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Reproductive > Pelvic organ prolapse > Flashcards

Pelvic organ prolapse Flashcards

1
Q

What is Prolapse?

What is Femlae 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, there are various different types. Such as:

  • Cystocoele
  • Rectocoele
  • Uretocoele
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2
Q

What is the incidence of Pelvic Organ Prolapse?

A

Estimated - 12-30% of multiparous women and 2% of nulliparous women.

Prevalence varies from 2% for symptomatic prolpase to 50% for asymptomatic prolpase.

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3
Q

Outline the anatomy of the pelvic floor.

A
  • Abdomino-pelvic cavity is an odd shaped box that contains all the abdominal & pelvic viscera.
  • Walls must be sufficiently flexible to withstand changes in volumes of the organs, and pressure changes wihtin the cavity.
  • Pelvic floor represents the bottom of this box and consists of all the soft tissue structures that close the space between the pelvic bones.
  • If the pelvic floor is normal, all the pelvic viscera will be maintained in their position both at rest and in periods of increased intra-abdominal pressure.
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4
Q

What daily increases in volume occur in the pelvic organs?

A
  • Bladder inflates and deflates about 7 times a day.
  • Rectum inflates and deflates about 1 time a day.
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5
Q

What are the three distinct layers of the pelvic floor?

A
  • Endo-pelvic Fascia
  • Pelvic Diagphragm
  • Urogenital Diaphragm
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6
Q

What is the Endo-pelvic fascia?

A
  • Network of fibro-muscular connective tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uterosacral ligaments/Pubocervical Fascia/Rectovaginal Fascia)
  • Fibro-muscular componenet can stretch (uterosacrals)
  • Connective tissue does not stretch or attenuate instead it breaks.
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7
Q

What is the Pelvic Diagphragm?

A
  • Layers of Striated Muscle with its fascial coverings (Levator ani & Coccygeus)
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8
Q

What is the Urogenital Diaphragm?

A
  • The superifical & deep transverse perineal muscles with their fascial coverings.
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9
Q

What are the Medial and Lateral extent of the Uterosacral/Cardinal Complex?

A
  • Medially to uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia.
  • Laterally to the sacrum & fascia overlying the Piriformis muscle.
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10
Q

How can the utero-sacral/cardinal complex be palpated?

A

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

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11
Q

Where does the utero-sacral/cardinal complex tend to break?

A

Tends to break medially (around the cervix).

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12
Q

What is the Pubocervical Fascia and what does it do?

A
  • Trapezoid Fibro-muscular tissue.

Function:

  • Provide the main support of the anterior vaginal wall.
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13
Q

What are the central, lateral and distal extents of the Pubocervical Fascia?

A
  • Centrally
    • ​Merge with the base of the Cardinal Ligaments & Cervix
  • Laterally
    • Arcus Tendineus Fascia Pelvis
  • Distally
    • ​Urogenital Diaphragm
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14
Q

Where does the Pubocervical Fascia tend to break?

A

Tends to break at lateral attachemnets or immediately in front of the cervix.

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15
Q

What is the Rectovaginal Fascia?

A
  • Fibro-muscular - elastic tissue
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16
Q

What are the central, lateral and distal extent of the Rectovaginal Fascia?

A
  • Centrally
    • ​merge with the base of Cardinal/uterosacral ligaments & peritoneum.
  • Laterally
    • ​fuses with fascia over the levator ani
  • Distally
    • ​firmly to the Perineal Body.
17
Q

Where does the Rectovaginal Fascai tend to break?

Causing?

A
  • If upper defect:
    • Enterocoele
  • If lower defect:
    • Perineal body descent & Rectocoele
18
Q

What are the Risk Factors for POP?

