Pelvic organ prolapse Flashcards
What is the Baden walker scoring system?
stage 0 no prolapse.
Stage 1: most distal proalspe more than 1cm above hymen
Stage 2 : between 1cm above and below hymen
Stage 3: most distal more than 1cm below the hymen
Stage 4: complete procidentia
What is the POPQ scoring system?
stage 0=no prolapse
Stage 1: most distal prolapse more than 1 cm above hymen
Stage 2: most distal prolapse between 1cm above and below hymen
Stage 3: most distale portion more than 1cm distal to the hymen but no further than 2 cm less than TVL
Stage 4: complete procidentia
More precise and reproducible than Baden walker system.
uses description relating to degree of descent of 9 points
- Aa: anterior wall 3cm proximal to external urethral meatus
-Ba: most prolapsed portion of anterior vagina
- C: leading edge of cervix/vaginal cuff
- gh: middle of urethral meatus to posterior hymen
- pb: posterior hymen to middle anal opening
- TVL: hymen to most distal point of vagina. maximal depth of vagina when prolapse reduced
- Ap: posterior wall is 3cm proximal to posterior hymen
- Bp: most prolapsed portion of posterior vaginal wall
- D: posterior fornix (if cervix present).
How would you counsel patient about treatment options for bulging symptoms?
- Kegel’s, topical estrogen if atrophic changes/postmenopausal
- treat any cause of chronic cough, constipation (causes chronic valsalva)
- Pessary (erosion rate 2-9%, if erosion, remove pessary for 2-4 wks and tx w/ local estrogen)
- Surgery
Refer to urogynecology. always option of Le Fort (complete obliteration, no sexual intercourse)
What are the different surgical options for pelvic organ prolapse?
(first 2 are prophylactic):
1. McCall Procedure: know this. Also have to do cysto to evaluate ureter.
2. Uterosacral ligament suspension: done vaginally or abdominally. need to do cysto after. Failure 50-70% at 5 years. plicate uterosacral ligaments to ipsilateral cuff angle (as high as ischial spine)
- Abdominal sacrocolpopexy: suture mesh from vagina/cervical stump to anterior longitudinal sacral ligaments below sacral promontory. It’s most successful but risk of bowel entanglement with mesh. Place peritoneum over the mesh to avoid this. Can injure middle sacral artery?
- Sacrospinous ligament fixation:
- usually deviates vault to pt’s right (sigmoid on left), vaginally. maintains adequate vaginal length/width
- must visualize sacrospinous ligament and put sutures directly in ligament or risk recurrent prolapse
- pudendal artery/nerve immediately posterior and inferior to ischial spine. place sutures >2cm medial to ischial spine to avoid pudendal nerve injury which can cause chronic pain.
- tie vaginal vault to R sacrospinous ligament. Easier on the R bc you have sigmoid colon in the way on the L. can do it vaginally but higher failure rate than abdominal sacrocolpopexy. Failure rate 50-70% at 5 years.
What are pessaries?
Ring with support: most common.
Incontinence dish: stress incontinence
Space-occupying (Gelhorn, cube, donut)
Remove q3 months if pt unable to maintain at home. If can maintain at home, remove/clean weekly. If going longer, use vaginal estrogen to prevent erosions (if post-menopausal and no hx breast cancer).
How do you avoid subsequent prolapse after hysterectomy?
Incorporate uterosacral ligaments into closure of the vaginal cuff.
How do you diagnose an enterocoele?
perform reto-vaginal exam, ask patient to Valsalva. Feel for bulge of cul-de-sac herniation (usually containing bowel) between fingers.
enterocele: small bowel prolapse
What are types of enterocele prevention?
avoid damage to ureters w/ all types!
Halban Culdoplasty: serial vertical sutures obliterating cul-de-sac incorporating uterosacral ligaments. performed abdominally. ONLY PREVENTS ENTEROCELE.
Moskowitz Culdoplasty: serial purse string sutures (circular) obliterating cul-de-sac incorporating uterosacral ligaments. abdominally.
