Pelvic Organ Prolapse Flashcards
Definition of prolapse
Protrusion of an organ or structure beyond its normal anatomical confines
Definition of female pelvic organ prolapse
The descent of pelvic organs towards or through the vagina
Is pelvic organ prolapse more common in multiparous or nulliparous women?
Multiparous women
3 layers of the pelvic floor
- Endo-pelvic fascia
- Pelvic diaphragm
- Urogenital diaphragm
What is the endo-pelvic fascia?
Network of fibromuscular connective tissue type that has a hammock like configuration and surrounds the various visceral structures (uterosacral ligaments/pubocervical fascia/rectovaginal fascia)
What is the pelvic diaphragm?
Layer of striated muscles with its fascial coverings (levator ani and coccygeus)
What is the Urogenital diaphragm?
The superficial and deep transverse perineal muscles with their facial coverings
Stretchiness of the endopelvic fascia
Fibromuscular component can stretch (uterosacraes)
Connective tissue does not stretch or attenuate, instead it breaks
What provides the main support of the anterior vaginal wall?
Trapeziodal fibro-muscular tissue of the pubo cervical fascia
Where does the utero-sacral/cardinal complex tend to break?
Medially (around the cervix)
Where does the pubocervical fascia tend to break?
At lateral attachments or immediately in front of the cervix
The rectovaginal fascia is made up of what?
Fibro-muscular elastic tissue
Where does the rectovaginal fascia tend to break?
Centrally
- if upper defect; enterocele
- if lower defect; perineal body descent and rectocele
Endopelvic support of the different levels
Level I - uterosacral ligaments - cardinal ligaments Level II - para-vaginal to ancus tendinous fascia: pubocervical/rectovaginal fascia level III - urogenital diaphragm - perineal body
Risk factors for pelvic organ prolapse
Pregnancy and vaginal childbirth Forceps delivery Large baby (>4500gm) Prolonged second stage Multiparity Advancing age Obesity Previous pelvic surgery - continence procedures - burch colosuspension - hysterectomy Hormonal (oestrogen deficiency/menopause) Quality of connective tissue (i.e. connective tissue diseases) Chronic constipation Occupation with heavy lifting Exercise (urogenital prolapse) - weight lifting - high impact aerobatics - long distance running Caffeine / Fizzy drinks Chronic cough Smoking Alcohol
Definition of a prolapse depends on….
Site of defect
The presumed pelvic viscera involved
Types of prolapse
Urethrocele Cystocele Uterovaginal Enterocele Rectocele
Definition of urethrocele prolapse
Prolapse of lower anterior vaginal wall involving your the urethra only
Definition of cystocele prolapse
Prolapse of upper anterior vaginal wall including the bladder
Definition of uterovaginal prolapse
Prolapse of uterus, cervix and upper vagina
Definition of enterocele prolapse
Prolapse of upper posterior wall of the vagina, usually containing loops of small bowel
Another name for enterocele prolapse
Apical prolapse
Definition of rectocele prolapse
Prolapse of lower posterior wall of the vagina involving the rectum building forwards into the rectum
Symptoms of pelvic organ prolapse
Vaginal
- sensation of buldge/protrusion
- seeing a buldge/protrusion
- pressure/heaviness
- difficulty inserting tampons
Back pain
Urinary
- incontinence
- frequency/urgency
- weak or prolonged urinary stream
- hesitancy or feeling of incomplete emptying
- manual reduction of prolapse to start or complete voiding
Bowel
- incontinence of flatus, liquid or solid stool
- feeling of incomplete emptying, straining
- urgency
- digital evacuation to complete defecation
- Splinting or pushing on or around vagina or perineum, to start or complete defecation
Investigations for pelvic organ prolapse
Examination to exclude pelvic mass (record position)
QoL
PV
- ask to cough (what part descends)
- then ask to stand and then cough to see if protrusion
Objective assessment
- Baden-Walker halfway grading
- POPQ score
Scanning
- USS/MRI
- Urodynamics
Dipstick/urinalysis to check for UTI if urinary symptomss
IVU or renal USS (if suspicion of ureteric obstruction)
Pelvic floor evaluation - stages
Stage 0 = TVL - 2cm
Stage I = < - 1cm
Stage II = >_ 1cm - 1cm but < +TVL - 2cm
Stage IV = >_ +TVL - 2cm
Prevention of pelvic organ prolapse
Avoid constipation
Effective management of chronic chest pathology (COPD and asthma)
Smaller family size
Improvement in antenatal and post natal care (e.g. pelvic floor muscle training)
Treatment of pelvic organ prolapse
- Nothing
- Conservative
- Physiotherapy
- pelvic floor muscle training (PFMT) - Pessary
- Surgery
When is pelvic floor muscle training used in the treatment for pelvic organ prolapse?
Causes of mild prolapse
Younger women who have not yet completed their family
What does pelvic floor muscle training do?
Increase pelvic floor strength and bulk -> so relieves the tension on the ligaments
Aims of surgery in the treatment of pelvic organ prolapse
Relieve symptoms / improve QoL
Restore anatomy
Restore/maintain bladder and bowel function
Maintain vaginal capacity for sexual function
Indications for surgery in the treatment of pelvic organ prolapse
Previous pelvic organ prolapse surgery
Unable to retain pessary for 2 weeks
< 40 y/o, how many women will get a prolapse?
5 - 15%
> 60 y/o, how many women will get a prolapse?
40 - 50%
What is the most important muscle of the pelvic floor and what is its innervation?
Levator ani
Pudendal nerve
Why is an instrumental delivery a risk factor for POP?
Can damage the muscles or the pudendal nerve
What is a ventouse delivery also known as?
Vacuum extraction
Why can a uterine prolapse result in back pain?
As the ligaments are all being pulled down
What is the POPQ score?
The clinical classification for pelvic organ prolapse
How many grades are there in POPQ?
1 - 4
What is the most common type of pessary?
Silicone
Types of pessary
Ring
“Plug”
When would a ring pessary be appropriate?
Sexually active
How often does the ring pessary need to be changed?
Every 6 - 9 months
When would a ‘plug’ pessary be appropriate?
Non sexually active women
How often is the ‘plug’ pessary changed?
Every 6 months
Types of surgery in POP
Anterior repair
Posterior repair
Hysterectomy
Supra-spinal fixation
When would an anterior repair be used in POP?
Cystocele
When would a posterior repair be used in POP?
Rectocele
When would a hysterectomy be done in a POP?
When there is a full uterine prolapse
When would a supra-spinal fixation be used in POP?
Enterocele
