Pelvic organ prolapse Flashcards
How many stages of pelvic organ prolapse are there?
5 stages
What is stage 0 pelvic organ prolapse?
No prolapse
What is stage 1 pelvic organ prolapse?
Most distal prolapse more than 1cm above the hymen
What is stage 2 pelvic organ prolapse?
Most distal prolapse between 1cm above and 1cm below hymen
What is stage 3 pelvic organ prolapse?
Most distal prolapse more than 1cm below hymen but no further than 2cm less than total vaginal length
What is stage 4 pelvic organ prolapse?
Complete procidentia
What is the management for pelvic organ prolapse?
Conservative management with Kegel exercises, avoiding chronic cough and constipation, pessary or surgery
What are the steps of a total vaginal hysterectomy?
- Grasp the anterior lip of cervix with tenaculum
- Inject the vaginal mucosa at the cervical vaginal junction with vasopressin around entire cervix
- Use scalpel and incise the mucosa around the entire cervix (make sure to stay above the pubovesical cervical fascia anteriorly and perirectal fascia posteriorly
- Apply downward traction on tenaculums and dissect the bladder off the anterior lower uterine segment all the way up to the peritoneal vseciouterine fold
- Right angle retractor is placed underneath the vaginal mucosa and bladder to elevate the bladder
- Grasp the vesicouterine fold and incise with mayo scissors and place finger into hole that was created and ensure in the peritoneal cavity. Place right angle retractor into hole
- Elevate the tenaculums to expose the posterior cul de sac. Use pickup to retract the posterior vaginal cuff and create tension on the peritoneum of cul de sac. Mayor scissors are used to incise the peritoneum. A finger is placed in the hole to ensure in the cul de sac then replace finger with right angle retractor
- Elevate the cervix and move lateral to expose the uteral sacral ligament. Haney clamp used to clamp above and below the uteral sacral ligament close to the uterine cervix to avoid damage to ureter laterally. Cut uterosacral ligament with mayo scissors. O-vicryl used to suture ligate the ligament. Suture then held with Kelly clamp.
- Next cardinal ligament is clamp next to uterine cervix and cut with mayo scissors. Cardinal ligament is suture ligated with 0-vicryl and held with Kelly clamp.
- Uteral sacral and cardinal ligaments are clamped and suture ligated on the opposite side
- Uterine arteries are clamped cut and suture ligated on both sides
- Cervix is retracted upward and small retractors are used to walk out the posterior uterine body to deliver the fungus posteriorly
- Finger inserted under the tuboovarian round ligament and pedicle clamped twice cut and suture ligated. Repeated on opposite side
- Vaginal cuff closure
What is an enterocoele?
Small bowel prolapse
Small bowel descends into the lower pelvic cavity and pushes on the top part of the vagina creating a bulge
How do you diagnose an enterocoele?
Perform a recto-vaginal exam and ask patient to valsalva. Usually can feel a bulge of the cul-de sac herniation between fingers
What procedure can prevent enterocoele?
Halban culdoplasty
vertical sutures obliterating cul-de sac incorporating the uterosacrals
What procedure can treat enterocoele?
- Moskowitz culdoplasty
- McCall culdoplasty
What procedures can treat vaginal vault prolapse?
- Abdominal sacrocolpopexy
- Sacrospinous ligament fixation
- Uterosacral ligament suspension
What is a McCall culdoplasty?
Plication of uterosacral ligaments in the midline
Usually performed as prophylaxis for vault prolapse
What are risk factors for recurrent prolapse after surgical repair?
- Age < 60
- BMI >26
Preoperative stage 3-4 prolapse
