Pelvic organ prolapse Flashcards
Prolapse
protrusion of an organ or structure beyond its normal anatomical confines
Female POP
descent of pelvic organs through or towards vagina
% of multiparous and nulliparous women
multi: 12-30% and 2% nulliparous
Asymptomatic prolapse
50%
Why must abdominopelvic cavity walls be flexible?
accommodate volume and pressure
What is the pelvic floor?
The soft tissues that close the space between the pelvic bones
What happens if the pelvic floor is normal?
all pelvic viscera in position at rest and with increased intra-abdominal pressure
6 dynamic pelvic organs
bladder, uterus, vagina, rectum, anus, urethra
3 layers of pelvic floor
endopelvic fascia
pelvic diaphragm
urogenital diaphragm
What 3 visceral structures does the endopelvic fascia surround?
uterosacral ligaments
pubocervical fascia
rectovaginal fascia
What is endopelvic fascia?
fibromuscular connective type tissue
2 muscles in pelvic diaphragm
levator ani and coccygeus
Urogenital diaphragm
superficial and deep transverse perineal muscles
Significance of fibromuscular connective tissue of endopelvic fascia
fibro-muscular can stretch but connective does not it breaks
Medial attachments of uterosacral/cardinal ligaments
cervix, lateral vaginal fornices, uterus, pubocervical and rectovaginal fascia
Lateral attachments of uterosacral/cardinal ligaments
sacrum and fascia overlying piriformis muscle
Palpation of uterosacral/cardical ligaments
down traction on cervix and if intact allows limited cervix side-side movements
Where does uterosacral/cardinal ligaments tend to break?
medially - cervix
What is the pubocervical fascia the main support for?
anterior vaginal wall
Where does pubocervical fascia tend to break?
lateral attachments or medially in front of cervix
Type of tissue that makes up rectovaginal fascia
fibromusculo elastic tissue
Upper and lower defects of rectovaginal fascia leads to…
upper - enterocoele
lower - perineal body descent and rectocoele
POP risk factors
advancing age - obesity - parity - forceps - big baby- pelvic surgeries - hormonal - hysterectomy - constipation - exercise - heavy lifting
urethrocoele
Prolapse of lower anterior vaginal wall involving urethra only
cystocoele
Prolapse of upper anterior vaginal wall involving bladder
Uterovaginal prolapse
prolapse of uterus, cervix and upper vagina
enterocoele
prolapse of upper posterior wall of vagina containing loops of small bowel
rectocoele
prolapse of lower posterior vaginal wall involving rectum bulging forwards into vagina
vaginal symptoms of POP
pressure heaviness sensation of a bulge or protrusion difficult inserting tampons seeing or feeling a bulge or protrusion
bowel symptoms of POP
splint/push around vagina to start defaecation
digital evacuation to complete emptying
urgency
incomplete emptying or straining
incontinence of flatus or liquid/solid stool
bladder symptoms of POP
urinary incontinence
frequency/urgency
weak or prolonged stream/hesitancy
manual reduction of prolapse to start or complete emptying
Assessment of POP
examine abdomen
record position eg left lateral
QOL
POPQ score
3 investigations and use
MRI/USS - levator ani thickness
urodynamics - UI or SI
IVU or renal USS - suspect ureteric obstruction
4 preventions of POP
avoid constipation
treat chronic lung disease
smaller family size
pelvic floor strength exercises
PFMT
increase pelvic floor strength for mild prolapse in young women
Supplementation of PFMT
perinometer
biofeedback
vaginal cores
electrical stimulation
Materials of pessaries
silicone, lucite, rubber, plastic
Advantages of silicone pessaries
long shelf life
resistance to autoclaving and recurrent cleaning
non-absorbent towards secretions and odors
inert
hypoallergenic
vaginal pessaries vs surgery
no real difference
Aim of surgical treatment
relieve symptoms
restore and maintain bladder and bowel function
maintain vaginal capacity for sexual function
What to remember in surgical treatment
prophylactic antibiotics and VTE
