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Reproductive System > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

What is a prolapse?

A

Protrusion of an organ or structure beyond its normal anatomical confines

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2
Q

What is female pelvic organ prolapse (POP)?

A

Refers to the descent of the pelvic organs towards or through the vagina

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3
Q

What is the incidence of prolapse?

A

True incidence is hard to determine

Estimated to affect 12-30% of multiparous and 2% of nulliparous women

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4
Q

What is the prevalence of prolapse?

A

Estimates vary from 2% for symptomatic prolapse to 50% for asymptomatic prolapse

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5
Q

What percentage of parous women will have some degree of prolapse?
How many of these will seek medical help?

A

Approx 50% of parous women will have some degree

Only 10-20% of these seek medical help

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6
Q

In the UK, what percentage of women on the waiting list for major gynaecological surgery is accounted for by POP?

A

20%

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7
Q

What percentage of indications for hysterectomy is prolapse?

A

7-14%

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8
Q

What does the abdominopelvic cavity contain?

A

All the abdominal and pelvic viscera

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9
Q

Why must the walls of the abdominopelvic cavity be of sufficient flexibility?

A

To withstand the changes in volumes of these organs and also pressure changes within the cavity

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10
Q

What will a normal pelvic floor maintain?

A

If pelvic floor is normal, all pelvic viscera will be maintained in their position, both at rest and in periods of increased intra-abdominal pressure

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11
Q

What are the layers of the pelvic floor?

A

Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm

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12
Q

What is the structure of the endopelvic fascia?

A

Network of fibromuscular connective type tissue that has a hammock-like configuration and surrounds the various visceral structures

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13
Q

What is the structure of the pelvic diaphragm?

A

Layer of striated muscles with its fascial coverings

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14
Q

What is the structure of the urogenital diaphragm?

A

Most superficial layer, superficial and deep transverse perineal muscles with their fascial coverings

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15
Q

What component of the endopelvic fascia can stretch?

A

Fibromuscular component - connective tissue does not stretch or attenuate, it will break

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16
Q

What is the utero-sacral/cardinal complex?

Where does it lie?

A

Main support of the uterus
Medially to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
Laterally to the sacrum and fascia overlying the piriformis muscle

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17
Q

How can you palpate the utero-sacral complex?

A

Easily palpated by down traction on the cervix and if intact allows limited side-to-side movement of the cervix

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18
Q

Where does the utero-sacral complex tend to break?

A

Medially - around the cervix

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19
Q

What are the features of the rectovaginal fascia?

A

Fibromusculo-elastic tissue
Centrally merges with base of the utero-sacral ligaments and peritoneum
Laterally fuses with fascia over the elevator ani
Distally firmly attached to the perineal body

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20
Q

Where does the rectovaginal fascia tend to break?

A

Tends to break centrally
Upper defect - enterocele
Lower defect - perineal body descent and rectocele

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21
Q

What is the level I endopelvic support?

A

Utero-sacral ligaments
Cardinal ligaments

Best support

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22
Q

What is the level II endopelvic support?

A

Para-vaginal to arcus tendinous fascia

Pubocervical/rectovaginal fascia

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23
Q

What is the level III endopelvic support?

A

Urogenital diaphragm

Perineal body

24
Q

What are the risk factors for uterovaginal prolapse?

A 
Pregnancy and vaginal birth - forceps delivery carries highest risk, large baby, prolonged second stage
Advancing age
Obesity 
Previous pelvic surgery 
Hormonal factors
Quality of connective tissue
Chronic cough/constipation 
Occupation with heavy lifting 
Exercise - weight lifting, high-impact aerobics, long-distance running
25
Q

In the Oxford Family Planning Association prolapse epidemiology study, what was the strongest risk factor for the development of prolapse?

A

Parity - adjusted relative risk of 10.9 while risk increased with increasing parity, rate of increase slowed after 2 deliveries

26
Q

Why might continence procedures (elevating bladder neck) lead to defects in other components?

A

Burch colposuspension, by fixing the lateral vaginal fornices to the ipsilateral iliopectineal ligaments, leaves a potential defect in the posterior vaginal wall which predisposes to rectocele and entoerocele formation
Following Birch colposuspension, 25% of women required further surgery for prolapse

27
Q

What does the classification of prolapse depend on?

A

Site of the defect and presumed pelvic viscera that are involved

28
Q

What is a urethrocele?

A

Prolapse of the lower anterior vaginal wall involving the urethra only

29
Q

What is a cystocele?

A

Prolapse of the upper anterior vaginal wall involving the bladder

30
Q

What is a uterovaginal prolapse?

