Pelvic Organ Prolapse Flashcards
define pelvic organ prolapse
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
prevalence of pelvic organ prolapse
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.
medial to the uterosacral ligament
uterus
cervix
lateral vaginal fornices
pubocervical and rectovaginal fascia
lateral to the uterosacral ligament
sacrum
fascio overlying piriformis
how can the uterosacral ligament be palpates?
down traction of the cervix
what does the uterosacral ligament allow?
side to side movement of the cervix
where does the uterosacral ligamenttend to break?
medially round the cervix
what is the pubocervical fascia?
trapezoid fibromuscular tissue
what provides provides the main support of the ant vag wall?
pubocervical fascia
what does the pubocervical fascia merge with centrally?
cardinal ligaments
cervix
what does the pubocervical fascia merge with laterally?
arcus tendinous fascia pelvis
what does the pubocervical fascia merge with distally?
urogenital diaphram
what kind of tissue is the rectovaginal fascia?
fibromuscular elastic
what does the rectovaginal fascia merge with centrall?
base of the cardinal/uterosacral ligaments
peritoneum
what doe sthe rectovaginal fascia merge with laterally?
fascia over the levator ani
what does the rectovaginal fascia merge with distally?
perineal body
where does the rectovaginal fascia tend to break?
centrally
endopelvis support: level I
uterosacral ligaments
cardinal ligaments
endopelvis support: level II
para vagina to arcus tendinous fascia: pubocervical/rectovaginal fascia
endopelvis support: level III
urogenital diaphragm
perineal body
risk factors for pelvic organ prolapse
pregnancy and vaginal birth advancing age obesity previous pelvic surgery menopause (hormones) quality of connective tissue constipation occupation with heavy lifting exercise
how does pregnancy and vaginal birth increase your risks of pelvic organ prolase?
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
how can exercise increase your risk of a pelvic organ prolapse?
weight lifting
high impact aerobics
long distance running
types of pelvic organ prolase
urethrocele cystocele uterovaginal enterocele rectocele
types of prolapse: urethrocele
prolapse of the lower ant vaginal wall involving the urethra only
types of prolapse: cystocele
prolapse of the upper anterior vaginal wall involving the bladder
types of prolapse: uterovaginal
prolapse of the uterus, cervic and upper vagina
types of prolapse: enterocele
prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
types of prolapse: rectocele
prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
what is the issue with classifying prolapses?
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.
what is a pure apical prolapse?
one in which there is no anterior or posterior vaginal wall prolapse
typical symptoms in women with prolapse: vaginal
sensation of a bulge or protrusion seeing or feeling a bulge or protrusion pressure heaviness difficulty in inserting tampons
typical symptoms in women with prolapse: urinary
urinary incontinence
frequency/urgency
weak or prolonged urinary stream/hesitancy/feeling of incomplete emptying
manual reduction of prolapse to start or complete voiding
typical symptoms in women with prolapse: bowel
- 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
assessment of prolapse
• 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
investigation of prolapse
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
prevention of prolapse
- Avoid constipation
- Effective management of chronic chest pathology – COPD and asthma
- Smaller family size
- Improvements in antenatal and intrapartum care
PT for prolapse
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.
pessaries for prolapse
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
surgery for prolapse
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
