Pelvic Organ prolapse Flashcards
Describe the anatomy of the pelvic floor
3 layers working as one unit:
-
Endopelvic fascia (connective tissue)
- Uterosacral/cardinal ligaments
- Pubocervical fascia
- Rectovaginal fascia
-
Pelvic diaphragm (striated muscle)
- Levator ani
- Coccygeus
-
Urogenital diaphragm
- Superficial transverse perineal muscle
- Deep transverse perineal muscle
What is the defintion of prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines.
What is the defintion of female pelvic organ prolapse?
Refers to the descent of the pelvic organs towards or through the vagina.
Occurs due to progressive weakness of pelvic floor muscles followed by breakdown in fascial support.
- Muscle trauma
- Neuropathic injury
- Disruption
- Stretching
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving the urethra only
What is a cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder
What is a rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
What is an enterocele?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
What is a uterovaginal prolapse?
This term is used to describe prolapse of the uterus, cervix and upper vagina
What are risk factors for the development of pelvic organ prolapse?
-
Pregnancy and labour related issues -
- Large baby (>4500 gms),
- Prolonged Second stage,
- Forceps delivery,
- Parity
- Vaginal delivery
- Advanced Age
- Obesity
-
Previous Pelvic Procedures
- Continence procedures - Burch culposuspension,
- Hysterectomy
- Hormonal Factors
- Quality of Connective Tissue
- Increased IAP - Constipation, chronic coughing
- Occupation with Heavy Lifting
- Exercise - Weight Lifting, High Impact
- Persistant cough, increased BMI
What are general symptoms of pelvic organ prolapse?
- Dragging sensation/Something coming down
-
Depending on site of prolapse
- Cystitis
- Frequency
- Stress incontinence
- Difficulty defecating
What are symptoms of vaginal prolapse?
- Sensation of a bulge or protrusion
- Seeing or feeling a bulge or protrusion
- Pressure
- Heaviness
- Difficulty in inserting tampons
- Dysparuenia
What are symptoms of a rectocele/Enterocele?
- Incontinence of flatus, or liquid or 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
What are symptoms of a cystocele/urethrocele
- Incontinence
- LUTS - storing/voiding symptoms: frequenct, urgency, poor stream, hesitancy, incomplete emptying
- To reduce the prolapse manually before voiding
How would you examine someone with symptoms of a prolapse?
Left lateral side with Sim’s speculum - ask the patient to bear down
What investigations would you consider doing in a woman with pelvic organ prolapse?
- Bedside - Dipstick
- Bloods - none
- Imaging - Bladder scan, IVU/renal USS (exclude pelvic mass/ureteric obstruction)
- Other - urodynamics (if incontinence present), urinalysis if urinary symtpoms
What is stage 0 POPQ prolapse?
No prolapse
What is stage 1 POPQ prolapse?
Most distal portion of the prolapse is >1cm proximal to the level of the hymen
What is stage 2 POPQ prolapse?
Most distal portion of the prolapse is < 1cm proximal or distal to the level of the hymen
What is stage III POPQ prolapse?
Most distal portion of the prolapse is > 1cm beyond the hymen but protrudes no further than total length of the vagina
What is stage IV POPQ prolapse?
Complete vaginal eversion
How does a pessarie work?
Reduce prolapsed tissue inside the vagina, provide support to related pelvic structures, and relieve pressure on the bladder and bowel in order to avert or delay the need for surgery