McCall culdoplasty: pulls uterosacral ligaments in the midline. attaching the uterosacral to peritoneum and then vaginal vault. Performed VAGINALLY. PROPHYLAXIS FOR VAULT PROLAPSE. need cyst to confirm ureteral integrity (can kink ureter up to 11% and occlude it 2% of the time).
What are most important parts of prolapse evaluation?
assess and grade the 5 compartments:
- uterine prolapse (ir vault apex prolapse if uterus absent)
- anterior vaginal wall (cystocele)
- posterior vaginal wall (rectocele): prolapse BELOW rectovaginal septum apex
- Enterocele (present or absent): prolapse ABOVE rectovaginal septum apex.
- Vaginal outlet (perineal body) - important in repair of rectocele
Use speculum and bimanual w/ rectal exam. examine in supine and standing positions.
Discriminate btw cystocele and stress incontinence.
Assess lower urinary tract function (evaluate for incontinence) and adequacy of bladder emptying.
If apical prolapse, do eval for occult stress incontinence.
40% of women w/o stress incontinence develop sx after surgical correction of pOP.
What are risk factors for recurrent prolapse after surgical repair?
Age <60
Obesity
Pre-operative stage 3-4 prolapse
Describe the sacrospinous ligament fixation?
For the dissection: enter the rectovaginal space, penetrate the right rectal pillar into the pararectal space.
A routine posterior vaginal incision is made and extended to the top of the vagina. Using sharp dissection the vagina is freed from the underlying rectovaginal fascia and rectum until the pelvic floor (puborectalis) muscle is seen. Using sharp and blunt dissection the sacrospinous ligament running from the ischial spine to the sacral bone is palpated and identified.
Two sutures are placed through the strong ligament and secured to the top of the vagina. This results in increased support to the upper vagina. There is no shortening of the vagina.
Place suture in sacrospinous ligament: 1-2 fingerbreaths medial, through the ligament.
If enounter bleeding, likely injured the pudendal vessel. Use pressure, tie suture. last resort would be a hypogastric artery ligation.
If pt has excruciating buttock pain, what nerve is injured? sciatic nerve. take back to RO to remove stitch.
Post-op recurrence of cystocele, loss of UVJ support and SUI common. less effective for anterior wall support.
What are the 2 types of vaginal vault suspension?
How do you close the vault in case of uterine prolapse?
Sacrospinous ligament vaginal vault suspension
Uterosacral ligament vaginal vault suspension.
Shorten ligaments prior to incorporating pedicles in the vault.
Describe the uterosacral ligament suspension
vaginal approach. open vaginal apex, dissect and identify uterosacral ligament. 2 or 3 permanent sutures placed through each ligament. should be 1.5cm posterior and medial to ischial spine.
- one arm of each suture passed through anterior muscular and posterior end-pelvic fascia. sutures tied to elevate the vaginal apex.
- positions vaginal apex in anatomically correct orientation and decreases problems w/ SUI.
- complication: ureteral obstruction (need cysto!). kinking of ureters occurs in 11% of cases. If both ureters don’t efflux, remove most lateral suture on that side.
- can ligate sacral nerve if sutures placed too deep in pelvic sidewall.
Describe an abdominal sacral colpopexy
provides permanent support of vaginal apex by affixing mesh graft to anterior and posterior dissections of vaginal apex (or to cervix) and via retroperitoneal tunnel, fixation of graft to anterior sacrum
- dissect posteriorly to rectovaginal septum for mesh placement, can reduce rectocele, obliterates cul-de-sac and prevents recurrence of enterocele.
- complications: bleeding from middle sacral vessels and mesh erosion into vaginal apex
- need Urethropexy (Burch or similar) also. Burch colposuspension done in women w/ symptomatic SUI or prophylactic in women w/ advanced prolapse who are likely to develop SUI after colpopexy.
Describe partial and complete colpocleisis
Partial (Le Fort): done when uterus left in-situ. remove strips of anterior and posterior vaginal epithelium and obliterates mid-portion of vagina. lateral portions left open for draining for uterine bleeding/discharge.
Complete: done when pt is s/p hyst. obliterates vaginal vault with repair of enterocele prior to closing off vagina. permanent correction of prolapse for women who won’t be sexually active.
Undergo EMB, pap and urodynamics prior to procedure.
