by?

A

Endopelvic fascial attachments that support the vagina @ 3 levels

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6
Q

What makes up the pelvic floor?

A
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7
Q

What is level 1 of the pelvic floor?

A
  • cervix and upper 1/3 vagina
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8
Q

What is level 1 of the pelvic floor supported by?

A

Cardinal (transverse cervical) and uterosacral ligaments

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9
Q

What is level 2 of the pelvic floor?

A

Mid-portion of the vagina

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10
Q

What is the mid-portion of the vagina (level 2) attached by?

A

Endopelvic fascia laterally to pelvic side walls

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11
Q

What is level 3 of the pelvic floor?

A

Lower 1/3 of the vagina

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12
Q

What is the lower 1/3 of the vagina (level 3) supported by?

A

Levator ani muscles and perineal body

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13
Q

What do Levator ani muscles form?

A

The floor of the pelvis form attachments on the bony pelvic walls and incorporate the perineal body

Leavator ani + associated fascia termed the pelvic diaphragm

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14
Q

What are the 3 components of each Levator ani muscle?

A

ischiococcygeus, iliococcygeus, pubococcygeous

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15
Q

What does the pelvic floor look like?

A
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16
Q

How are the types of prolapse classified?

A

Anatomically acc. To site of defect and pelvic organs affected

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17
Q

What are the different types of prolapse?

A
  • uterine prolapse or vaginal vault prolapse
  • anterior vaginal wall
  • posterior vaginal wall
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18
Q

What are the 3 types of anterior vaginal wall prolapses?

A
  • urethrocele
  • cystocoele
  • cystourethrocoele
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19
Q

What are the two types of posterior vaginal wall prolapses?

A
  • enterocoele
  • retocoele
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20
Q

What is the normal pelvic anatomy?

A
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21
Q

What are the different types of pelvic organ prolapse?

A
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22
Q

What do you need to record when grading a prolapse?

A
  • position of patient
  • rest or straining
  • use of traction
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23
Q

What is one method of grading uterine prolapse?

A

Grade 1: Uterus dropped slightly, within vagina, many unaware of the prolapse, noticed during a routine pelvic examination

Grade 2: The cervix and uterus dropped further, felt or seen at the introitus

Grade 3: Cervix and uterus seen or felt outside the vagina. This is the most severe of uterine prolapse and also known as procidentia

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24
Q

What is the Baden Walker / Quantative POP Classification for pelvic organ prolapse?

A

Stage 0: no descent of pelvic organs
Stage 1: Descent to any point in the vagina above the hymen
Stage 2: Descent to the level of the hymen
Stage 3: Descent beyond the hymen
Stage 4: the entire uterus outside the vagina
(procidentia)

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25
Q

What does the Baden Walker Classification use as a landmark?

A
26
Q

What is this?

A

Procidentia

27
Q

What is this?

A

Cystocele

28
Q

What is a cystocele?

A

When there is a defect in the anterior wall supports and this allows the bladder to prolapse into the vaginal wall

29
Q

Does a cystocele always present with symptoms?

A

May be asymptomatic

30
Q

What are some of the symptoms of a cystocele? (5)

A
  • incomplete emptying
  • hesitancy
  • slow stream
  • frequency
  • urinary incontinence (stress): can lessen with higher degrees of prolapse due to urethral kinking
31
Q

What is this?

A

Rectocele

32
Q

What is a rectocele?

A

Where the defect is in the posterior wall supports of the vagina and as a result the rectum bulges forward into the vagina

33
Q

What symptoms can a rectocele cause? (4)

A

difficulty emptying the bowel:
* constipation
* incomplete emptying
* straining
* post-void soiling

34
Q

What is this?

A

Enterocoele

35
Q

What is an enterocoele?

A

Where the small bowel prolapses into the top of the vagina between the uterus and rectum

36
Q

What is different about an enterocoele compared to the other pelvic organ prolapses?

A

It is a true hernia - protrusion of the peritoneum of the pouch of Douglas through upper posterior wall of vagina - resulting pouch usually contains loops of small bowel

37
Q

What are the risk factors/etiologies for pelvic organ prolapse? (5)

A
  • pregnancy & delivery
    esp. bigger babies, longer 2nd stage, instrumental delivery
  • CT disorders (eg EDS)
  • menopause
  • anything that increases intraabdominal pressure (constipation, high BMI, chronic cough, heavy lifting, mass)
  • surgery
38
Q

What is seen in the history of a patient with pelvic organ prolapse?

A
  • ‘Dragging sensation/something coming down’
    -(suprapubic or vaginal discomfort. Occasionally backache)
    • Worse at end of day
    • Worse at straining/exercise
    • ? Lump at introitus or outside
  • Dysparuenia
  • Vaginal discharge/bleeding (if at intrutis then PCB)
  • Urinary/Bowel Symptoms
    (include splinting - applying digital pressure to aid emptying)
  • QOL
  • Pre-disposing factors

Note: medical, surgical, medications, family and social history can be relevant to surgical risk

39
Q

What examination is done for pelvic organ prolapse?

A
  • observation (eg with procidentia will find it difficult to walk)
  • abdomen (mass)
  • pelvic =. Mass, pelvic floor tone, ask them to bear down having moved your finger back a bit from the cervix and will feel it come down to it
  • Sims speculum in left lateral position
  • PR/DRE = to evaluate (P) wall prolapse
40
Q

What investigations are needed to diagnose a pelvic organ prolapse?

