Pelvic Organ Prolapse Flashcards
What is the pelvic floor made up of?
Endo-pelvic fascia - uterosacral / cardinal etc.
Pelvic Diaphragm - levator ani
Urogenital diaphragm
What is the uterosarcral ligament?
Allows side to side movement of uterus
Breaks medially
Extends medially from uterus to lateral of sacrum
What is the pubocervical ligament
Supports anterior vaginal wall
Breaks laterally causing bladder prolapse
Merges centrally with cardinal ligament and cervix
What is the rectovaginal ligament
Breaks centrally
Merges with cardinal and uterosacral ligament
Lateral with levator ani
What causes pelvic organ prolapse?
Weakness of pelvic floor
Break in fascial support / pelvic structure
Nerve damage
- Increased risk with hysterectomy / pelvic surgery
Increase in intra-abdominal pressure
What is the main support of the pelvic floor
Levator ani
What are the symptoms of pelvic organ prolapse?
Asymptomatic Sensation of bulge Pressure / pain Heaviness Can't insert tampon Urinary / faecal incontinence (cystocele) Frequency / urgency / hesitancy / weak stream / incomplete emptying Need to reduce prolapse to defaecate Bleeding Sexual dysfunction Pain
What are the RF
Age Menopause High parity / Pregnancy Vaginal Birth / instrumental Large baby Obesity Previous pelvic surgery
Constipation
Weight lifting
Chronic lung disease - cough
Ascites / mass
What is a urethrocele
Prolapse of anterior vaginal wall due to urethra descent
What is a Cystocele
Prolapse of anterior vaginal wall due to bladder descent
Most common
What is a uterovaginal prolapse
Prolapse of uterus, cervix and upper vagina
What is an enterocoele
Prolapse of posterior wall containing small bowel
What is a rectocele
Prolapse of posterior wall involving rectum
Particularly associated with constipation / urinary obstruction
Have to move to defaecate
What is a vault
Vaginal vault after hysterectomy as nothing to hold up
How do you Dx pelvic organ prolapse?
What is used to grade
Examination VE to find if anterior or posterior Valsalva to find maximal descent Test muscles POPQ to grade
How do you investigate complications
USS MRI Urodynamic studies IVU Renal USS
How do you Rx pelvic organ prolapse
Avoid constipation / laxatives Weight loss Address chest pathology Pelvic floor muscle training Vaginal oestrogen cream Treat associated Sx e.g. incontinence Pessaries to hold it up - change every 4 months Surgery (Hysterectomy)
What are the aims of Rx
Maintain sexual function
restore bladder and bowel
relieve symptoms
What are the complications of POP
Obstructed ureters leading to hydronephrosis and renal failure
Embarrassment
Difficult exercise / walking
Sexual dysfunction
What type of hysterectomy is available
Abdominal
Laparotomy
Transvaginal
What are the indications of hysterectomy
Malignancy FIbroids Heavy bleeding Endometriosis PPH is rare
What ligament can be damaged in hysterectomy
Uterosacral
What are main ligament supporting the uterus
Uterosacral
Cardinal
Round ligament
What is the cardinal body
Muscles of urogenital diaphragm and superficial transvere
What is anococcygeal
All leavator ani and muscles join + external anal sphicnter
What discharge is common with pessaries / other SE
Pink
Vaginal irritation / erosion - oestrogen cream helps
What typically causes urinary incontinence
Cystocele
What is Rx for vaginal fault
Sacrocoloplexy
Suspends vaginal to sacral promontory
What is Rx for cytocele
Colporrhagry
Vaginal wall repaired
What is Rx for uterine prolapse
Hysterectomy
Sacrohysteropaxy
What do you ask in Hx
Onset, duration, progress Any Rx Any RF Other Sx FH prolapse Medical and surgical Hx Obstetric Hx Sexual Hx Medication Social Allergies
What do you do if relapse after surgery
Conservative Rx
