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Systems: Reproduction AB > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

Prolapse

A

Protrusion of an organ or structure beyond its normal anatomical confines.

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2
Q

Female pelvic organ prolapse

A

Refers to the descent of the pelvic organs towards or through the vagina.

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3
Q

What is the epidemiology of pelvic organ prolapse?

A
  • 12–30% of multiparous and 2% of nulliparous women.
  • Prevalence estimates varying from 2% for symptomatic prolapse to 50% for asymptomatic prolapse.
  • Accounts for 20% of women on gynaecological surgery waiting list
  • Approximately 50% of parous women will have some degree and only 10–20% of these seek medical help
  • The indication of 7-14% of hysterectomies is PROLAPSE
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4
Q

What is the pelvic flood?

A

All of the soft tissue structures that close the space between the pelvic bones

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5
Q

What is the function of a normal pelvic floor?

A

Maintain the pelvic viscera at rest and in periods of increased intra-abdominal pressure

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6
Q

What must be true of the walls of the abdomino-pelvic cavity?

A

Must be of sufficient flexibility to withstand changes in volumes of these organs & also pressure changes within the cavity

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7
Q

What are the 3 distinct layers of the pelvic floor?

A
  • Endo-pelvic fascia
  • Pelvic diaphragm
  • Urogenital diaphragm
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8
Q

What is the endo-pelvic fascia?

A
  • Network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
  • Fibro-muscular component can stretch but the connective tissue des not (it breaks)
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9
Q

What is the pelvic diaphragm?

A

Layer of striated muscles with its fascial coverings (Levator ani & coccygeus).

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10
Q

What is the urogenital diaphragm?

A

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

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11
Q

How do the 3 layers of the pelvic floor form a functional unit?

A

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

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12
Q

What is medial to the uterosacral ligament?

A
  • Uterus
  • Cervix
  • Lateral vaginal fornices
  • Pubocervical fascia
  • Rectovaginal fascia
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13
Q

What is lateral to the uterosacral ligament?

A
  • Sacrum

- Fascia overlying piriformis muscle

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14
Q

How is the uterosacral ligament easily palpated?

A

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

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15
Q

Where does the uterosacral ligament tend to break?

A

Medially (around the cervix)

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16
Q

What is the pubocervical fascia?

A

Trapezoidal fibro-muscular tissue

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17
Q

What does the pubocervical fascia do?

A

Provides the main support of the anterior vaginal wall

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18
Q

What does the pubocervical ligament merge with centrally?

A

Base of the cardinal ligaments and cervix

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19
Q

What does the pubocervical ligament merge with laterally?

A

Arcus tendineus fascia pelvis

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20
Q

What does the pubocervical fascia merge with distally?

A

Urogenital diaphragm

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21
Q

Where does the pubocervical fascia tend to break?

A

Tend to break at lateral attachments or immediately in front of the cervix.

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22
Q

What is the rectovaginal fascia?

A

Fibro-musculo- elastic tissue.

23
Q

What does the rectovaginal fascia merge with centrally?

A

Base of Cardinal/ uterosacral ligaments & peritoneum.

24
Q

What does the rectovaginal fascia fuse with laterally?

A

Fascia over the levator ani

25
Q

What is the rectovaginal fascia firmly attached to distally?

A

Perineal body

26
Q

Where does the rectovaginal fascia tend to break?

A

Centrally

  • If upper defect: Enterocele.
  • If lower defect: perineal body descent & Rectocele.
27
Q

What are the 3 levels of endopelvic support?

A

Level I:

  • Utero-sacral ligaments
  • Cardinal ligaments

Level II:
-Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia

Level III:

  • Urogenital Diaphragm
  • Perineal body
28
Q

What are the risk factors for POP?

A

-Pregnancy and vaginal birth
-Advancing age
-Obesity
-Previous pelvic surgery
-Hormonal factors
-Quality of connective tissue
-Constipation
Occupation with heavy lifting
-Exercise ( weight lifting, high impact aerobics and long distance running)

29
Q

What features associated with pregnancy and vaginal birth increase the risk of POP?