A

None - CLINICAL DIAGNOSIS

41
Q

What investigations may be considered to aid diagnosis of a pelvic organ prolapse? (4)

A
  • urinalysis (if urinary symptoms - infection)
  • pelvic US (if mass suspected)
  • urodynamics (urge/mixed incontinence symptoms)
  • ultrasound assessment of pelvic floor
42
Q

Why might patients with a pelvic organ prolapse need investigations?

A

To assess fitness for surgery

43
Q

What are some ways to prevent pelvic organ prolapse? (5)

A

Vaginal delivery issues:
* recognition and management of obstructed labour
* avoidance of excessively long 2nd stage
* ?? C-section

Post-delivery:
* pelvic floor exercises

Others:
* modifiable risk factors

44
Q

How are pelvic organ prolapses managed?

A
  • if asymptomatic ?no treatment
  • alter modifiable predisposing factors
  • physio - PFE’s (helps mild to moderate prolapse)
  • pessaries (usually combined with oestrogen)
  • oestrogen replacement - topical usually (vagifen cream)
  • surgical
  • modifiable risk factors
45
Q

What pelvic floor exercises are recommended for mild prolapse?

A
  • PFMT: physio led x3/12 8 contractions 3 times/day
    (One to one training for 4-6months has lead to improvement in prolapse symptoms and staging in single centre trails for grade 1-3 prolapse)
  • weights: 2/day, when can do for 15 mins then increase the weight (eg vaginal cones)
46
Q

What were the traditional indications for pessaries? (5)

A
  • wishing to delay surgery until childbearing complete
  • during pregnancy
  • whilst awaiting surgical correction of prolapse
  • serious chronic health problems, such as lung or heart disease where surgery is a considerable risk
  • surgery is not desirable - age -> major factor
47
Q

What do the NICE guidelines of 2019 suggest as management of pelvic organ prolapse?

A
  • discuss management options with women who have pelvic organ prolapse, including no treatment, non-surgical treatment and surgical options, taking into account:
  • the woman’s preference
  • site of prolapse
  • lifestyle factors
  • comorbidities including cognitive or physical impairments
  • age
  • desire for childbearing
  • previous abdominal or pelvic floor surgery
  • benefits and risks of individual procedures
48
Q

What are the two main types of pessaries?

A
49
Q

What are the different types of pessaries?

A

Support & space occupying pessaries

50
Q

What are the complications of pessaries? (9)

A
  • discomfort
  • need to be changed every 6-9 months
  • expulsion
  • difficulty removing (fibrosis)
  • discharge/infections
  • vaginal bleeding: erosions/ulceration
  • fistulas (consider vagifem)
  • urinary retention
  • problems with intercourse (esp. shelf pessary)
51
Q

What are the aims of surgical treatment in pelvic organ prolapse?

A
  • the restoration of normal vaginal anatomy
  • the resoration or maintenance of normal bladder function
  • the restoration or maintenance of normal bowel function
  • the restoration or maintenance of normal sexual function
52
Q

What concomitant surgery should be considered when doing surgery for prolapse?

A

Surgery for stress incontinence

53
Q

What surgeries are there for uterine prolapse? (3)

A
  • vaginal hysterectomy
  • vaginal sacro-spinous hysteropexy with sutures
  • Manchester repair

[* Sacro-hysteropexy with mesh - to preserve uterus ]

54
Q

What is the issue with vaginal hysterectomy for the surgical treatment of uterine prolapse?

A

Doesn’t address underlying poor pelvic support - up to 40% of women subsequently present with vault prolapse

55
Q

How is the no longer done sacro-hysteropexy with mesh done?

A

Uterus and cervix are attached to sacrum using a bifurcated non-absorbable mesh

Open or laparoscopic

56
Q

What are the surgical options for vaginal vault prolapse? (2)

A
  • [ sacrocloprpexy - open or laparoscopic fixes vault to sacrum using a mesh]
  • sacrospinous fixation - vaginally, suspends vault to sacrospinous ligament
57
Q

What are the surgical options for vaginal wall prolapse?

A
  • anterior and posterior repairs - often combined: 90% of all prolapse procedures (also called colporrhapy)
  • no MESH
58
Q

What are some considerations for vaginal hysterectomy?

A
  • anaesthetic: GA vs Spinal
  • catheter and vaginal pack initially
  • hospital x3-4 days
  • minimal exertion 1st week, no heavy lifting or driving for several weeks
59
Q

What were the concerns surrounding Mesh?

A
  • 2008: FDA: public health safety notification regarding adverse events related to urogynaecological use of surgical mesh
    e.g. increased risk of repeat surgery, mesh
    erosion (anterior vaginal wall repair),
    dyspareunia
  • 2011: FDA: synthetic and metallic mesh associated with increased risk of adverse events e.g. mesh erosion which can require multiple surgeries and may result in consequences like pain after removal

In 20191the US FDA ordered manufactures of synthetic mesh for VAGINAL repairs of Pelvic Organ Prolapse, to discontinue sale and distribution in US.

This order does not apply to abdominally placed mesh for POP or that used for Stress Urinary Incontinence.

In 2016 the Lancet published the Scottish Cohort Study of mesh use between 1997-2016 and concluded,

“Our results support the use of mesh procedures for incontinence, although further research on longer term outcomes would be beneficial. Mesh procedures for anterior and posterior compartment prolapse cannot be recommended for primary prolapse repair.”

60
Q

What is the current situation surrounding the use of Mesh in Ireland?

A

July 2018:
HSE placed a pause on the use of mesh procedures for:
-Stress Incontinence
-Pelvic Organ prolapse procedures
Until recommendations surrounding
-Informed Consent
-Accreditation System
-National Mesh Register
Are in place.

OBGYN (25 decks)

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