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Year 3 > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

define pelvic organ prolapse

A

Prolapse is a protrusion of an organ or structure beyond its normal anatomical confines. Female POP refers to the descent of the pelvic organs towards or through the vagina

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2
Q

prevalence of pelvic organ prolapse

A

Approximately 50% of multiparous women will have some degree and only 10-20% of these seek
medical help. In the UK, POP accounts for 20% of women on the waiting list for major gynaecological
surgery. The indication of 7-14% of hysterectomies is prolapse.

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3
Q

medial to the uterosacral ligament

A

uterus
cervix
lateral vaginal fornices
pubocervical and rectovaginal fascia

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4
Q

lateral to the uterosacral ligament

A

sacrum

fascio overlying piriformis

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5
Q

how can the uterosacral ligament be palpates?

A

down traction of the cervix

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6
Q

what does the uterosacral ligament allow?

A

side to side movement of the cervix

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7
Q

where does the uterosacral ligamenttend to break?

A

medially round the cervix

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8
Q

what is the pubocervical fascia?

A

trapezoid fibromuscular tissue

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9
Q

what provides provides the main support of the ant vag wall?

A

pubocervical fascia

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10
Q

what does the pubocervical fascia merge with centrally?

A

cardinal ligaments

cervix

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11
Q

what does the pubocervical fascia merge with laterally?

A

arcus tendinous fascia pelvis

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12
Q

what does the pubocervical fascia merge with distally?

A

urogenital diaphram

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13
Q

what kind of tissue is the rectovaginal fascia?

A

fibromuscular elastic

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14
Q

what does the rectovaginal fascia merge with centrall?

A

base of the cardinal/uterosacral ligaments

peritoneum

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15
Q

what doe sthe rectovaginal fascia merge with laterally?

A

fascia over the levator ani

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16
Q

what does the rectovaginal fascia merge with distally?

A

perineal body

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17
Q

where does the rectovaginal fascia tend to break?

A

centrally

18
Q

endopelvis support: level I

A

uterosacral ligaments

cardinal ligaments

19
Q

endopelvis support: level II

A

para vagina to arcus tendinous fascia: pubocervical/rectovaginal fascia

20
Q

endopelvis support: level III

A

urogenital diaphragm

perineal body

21
Q

risk factors for pelvic organ prolapse

A 
pregnancy and vaginal birth
advancing age
obesity
previous pelvic surgery
menopause (hormones)
quality of connective tissue
constipation
occupation with heavy lifting
exercise
22
Q

how does pregnancy and vaginal birth increase your risks of pelvic organ prolase?

A

a. Forceps delivery
b. Large baby >4.5kg
c. Prolonged second stage
d. Parity is the strongest risk factor for development of a prolapse, but rate of increase slows after two deliveries

23
Q

how can exercise increase your risk of a pelvic organ prolapse?

A

weight lifting
high impact aerobics
long distance running

24
Q

types of pelvic organ prolase

A 
urethrocele
cystocele
uterovaginal
enterocele
rectocele
25
Q

types of prolapse: urethrocele

A

prolapse of the lower ant vaginal wall involving the urethra only

26
Q

types of prolapse: cystocele

A

prolapse of the upper anterior vaginal wall involving the bladder

27
Q

types of prolapse: uterovaginal

A

prolapse of the uterus, cervic and upper vagina

28
Q

types of prolapse: enterocele

A

prolapse of the upper posterior wall of the vagina usually containing loops of small bowel

29
Q

types of prolapse: rectocele

A

prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina

30
Q

what is the issue with classifying prolapses?

A

This classification implies an unrealistic certainty as to the structures on the other side of the vaginal bulge. This is often a false assumption, particularly in women who have had previous prolapse surgery.

31
Q

what is a pure apical prolapse?

A

one in which there is no anterior or posterior vaginal wall prolapse

32
Q

typical symptoms in women with prolapse: vaginal

A 
sensation of a bulge or protrusion
seeing or feeling a bulge or protrusion
pressure
heaviness
difficulty in inserting tampons
33
Q

typical symptoms in women with prolapse: urinary

A

urinary incontinence
frequency/urgency
weak or prolonged urinary stream/hesitancy/feeling of incomplete emptying
manual reduction of prolapse to start or complete voiding

34
Q

typical symptoms in women with prolapse: bowel

A
  • Incontinence of flatus, or liquid/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
35
Q

assessment of prolapse

A 
• Examination to exclude pelvic mass
• Record the position of examination
o Left lateral vs lithotomy vs standing
• QoL
• Objective assessment
o Baden, Walker, Halfawy grading
o POPQ score
36
Q

investigation of prolapse

A

There is no need to investigate as diagnosis is made on clinical examination. The following may be
carried out if there is suspected complications:
1. USS/MRI
a. Allow identification of fascial defects/measurement of levator ani thickness (research
only)
2. Urodynamics
a. Concurrent UI or to exclude occult SI
3. IVU or renal USS
a. If suspect obstruction

37
Q

prevention of prolapse

A
  • Avoid constipation
  • Effective management of chronic chest pathology – COPD and asthma
  • Smaller family size
  • Improvements in antenatal and intrapartum care
38
Q

PT for prolapse

A

Pelvic floor muscle training (PFMT) can increase the pelvic floor strength and bulk which can relieve
the tension on the ligaments. This can help in cases of mild prolapse. Younger women who have not
yet completed their family. No role in advanced cases and cannot treat fascial defects. Education
about pelvic floor exercises may be supplemented with the use of a perineometer and biofeedback,
vaginal cones and electrical stimulation.

39
Q

pessaries for prolapse

A

Pessaries are left in place for 8-9 months and can cause discharge. Today they are generally made
from silicone, Lucite, rubber or plastic. Silicone is advantageous:
• Long shelf-life
• Resistance to autoclaving and repeated cleaning
• Non-absorbent towards secretions and odours
• Inertness
• Hypoallergenic

40
Q

surgery for prolapse

A 
Aim is to:
1. Relieve symptoms
2. Restore/maintain bladder and bowel function
3. Maintain vaginal capacity for sexual function
Remember:
1. Prophylactic antibiotics
2. Thrombo-embolic prophylaxis
3. Postoperative urinary vs SPC

Year 3 (164 decks)

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