A
  • Forceps Delivery
  • Large Baby (>4500gm)
  • Prolonged Second Stage of Labour
  • Parity (having babies) - more babies, more risk
  • Advancing Age - muscles and ligaments are weaker
  • Obesity - increased pressure on the pelvic floor.
  • Previous pelvic surgery

Other risk factors

  • Hormonal factors
  • Quality of Connective Tissue
  • Constipation
  • Occupation Heavy Lifting
  • Exercise - weights, high impact aerobics and long distance running.
19
Q

What is a Urethrocoele?

A
  • Prolapse of the lower anterior vaginal wall involving the urethra only.
20
Q

What is a Cystocoele?

A
  • Prolapse of the upper anterior vaginal wall involving the bladder.
21
Q

What is a uterovaginal prolapse?

A

Prolapse of the uterus, cervix and upper vagina.

22
Q

What is an enterocoele?

A
  • Prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel.
23
Q

What is a Rectocoele?

A
  • Prolapse of teh lower posterior wall of the vagina involving teh rectum bulging forwards into the vagina.
24
Q

What are the typical vaginal symptoms of women with a POP?

A
  • Sensation of a bulge or protrusion
  • Seeing or feeling a bulge or protrusion
  • Pressure
  • Heaviness
  • Difficulty inserting tampons - seen in younger women.
25
Q

What urinary symptoms do women with POP present with?

A
  • Urinary incontinence
  • Frequency/Uregency
  • Weak or prolonged urinary stream/Hesistancy/ Feeling of incomplete emptying
  • Manual reduction of prolapse to start or complete voiding.
26
Q

What bowel symptoms do women with POP present with?

A
  • Incontinence of flaus, or liquid, or solid stool
  • Feeling of incomplete emptying/ Straining
  • Urgency
  • Digital evacuation to complete defacation
    • Splinting - pushing in or around teh vagina or perineum, to start or complete defecation.
27
Q

How is POP assesed?

A
  • Examination to exclude pelvic mass.
  • Record the position of examination
    • Left lateral
    • Lithotomy
    • Standing
  • Quality of Life Impact

Objective Assessments:

  • Baden-Walker-Halfway Grading
  • POPQ Score - GOld Standard
28
Q

What investigations are used in POP?

A
  • Clinical Examination only. There are no other investigations needed to diagnose a prolapse.

However, other investigations can be used to look for complications.

  • USS/MRI - Allow idenification of fascial defects/measurement of Levator ani thickness (research only).
  • Urodynamics - concurrent UI or to exclude Occult stress incontinence.
  • IVU or Renal USS - if suspicion of ureteric Obstruction.
29
Q

What methods can be used to prevent POP?

A
  • Avoid constipation.
  • Effective management of chronic chest pathology (COPD & Asthma).
  • Smaller family size.
  • Improvements in antenatal and intra-partum care:
    • Antenatal and post natal pelvic floor muscel training - thought to be protective.
30
Q

What is the role of pelvic floor muscle training in physiotherapy?

A

Physiotherapy

  • Pelvic floor muscle training (PFMT)
    • ​Increase the pelvic floor strength & bulk -> relieve the tension
    • Used in mild prolapse
    • WIth younger women who want more children
    • Not used in advanced cases.
    • Cannot treat fascial defects.
  • Education about pelvic floor exercises may be supplemented with the use of perineometer, biofeedback, vaginal cones and electrical stimulation.
31
Q

What material are pessariies made of?

What are the advantages of this?

A

Silicone

Advantages

  • Long shelf life
  • Resistance to autoclaving and repeated cleaning
  • Non absorbent to secretions and odours
  • Inertness
  • Hypoallergenic
32
Q

What is the differences in using a vaginal pessary and having surgery?

A

No significant differences in median parity, HRT, pre-operative bowel, urinary and sexual symptoms.

Pessaries cant be used:

  • Previous POP surgery
  • Unable to retain pessary for 2 weeks

At 1 year successful pessary treatment is as effective as surgery.

33
Q

What is the aim of surgical treatment in POP?

What propylaxis needs to be remebered?

A

Aim

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

Propylaxis

  • Antibiotics
  • Thrombo-embolic

Reproductive (34 decks)

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