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Reproduction > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

Define prolapse and female pelvic organ prolapse (POP)

A
  • Prolapse, Protrusion of an organ or structure beyond its normal anatomical confines
  • Female POP, Refers to the descent of the pelvic organs towards or through the vagina
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2
Q

6 dynamic organs of the pelvic floor

A
  • Uterus
  • Vagina
  • Bladder
  • Urethra
  • Rectum
  • Anus
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3
Q

3 layers of the pelvic floor

A
  • Endo-pelvic fascia
  • Pelvic diaphragm
  • Urogenital diaphragm

(They do not parallel each other and vary in thickness from place to place)

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4
Q

Describe the endo-pelvic fascia

A
  • Network of fibro-muscular connective type tissue
  • Has “hammock like” configuration
  • Surrounds the various visceral structure
  • Fibro-muscular component can stretch (uterosacral)
  • Connective tissue does not stretch or attenuate but breaks
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5
Q

Describe the pelvic diaphragm

A

Layer of striated muscle with its fascial coverings (levator ani & coccygeus)

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6
Q

Describe the urogenital diaphragm

A

-The superficial & deep transverse perineal muscles with their fascial coverings

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7
Q

Describe the 3 levels of endopelvic support

A 
Level 1
-Utero-sacral ligaments
-Cardinal ligaments 
Level 2
-Para-vagina to arcus tendineus fascia: Pubocervical/Rectovaginal fascia 
Level 3 
-Urogenital diaphragm
-Perineal body
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8
Q

Risk factors for POP

A
  • Pregnancy + vaginal delivery (forceps, macrosomia, prolonged 2nd stage)
  • Age
  • Obesity
  • Previous pelvic surgery
  • Occupation with heavy lifting
  • Exercise (weight lifting, long-distance running)

Parity is the single largest risk factor

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9
Q

5 traditional classifications of POP

A
  • Urethrocele
  • Cystocele
  • Uterovaginal prolapse
  • Enterocele
  • Rectocele
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10
Q

Define urethrocele and cystocele

A
  • Urethrocele, Prolapse of lower ant. vaginal wall involving the urethra only
  • Cystocele, Prolapse of upper ant. vaginal wall involving the bladder
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11
Q

Define uterovaginal prolapse, enterocele and rectocele

A
  • Uterovaginal prolapse, Prolapse of uterus cervix and upper vagina
  • Enterocele, Upper post. wall of vagina, usually contains loops of small bowel
  • Rectocele, Lower post. wall of vagina involving rectum bulging forwards into vagina
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12
Q

Problem with the traditional classification of POP

A
  • Implies an unrealistic certainty as to the structures on the other side of vaginal bulge
  • This is often a false assumption, particularly in women with previous prolapse surgery
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13
Q

Vaginal symptoms of POP

A
  • Sensation/seeing/feeling of bulge/protrusion
  • Pressure
  • Difficulty inserting tampons
  • Heaviness
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14
Q

Urinary symptoms of POP

A
  • Urinary incontinence
  • Frequency/urgency
  • Weak/prolonged urinary stream, hesitancy, feeling of incomplete voiding
  • Manual reduction of prolapse to start or complete voiding
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15
Q

Bowel symptoms of POP

A
  • Incontinence (flatus//liquid/stool)
  • Feeling of incomplete emptying/straining
  • Urgency
  • Digital evacuation to complete defecation
  • Splinting/pushing on/around the vagina/perineum to start/complete defecation
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16
Q

Assessment of POP

A

-Examination to exclude pelvic mass
-Record position of exam (left lateral/lithotomy/standing)
-QOL
-Objective assessment
Baden-walker grading
POPQ score(Gold standard)

17
Q

POP-Q gradings

A
  • Stage 0 (TVL-2cm)
  • Stage 1 (< - 1cm_
  • Stage 2 (> - 1cm = + 1cm)
  • Stage 3 (> 1cm but < + TVL - 2cm)
  • Stage 4 (>/= + TVL - 2cm)
18
Q

Investigations for POP

A
  • USS/MRI, allow identification of fascial defects
  • Urodynamics, concurrent UI or to exclude Occult SI
  • IVU or Renal USS, If suspicion of ureteric obstruction
19
Q

Prevention of POP

A
  • Avoid constipation
  • Effective management of chronic chest pathology (COPD & asthma)
  • Smaller family size
  • Improvements in antenatal and Intrapartum care(antenatal + post-natal PFMT [no evidence it works but logically it should] )
20
Q

Treatment for POP

A
  • Physiotherapy (PFMT)
  • Pessaries (silicone is favoured)
  • Surgery
21
Q

What is more effective pessaries or surgery

A

No difference at 1 year follow-up

22
Q

What causes POP

A

Progressive weakness of the pelvic floor muscles followed by the breakdown in fascial support

23
Q

Summary

A

Pelvic floor made from 3 distinct anatomical layers but function as 1 unit

  • Prolapse occur due to progressive weakness of the pelvic floor muscles followed by breakdown in fascial support
  • Affect 50% of multiparous women (10% asymptomatic)
  • Assessment includes pelvic exam, assessment of pelvic floor and QOL
  • Management is tailored to patients needs (PFMT, pessaries and surgery)

Reproduction (22 decks)

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