A
  • Forceps Delivery
  • Large baby (> 4500 gm)
  • Prolonged Second Stage
  • Parity (strongest risk factor)
30
Q

How can continence procedures increase the risk of POP?

A

While elevating the bladder neck, may lead to defects in other pelvic compartments:

31
Q

How can Burch colposuspension increase the risk of POP?

A
  • 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 enterocele formation
  • Overall 25% of women following Burch colposuspension required further surgery for prolapse.
32
Q

What does the classification of prolapse depend on?

A

Site of defect and the presumed pelvic viscera involved

33
Q

Urethrocele

A

Prolapse of the lower anterior vaginal wall involving the urethra only.

34
Q

Cystocele

A
  • Prolapse of the upper anterior vaginal wall involving the bladder
  • Anterior wall prolapse
35
Q

Uterovaginal prolapse

A

Prolapse of the uterus, cervix and upper vagina

36
Q

Enterocele

A
  • Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
  • Apical prolapse
37
Q

Rectocele

A

Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
-Posterior wall prolapse

38
Q

What is an apical prolapse?

A

Does not involve anterior/posterior wall, the cervix simply comes down

39
Q

What vaginal symptoms can POP present with?

A
  • Sensation of a bulge or protrusion
  • Seeing or feeling a bulge or protrusion
  • Pressure
  • Heaviness
  • Difficulty in inserting tampons
40
Q

What urinary symptoms can POP present with?

A
  • Urinary Incontinence
  • Frequency/ Urgency
  • Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
  • Manual reduction of prolapse to start or complete voiding
41
Q

What bowel symptoms can POP present with?

A

-Incontinence of flatus, or liquid or solid stool
-Feeling of incomplete emptying/ Straining
Urgency
-Digital evacuation to complete defecation (Splinting, or pushing on or around the vagina or perineum, to start or complete defecation)

42
Q

How is POP assessed?

A
  • Examination to exclude pelvic mass
  • Record the position of examination: left lateral Vs Lithotomy Vs Standing.
  • Quality of Life

Objective assessment

  • Baden- Walker- Halfawy Grading
  • POPQ Score
  • Others
43
Q

What is the gold standard assessment for POP?

A

POPQ score

44
Q

How is POP investigated?

A

USS / MRI: Allow identification of fascial defects/ measurement of Levator ani thickness (research only).

Urodynamics: concurrent UI or to exclude Occult SI.

IVU or Renal USS (if suspicion of ureteric Obstruction).

45
Q

How is POP prevented?

A
  • Avoid constipation.
  • Effective management chronic chest pathology (COAD & asthma).
  • Smaller family size.
  • Improvements in antenatal and intra-partum care (muscle training?)
46
Q

How can POP be treated?

A
  • Physiotherapy
  • Pessaries
  • Surgery
47
Q

What phsyiotherpay can be used for POP?

A

Pelvic floor muscle training (PFMT):

-Increase the pelvic floor strength & bulk to relieve the tension

48
Q

Who is physiotherapy used in?

A
  • Cases of mild prolapse
  • Younger women who have not yet completed their family.
  • No role in advanced cases.
  • Cannot treat fascial defects.
49
Q

How can pelvic floor exercises be supplemented?

A

By the use of a perineometer and biofeedback, vaginal cones and electrical stimulation.

50
Q

What are pessaries usually made from?

A

Today, pessaries are generally made from a variety of materials including silicone, Lucite, rubber or plastic.

51
Q

What are the advantages of silicone pessaries?

A
  • Long Shelf-life
  • Resistance to autoclaving and repeated cleaning
  • Non-absorbent towards secretions and odors
  • Inertness
  • Hypoallergenic nature.
52
Q

What is the aim of surgery?

A
  • Relieve symptoms,
  • Restore/maintain bladder & bowel function and
  • Maintain vaginal capacity for sexual function.
53
Q

What further management should patients undergoing surgery receive?

A
  • Prophylactic Antibiotics.
  • Thrombo-embolic prophylaxis.
  • Postoperative Urinary Vs supra-pubic catheter
54
Q

Which treatment is more effective? Vaginal pessary or surgery?

A

Both as effective as each other

Systems: Reproduction AB (35 decks)

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