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Reproduction Pathology > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

Definition of prolapse

A

Protrusion of an organ or structure beyond its normal anatomical confines

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2
Q

Definition of female pelvic organ prolapse

A

The descent of pelvic organs towards or through the vagina

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3
Q

Is pelvic organ prolapse more common in multiparous or nulliparous women?

A

Multiparous women

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4
Q

3 layers of the pelvic floor

A
  1. Endo-pelvic fascia
  2. Pelvic diaphragm
  3. Urogenital diaphragm
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5
Q

What is the endo-pelvic fascia?

A

Network of fibromuscular connective tissue type that has a hammock like configuration and surrounds the various visceral structures (uterosacral ligaments/pubocervical fascia/rectovaginal fascia)

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6
Q

What is the pelvic diaphragm?

A

Layer of striated muscles with its fascial coverings (levator ani and coccygeus)

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7
Q

What is the Urogenital diaphragm?

A

The superficial and deep transverse perineal muscles with their facial coverings

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8
Q

Stretchiness of the endopelvic fascia

A

Fibromuscular component can stretch (uterosacraes)

Connective tissue does not stretch or attenuate, instead it breaks

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9
Q

What provides the main support of the anterior vaginal wall?

A

Trapeziodal fibro-muscular tissue of the pubo cervical fascia

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10
Q

Where does the utero-sacral/cardinal complex tend to break?

A

Medially (around the cervix)

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11
Q

Where does the pubocervical fascia tend to break?

A

At lateral attachments or immediately in front of the cervix

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12
Q

The rectovaginal fascia is made up of what?

A

Fibro-muscular elastic tissue

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13
Q

Where does the rectovaginal fascia tend to break?

A

Centrally

  • if upper defect; enterocele
  • if lower defect; perineal body descent and rectocele
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14
Q

Endopelvic support of the different levels

A 
Level I 
- uterosacral ligaments
- cardinal ligaments
Level II
- para-vaginal to ancus tendinous fascia: pubocervical/rectovaginal fascia
level III
- urogenital diaphragm 
- perineal body
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15
Q

Risk factors for pelvic organ prolapse

A 
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
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16
Q

Definition of a prolapse depends on….

A

Site of defect

The presumed pelvic viscera involved

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17
Q

Types of prolapse

A 
Urethrocele
Cystocele 
Uterovaginal 
Enterocele
Rectocele
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18
Q

Definition of urethrocele prolapse

A

Prolapse of lower anterior vaginal wall involving your the urethra only

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19
Q

Definition of cystocele prolapse

A

Prolapse of upper anterior vaginal wall including the bladder

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20
Q

Definition of uterovaginal prolapse

A

Prolapse of uterus, cervix and upper vagina

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21
Q

Definition of enterocele prolapse

A

Prolapse of upper posterior wall of the vagina, usually containing loops of small bowel

22
Q

Another name for enterocele prolapse

A

Apical prolapse

23
Q

Definition of rectocele prolapse

A

Prolapse of lower posterior wall of the vagina involving the rectum building forwards into the rectum

24
Q

Symptoms of pelvic organ prolapse

A

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

25
Q

Investigations for pelvic organ prolapse

A

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)

26
Q

Pelvic floor evaluation - stages

A

Stage 0 = TVL - 2cm
Stage I = < - 1cm
Stage II = >_ 1cm - 1cm but < +TVL - 2cm
Stage IV = >_ +TVL - 2cm

27
Q

Prevention of pelvic organ prolapse

A

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)

28
Q

Treatment of pelvic organ prolapse

A
  1. Nothing
  2. Conservative
  3. Physiotherapy
    - pelvic floor muscle training (PFMT)
  4. Pessary
  5. Surgery
29
Q

When is pelvic floor muscle training used in the treatment for pelvic organ prolapse?

A

Causes of mild prolapse

Younger women who have not yet completed their family

30
Q

What does pelvic floor muscle training do?

A

Increase pelvic floor strength and bulk -> so relieves the tension on the ligaments

31
Q

Aims of surgery in the treatment of pelvic organ prolapse

A

Relieve symptoms / improve QoL
Restore anatomy
Restore/maintain bladder and bowel function
Maintain vaginal capacity for sexual function

32
Q

Indications for surgery in the treatment of pelvic organ prolapse

A

Previous pelvic organ prolapse surgery

Unable to retain pessary for 2 weeks

33
Q

< 40 y/o, how many women will get a prolapse?

A

5 - 15%

34
Q

> 60 y/o, how many women will get a prolapse?

A

40 - 50%

35
Q

What is the most important muscle of the pelvic floor and what is its innervation?

A

Levator ani

Pudendal nerve

36
Q

Why is an instrumental delivery a risk factor for POP?

A

Can damage the muscles or the pudendal nerve

37
Q

What is a ventouse delivery also known as?

A

Vacuum extraction

38
Q

Why can a uterine prolapse result in back pain?

A

As the ligaments are all being pulled down

39
Q

What is the POPQ score?

A

The clinical classification for pelvic organ prolapse

40
Q

How many grades are there in POPQ?

A

1 - 4

41
Q

What is the most common type of pessary?

A

Silicone

42
Q

Types of pessary

A

Ring

“Plug”

43
Q

When would a ring pessary be appropriate?

A

Sexually active

44
Q

How often does the ring pessary need to be changed?

A

Every 6 - 9 months

45
Q

When would a ‘plug’ pessary be appropriate?

A

Non sexually active women

46
Q

How often is the ‘plug’ pessary changed?

A

Every 6 months

47
Q

Types of surgery in POP

A

Anterior repair
Posterior repair
Hysterectomy
Supra-spinal fixation

48
Q

When would an anterior repair be used in POP?

A

Cystocele

49
Q

When would a posterior repair be used in POP?

A

Rectocele

50
Q

When would a hysterectomy be done in a POP?

A

When there is a full uterine prolapse

51
Q

When would a supra-spinal fixation be used in POP?

A

Enterocele

Reproduction Pathology (28 decks)

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