A

Prolapse of the uterus, cervix and upper vagina

31
Q

What is an enterocoele?

A

Apical prolapse

Prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel

32
Q

What is a rectocele?

A

Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina

33
Q

Why might there be a problem with the traditional classification of prolapse?

A

Implies an unrealistic certainty as to the structures on the other side of the prolapse - often a false assumption

34
Q

What is the assessment of POP?

A

Examination to exclude pelvic mass
Record the position of examination e.g. left lateral vs lithotomy vs standing
Quality of life

35
Q

What can you use in the objective assessment of POP?

A

Baden-Walker-Halfway Grading

POP Q score

36
Q

What is currently considered the gold standard for objective assessment of POP?

A

POP Q score - endorsed by ICS

37
Q

What are the stages of the POP Q score?

A

Stage 0 - Aa, Ap, Ba, Bp at -3cm and C or D less than/equal to -(tvl -2) cm

Stage I - Stage 0 criteria not met and leading edge < -1cm

Stage II - Leading edge greater than/equal to -1cm but less than/equal to +1cm

Stage III - Leading edge > +1cm but < + (tvl -2) cm

Stage IV - Leading edge greater than/equal to + (tvl - 2) cm

38
Q

In the POP-Q system what does Aa stand for and what is its range of values?

A

Anterior vaginal wall 3cm proximal to the hymen

-3cm to +3cm

39
Q

In the POP-Q system what does Ba stand for and what is its range of values?

A

Most distal position of remaining upper anterior vaginal wall

-3cm to + tvl

40
Q

In the POP-Q system what does C stand for?

A

Most distally edge of cervix or vaginal cuff scar

41
Q

In the POP-Q system what does D stand for?

A

Posterior fornix (N/A if post-hysterectomy)

42
Q

In the POP-Q system what does Ap stand for and what is its range of values?

A

Posterior vaginal wall 3cm proximal to the hymen

-3cm to +3cm

43
Q

In the POP-Q system what does Bp stand for and what is its range of values?

A

Most distal position of remaining upper posterior vaginal wall

-3cm to +tvl

44
Q

In the POP-Q system what does gh stand for?

A

Genital hiatus

Measured from middle of external urethral meatus to posterior midline hymen

45
Q

In the POP-Q system what does pb stand for?

A

Perineal body

Measured from posterior margin of gh to middle of anal opening

46
Q

In the POP-Q system what does tvl stand for?

A

Total vaginal length

Depth of vagina when point D or C is reduced to normal position

47
Q

What are the investigations for POP?

A

USS/MRI - allow identification of fascial defects/measurement of levator ani thickness
Urodynamics - concurrent UI or to exclude occult SI
IVU or Renal USS - if suspicious or ureteric obstruction

POP is a clinical diagnosis - not one made by investigations, investigations may be done for other associated/concurrent problems or defects

48
Q

What are the typical vaginal symptoms of POP?

A 
Sensation of bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure 
Heaviness
Difficulty inserting tampons
49
Q

What are the urinary symptoms of POP?

A

Urinary incontinence
Frequency/urgency
Weak or prolonged urinary stream/hesitance/feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding

50
Q

What are the bowel symptoms of POP?

A

Incontinence of flatus, or liquid or solid stool
Feeling of incomplete emptying/straining
Urgency
Digital evacuation to complete defaecation
Splinting/pushing on/around the vagina or perineum to start or complete defaecation

51
Q

What is the prevention of POP?

A

Avoid constipation
Effective management of chronic chest pathology e.g. COPD and asthma
Smaller family size
Improvements in antenatal and intrapartum care

52
Q

How can physiotherapy be used to treat POP?

A

Pelvic floor muscle training
Increase pelvic floor strength and bulk to relieve the tension on the ligaments
Cases of mild prolapse - no role in advanced cases
Younger women who have not yet completed their family
Cannot treat fascial defects
Education about pelvic floor exercised may be supplemented with the use of a perineometer and biofeedback, vaginal cones and electrical stimulation

53
Q

Why is silicone advantageous in pessaries in treatment of POP?

A

Long shelf life
Resistance to autoclaving and repeated cleaning
Non-absorbent towards secretions and odours
Inertness
Hypoallergenic nature

54
Q

What are the exclusions for pessary use in treatment of POP?

A

Previous POP surgery

Unable to retain pessary for 2 weeks

55
Q

What is the aim of surgical treatment for POP?

A

Relieve symptoms
Restore/maintain bladder and bowel function
Maintain vaginal capacity for sexual function

Reproductive System (33 decks)

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