Pelvic Organ Prolapse Flashcards
What is a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines
What is female pelvic organ prolapse (POP)?
Refers to the descent of the pelvic organs towards or through the vagina
What is the incidence of prolapse?
True incidence is hard to determine
Estimated to affect 12-30% of multiparous and 2% of nulliparous women
What is the prevalence of prolapse?
Estimates vary from 2% for symptomatic prolapse to 50% for asymptomatic prolapse
What percentage of parous women will have some degree of prolapse?
How many of these will seek medical help?
Approx 50% of parous women will have some degree
Only 10-20% of these seek medical help
In the UK, what percentage of women on the waiting list for major gynaecological surgery is accounted for by POP?
20%
What percentage of indications for hysterectomy is prolapse?
7-14%
What does the abdominopelvic cavity contain?
All the abdominal and pelvic viscera
Why must the walls of the abdominopelvic cavity be of sufficient flexibility?
To withstand the changes in volumes of these organs and also pressure changes within the cavity
What will a normal pelvic floor maintain?
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
What are the layers of the pelvic floor?
Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the structure of the endopelvic fascia?
Network of fibromuscular connective type tissue that has a hammock-like configuration and surrounds the various visceral structures
What is the structure of the pelvic diaphragm?
Layer of striated muscles with its fascial coverings
What is the structure of the urogenital diaphragm?
Most superficial layer, superficial and deep transverse perineal muscles with their fascial coverings
What component of the endopelvic fascia can stretch?
Fibromuscular component - connective tissue does not stretch or attenuate, it will break
What is the utero-sacral/cardinal complex?
Where does it lie?
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
How can you palpate the utero-sacral complex?
Easily palpated by down traction on the cervix and if intact allows limited side-to-side movement of the cervix
Where does the utero-sacral complex tend to break?
Medially - around the cervix
What are the features of the rectovaginal fascia?
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
Where does the rectovaginal fascia tend to break?
Tends to break centrally
Upper defect - enterocele
Lower defect - perineal body descent and rectocele
What is the level I endopelvic support?
Utero-sacral ligaments
Cardinal ligaments
Best support
What is the level II endopelvic support?
Para-vaginal to arcus tendinous fascia
Pubocervical/rectovaginal fascia
What is the level III endopelvic support?
Urogenital diaphragm
Perineal body
What are the risk factors for uterovaginal prolapse?
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
In the Oxford Family Planning Association prolapse epidemiology study, what was the strongest risk factor for the development of prolapse?
Parity - adjusted relative risk of 10.9 while risk increased with increasing parity, rate of increase slowed after 2 deliveries
Why might continence procedures (elevating bladder neck) lead to defects in other components?
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
What does the classification of prolapse depend on?
Site of the defect and presumed pelvic viscera that are involved
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethra only
What is a cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder
What is a uterovaginal prolapse?
Prolapse of the uterus, cervix and upper vagina
What is an enterocoele?
Apical prolapse
Prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel
What is a rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
Why might there be a problem with the traditional classification of prolapse?
Implies an unrealistic certainty as to the structures on the other side of the prolapse - often a false assumption
What is the assessment of POP?
Examination to exclude pelvic mass
Record the position of examination e.g. left lateral vs lithotomy vs standing
Quality of life
What can you use in the objective assessment of POP?
Baden-Walker-Halfway Grading
POP Q score
What is currently considered the gold standard for objective assessment of POP?
POP Q score - endorsed by ICS
What are the stages of the POP Q score?
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
In the POP-Q system what does Aa stand for and what is its range of values?
Anterior vaginal wall 3cm proximal to the hymen
-3cm to +3cm
In the POP-Q system what does Ba stand for and what is its range of values?
Most distal position of remaining upper anterior vaginal wall
-3cm to + tvl
In the POP-Q system what does C stand for?
Most distally edge of cervix or vaginal cuff scar
In the POP-Q system what does D stand for?
Posterior fornix (N/A if post-hysterectomy)
In the POP-Q system what does Ap stand for and what is its range of values?
Posterior vaginal wall 3cm proximal to the hymen
-3cm to +3cm
In the POP-Q system what does Bp stand for and what is its range of values?
Most distal position of remaining upper posterior vaginal wall
-3cm to +tvl
In the POP-Q system what does gh stand for?
Genital hiatus
Measured from middle of external urethral meatus to posterior midline hymen
In the POP-Q system what does pb stand for?
Perineal body
Measured from posterior margin of gh to middle of anal opening
In the POP-Q system what does tvl stand for?
Total vaginal length
Depth of vagina when point D or C is reduced to normal position
What are the investigations for POP?
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
What are the typical vaginal symptoms of POP?
Sensation of bulge or protrusion Seeing or feeling a bulge or protrusion Pressure Heaviness Difficulty inserting tampons
What are the urinary symptoms of POP?
Urinary incontinence
Frequency/urgency
Weak or prolonged urinary stream/hesitance/feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
What are the bowel symptoms of POP?
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
What is the prevention of POP?
Avoid constipation
Effective management of chronic chest pathology e.g. COPD and asthma
Smaller family size
Improvements in antenatal and intrapartum care
How can physiotherapy be used to treat POP?
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
Why is silicone advantageous in pessaries in treatment of POP?
Long shelf life
Resistance to autoclaving and repeated cleaning
Non-absorbent towards secretions and odours
Inertness
Hypoallergenic nature
What are the exclusions for pessary use in treatment of POP?
Previous POP surgery
Unable to retain pessary for 2 weeks
What is the aim of surgical treatment for POP?
Relieve symptoms
Restore/maintain bladder and bowel function
Maintain vaginal capacity for sexual function
