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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
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
26
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
27
What does the classification of prolapse depend on?
Site of the defect and presumed pelvic viscera that are involved
28
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethra only
29
What is a cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder
30
What is a uterovaginal prolapse?
Prolapse of the uterus, cervix and upper vagina
31
What is an enterocoele?
Apical prolapse | Prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel
32
What is a rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
33
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
34
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
35
What can you use in the objective assessment of POP?
Baden-Walker-Halfway Grading | POP Q score
36
What is currently considered the gold standard for objective assessment of POP?
POP Q score - endorsed by ICS
37
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
38
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
39
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
40
In the POP-Q system what does C stand for?
Most distally edge of cervix or vaginal cuff scar
41
In the POP-Q system what does D stand for?
Posterior fornix (N/A if post-hysterectomy)
42
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
43
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
44
In the POP-Q system what does gh stand for?
Genital hiatus | Measured from middle of external urethral meatus to posterior midline hymen
45
In the POP-Q system what does pb stand for?
Perineal body | Measured from posterior margin of gh to middle of anal opening
46
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
47
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
48
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 ```
49
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
50
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
51
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
52
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
53
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
54
What are the exclusions for pessary use in treatment of POP?
Previous POP surgery | Unable to retain pessary for 2 weeks
55
What is the aim of surgical treatment for POP?
Relieve symptoms Restore/maintain bladder and bowel function Maintain vaginal capacity for sexual function

Reproductive System (33 decks)

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