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Pelvic Organ Prolapse Flashcards

1
Q

Define prolapse

A

Protrusion of an organ/structure beyond its normal anatomical confines

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2
Q

Define pelvic organ prolapse

A

Descent of an organ towards/through the vagina

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3
Q

Define cystocele

A

Prolapse of upper anterior vaginal wall involving the urethra only

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4
Q

Define anterior vaginal wall prolapse

A

Herniated anterior vaginal wall

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5
Q

Define rectocele

A

Prolapse of the lower posterior vaginal wall involving the rectum bulging into the vagina

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6
Q

Define posterior vaginal wall prolapse

A

Herniated posterior vaginal wall

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7
Q

Define urethrocele

A

Prolapse of the lower anterior vaginal wall involving the urethra only

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8
Q

Define apical prolapse

A

Downward displacement of the vaginal apex

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9
Q

What is the scale of POP?

A

Around 50% of parous woman will have some degree of POP

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10
Q

If all the pelvic floor is normal the pelvic viscera will _________________

A

Be maintained in their position at rest and during periods of increased intraabdominal pressure

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11
Q

What are the three distinct layers of the pelvic floor?

A

Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm

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12
Q

What is the endopelvic fascia?

A

Network of fibromuscular connective type tissue that has a hammock like configuration and surrounds the various visceral structures
(Uterosacral ligament & pubocervical & rectovaginal ligaments)

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13
Q

What does the pelvic diaphragm consist of?

A

Layers of striated muscle & fascial coverings (levator ani & coccygeus)

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14
Q

What does the urogenital diaphragm consist of?

A

Superficial & deep transverse perineal muscles & their fascial coverings

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15
Q

Where does the uterosacral ligament pass?

A

Medial to uterus, cervix, lateral to vaginal fornices, pubocervical & rectovaginal fascia
Overlies the piriformis muscle

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16
Q

How can you palpate the uterosacral ligament?

A

Down traction on cervix

If in tact allows limited side to side movement of cervix

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17
Q

Where does the uterosacral ligament tend to break?

A

Medially (around cervix)

If it fails usually get uterine prolapse

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18
Q

Which fascia provides the main support of the anterior vaginal wall?

A

Pubocervical fascia

19
Q

What does the pubocervical fascia merge with centrally?

A

Base of cardinal ligaments and cervix

20
Q

What occurs if the pubocervical fascia breaks?

A

Bladder comes down into anterior vaginal wall

21
Q

Where is the rectovaginal fascia?

A

Centrally merges with base of cardinal ligaments, uterosacral ligaments & peritoneum
Laterally fuses with fascia over levator ani
Distally attaches to peritoneal body

22
Q

If the rectovaginal fascia fails what results?

A

Rectal/posterior wall prolapse

If upper defect may even get enterocele

23
Q

What are the risk factors for POP?

A

Factors increasing intrabdominal pressure and putting strain on the anatomical structure

Pregnancy & vaginal birth - forcep delivery, large babies (>4.5kg), prolonged second stage
Advanced age - muscles & ligaments weaken
Obesity - inc. pressure on pelvic floor
Prev pelvic floor surgery (heals with fibrous tissue which is weaker and less elastic)
Hormonal factors (menopause)
Quality of connective tissue (certain syndromes lead to weak connective tissue)
Constipation
Exercise - heavy lifting, high impact & long distant running

24
Q

Define enterocele

A

Prolapse of the upper posterior vaginal wall usually containing loops of small bowel

25
Q

Define uterovaginal prolapse

A

Prolapse of the uterus, cervix and upper vagina

26
Q

How can you distinguish between an anterior and posterior vaginal wall prolapse?

A

Use sims speculum to hold one of the walls and ask patient to push - check both sides to see which it is

27
Q

What occurs in apical prolapse?

A

Pure prolapse - central compartment (cervix/vagina) prolapses (NOT involving posterior/anterior walls)

28
Q

What are the vaginal symptoms of POP?

A 
Sensation of bulge/protrusion/fullness
Seeing/feeling bulge
Pressure
Heaviness/dragging sensation 
Difficulty inserting tampons
Difficulty during sex
29
Q

What are the urinary symptoms of POP?

A

Urinary incontinence
Frequency/urgency
Weak/prolonged urinary stream/hesitancy/feeling of incomplete emptying

30
Q

What are the bowel symptoms of POP?

A

Incontinence of flatus/liquid/stool
Feeling of incomplete emptying
Urgency
Digital evacuation to complete defaecation
Splinting/pushing around/on vagina/perineum to start defaecation

31
Q

How do you assess a POP?

A

Examination only!!
Urodynamics only if concurrent urinary incontinence
IVU/Renal USS only if suspicion of ureteric obstruction

32
Q

How do you prevent POP?

A

Avoid constipation
Management of chronic chest pathology - asthma/COPD
Small family size
Improvements in antenatal/intrapartum care

33
Q

How do you treat POP?

A

POP inside introitus - pelvic floor muscle exercises

POP outside - pelvic floor muscles wont bring prolapse back inside

34
Q

Why are pelvic floor muscle exercises the mainstay of Rx for POP?

A

There is little pressure on the ligaments supporting the pelvic viscera so long as the pelvic floor muscles are strong

It increases pelvic floor bulk and relieves tension on ligaments

35
Q

How do you carry out pelvic floor muscle exercises?

A

Sit on hard surface
Legs open & lean forward
Lift up and squeeze
10x quickly, 10x slowly

36
Q

When should pelvic floor muscle exercises be carried out?

A

In mild prolapse/young woman that have not completed their family

37
Q

What can education about pelvic floor muscle training be supplemented with?

A

Use of perineometer (measures strength of voluntary contractions of the pelvic floor muscles)
Biofeedback (sensors & monitor indicate if doing it correctly)
Vaginal cones
Electrical stimulation (helps them find muscle & contract it if v. weak)

38
Q

Apart from pelvic floor muscle training, what are the other Rx for POP?

A

Pessaries

Surgery

39
Q

What are the most common pessaries used for POP?

A

Ring pessaries

Cup holds prolapse up with pelvic bones, stalk of pessary allows patient to reposition

40
Q

How long can pessaries stay in for?

A

9m

41
Q

What are the SEs of using pessaries?

A

Discharge

No other complications apart from this

42
Q

What is more effective in Rx POP: surgery or pessaries?

A

Just as good as each other

Pessaries have less SEs

43
Q

What does surgery aim to do in Rx of POP?

A

Relieve symptoms, restore/maintain bladder/bowel function, maintain vaginal capacity for sexual function

Reproduction (28 decks)

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