Pelvic organ prolapse Flashcards
What is Prolapse?
What is Femlae POP?
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
What is the incidence of Pelvic Organ Prolapse?
Estimated - 12-30% of multiparous women and 2% of nulliparous women.
Prevalence varies from 2% for symptomatic prolpase to 50% for asymptomatic prolpase.
Outline the anatomy of the pelvic floor.
- 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.
What daily increases in volume occur in the pelvic organs?
- Bladder inflates and deflates about 7 times a day.
- Rectum inflates and deflates about 1 time a day.
What are the three distinct layers of the pelvic floor?
- Endo-pelvic Fascia
- Pelvic Diagphragm
- Urogenital Diaphragm
What is the Endo-pelvic fascia?
- 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.
What is the Pelvic Diagphragm?
- Layers of Striated Muscle with its fascial coverings (Levator ani & Coccygeus)
What is the Urogenital Diaphragm?
- The superifical & deep transverse perineal muscles with their fascial coverings.
What are the Medial and Lateral extent of the Uterosacral/Cardinal Complex?
- Medially to uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia.
- Laterally to the sacrum & fascia overlying the Piriformis muscle.
How can the utero-sacral/cardinal complex be palpated?
Easily palpated by down traction on the Cervix and if intact allows limited side-side movement of the cervix.
Where does the utero-sacral/cardinal complex tend to break?
Tends to break medially (around the cervix).
What is the Pubocervical Fascia and what does it do?
- Trapezoid Fibro-muscular tissue.
Function:
- Provide the main support of the anterior vaginal wall.
What are the central, lateral and distal extents of the Pubocervical Fascia?
-
Centrally
- Merge with the base of the Cardinal Ligaments & Cervix
-
Laterally
- Arcus Tendineus Fascia Pelvis
-
Distally
- Urogenital Diaphragm
Where does the Pubocervical Fascia tend to break?
Tends to break at lateral attachemnets or immediately in front of the cervix.
What is the Rectovaginal Fascia?
- Fibro-muscular - elastic tissue
What are the central, lateral and distal extent of the Rectovaginal Fascia?
-
Centrally
- merge with the base of Cardinal/uterosacral ligaments & peritoneum.
-
Laterally
- fuses with fascia over the levator ani
-
Distally
- firmly to the Perineal Body.
Where does the Rectovaginal Fascai tend to break?
Causing?
- If upper defect:
- Enterocoele
- If lower defect:
- Perineal body descent & Rectocoele
What are the Risk Factors for POP?
- 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.
What is a Urethrocoele?
- Prolapse of the lower anterior vaginal wall involving the urethra only.
What is a Cystocoele?
- 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?
- Prolapse of the upper posterior wall of the vagina, usually containing loops of small bowel.
What is a Rectocoele?
- Prolapse of teh lower posterior wall of the vagina involving teh rectum bulging forwards into the vagina.
What are the typical vaginal symptoms of women with a POP?
- Sensation of a bulge or protrusion
- Seeing or feeling a bulge or protrusion
- Pressure
- Heaviness
- Difficulty inserting tampons - seen in younger women.
What urinary symptoms do women with POP present with?
- Urinary incontinence
- Frequency/Uregency
- Weak or prolonged urinary stream/Hesistancy/ Feeling of incomplete emptying
- Manual reduction of prolapse to start or complete voiding.
What bowel symptoms do women with POP present with?
- 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.
How is POP assesed?
- 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
What investigations are used in POP?
- 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.
What methods can be used to prevent POP?
- 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.
What is the role of pelvic floor muscle training in physiotherapy?
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.
What material are pessariies made of?
What are the advantages of this?
Silicone
Advantages
- Long shelf life
- Resistance to autoclaving and repeated cleaning
- Non absorbent to secretions and odours
- Inertness
- Hypoallergenic
What is the differences in using a vaginal pessary and having surgery?
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.
What is the aim of surgical treatment in POP?
What propylaxis needs to be remebered?
Aim
- Relieve symptoms
- Restore/maintain bladder & bowel function
- Maintain vaginal capacity for sexual function
Propylaxis
- Antibiotics
- Thrombo-embolic
