Pelvic Organ Prolapse Flashcards
Define prolapse
Protrusion of an organ/structure beyond its normal anatomical confines
Define pelvic organ prolapse
Descent of an organ towards/through the vagina
Define cystocele
Prolapse of upper anterior vaginal wall involving the urethra only
Define anterior vaginal wall prolapse
Herniated anterior vaginal wall
Define rectocele
Prolapse of the lower posterior vaginal wall involving the rectum bulging into the vagina
Define posterior vaginal wall prolapse
Herniated posterior vaginal wall
Define urethrocele
Prolapse of the lower anterior vaginal wall involving the urethra only
Define apical prolapse
Downward displacement of the vaginal apex
What is the scale of POP?
Around 50% of parous woman will have some degree of POP
If all the pelvic floor is normal the pelvic viscera will _________________
Be maintained in their position at rest and during periods of increased intraabdominal pressure
What are the three distinct layers of the pelvic floor?
Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the endopelvic fascia?
Network of fibromuscular connective type tissue that has a hammock like configuration and surrounds the various visceral structures
(Uterosacral ligament & pubocervical & rectovaginal ligaments)
What does the pelvic diaphragm consist of?
Layers of striated muscle & fascial coverings (levator ani & coccygeus)
What does the urogenital diaphragm consist of?
Superficial & deep transverse perineal muscles & their fascial coverings
Where does the uterosacral ligament pass?
Medial to uterus, cervix, lateral to vaginal fornices, pubocervical & rectovaginal fascia
Overlies the piriformis muscle
How can you palpate the uterosacral ligament?
Down traction on cervix
If in tact allows limited side to side movement of cervix
Where does the uterosacral ligament tend to break?
Medially (around cervix)
If it fails usually get uterine prolapse
Which fascia provides the main support of the anterior vaginal wall?
Pubocervical fascia
What does the pubocervical fascia merge with centrally?
Base of cardinal ligaments and cervix
What occurs if the pubocervical fascia breaks?
Bladder comes down into anterior vaginal wall
Where is the rectovaginal fascia?
Centrally merges with base of cardinal ligaments, uterosacral ligaments & peritoneum
Laterally fuses with fascia over levator ani
Distally attaches to peritoneal body
If the rectovaginal fascia fails what results?
Rectal/posterior wall prolapse
If upper defect may even get enterocele
What are the risk factors for POP?
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
Define enterocele
Prolapse of the upper posterior vaginal wall usually containing loops of small bowel
Define uterovaginal prolapse
Prolapse of the uterus, cervix and upper vagina
How can you distinguish between an anterior and posterior vaginal wall prolapse?
Use sims speculum to hold one of the walls and ask patient to push - check both sides to see which it is
What occurs in apical prolapse?
Pure prolapse - central compartment (cervix/vagina) prolapses (NOT involving posterior/anterior walls)
What are the vaginal symptoms of POP?
Sensation of bulge/protrusion/fullness Seeing/feeling bulge Pressure Heaviness/dragging sensation Difficulty inserting tampons Difficulty during sex
What are the urinary symptoms of POP?
Urinary incontinence
Frequency/urgency
Weak/prolonged urinary stream/hesitancy/feeling of incomplete emptying
What are the bowel symptoms of POP?
Incontinence of flatus/liquid/stool
Feeling of incomplete emptying
Urgency
Digital evacuation to complete defaecation
Splinting/pushing around/on vagina/perineum to start defaecation
How do you assess a POP?
Examination only!!
Urodynamics only if concurrent urinary incontinence
IVU/Renal USS only if suspicion of ureteric obstruction
How do you prevent POP?
Avoid constipation
Management of chronic chest pathology - asthma/COPD
Small family size
Improvements in antenatal/intrapartum care
How do you treat POP?
POP inside introitus - pelvic floor muscle exercises
POP outside - pelvic floor muscles wont bring prolapse back inside
Why are pelvic floor muscle exercises the mainstay of Rx for POP?
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
How do you carry out pelvic floor muscle exercises?
Sit on hard surface
Legs open & lean forward
Lift up and squeeze
10x quickly, 10x slowly
When should pelvic floor muscle exercises be carried out?
In mild prolapse/young woman that have not completed their family
What can education about pelvic floor muscle training be supplemented with?
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)
Apart from pelvic floor muscle training, what are the other Rx for POP?
Pessaries
Surgery
What are the most common pessaries used for POP?
Ring pessaries
Cup holds prolapse up with pelvic bones, stalk of pessary allows patient to reposition
How long can pessaries stay in for?
9m
What are the SEs of using pessaries?
Discharge
No other complications apart from this
What is more effective in Rx POP: surgery or pessaries?
Just as good as each other
Pessaries have less SEs
What does surgery aim to do in Rx of POP?
Relieve symptoms, restore/maintain bladder/bowel function, maintain vaginal capacity for sexual function
