Pelvic Organ Prolapse Flashcards
What is prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines.
What is Female POP?
The descent of the pelvic organs towards or through the vagina.
What are the 3 distinct layers of the pelvic floor?
Endo-Pelvic fascia - network of fibromuscular connective type tissue that has a hammock like configuration. Surrounds the various visceral structures (uterosacral ligaments, pubocervical fascia, retrovaginal fascia).
Pelvic Diaphragm - Layer of striated muscles with its fascial coverings (elevator ani and coccygeus)
Urogential Diaphragm - the superficial and deep transverse perineal muscles with their fascial coverings.
What is the function of the coccygeus muscle?
Rudimentary, would only move our tail if we still had one.
What are the boundaries of the utero-sacral/ cardinal complex?
Medial to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia.
Lateral to sacrum and fascia overlying Piriformis muscle.
Where can the utero-sacral complex be palpated?
Easily palpated by down traction on the cervix and if intact allows limited side-side movement of cervix.
How does the utero-sacral complex tend to break?
Breaks medially around the cervix, so it will drop down.
What are the boundaries of the pubocervical fascia?
Centrally it merges with base of carinal ligaments and cervix.
Laterally Arcus tendinous, fascia pelvis.
Distally with the urogenital diaphragm.
What is the function of the pubocervical fascia?
Trapezoidal fibromuscular tissue that provides the main support of the anterior vaginal wall.
Where does the pubocervical fascia tend to break?
Laterally at attachments or immediately infront of cervix.
What are the boundaries of the rectovaginal fascia?
Centrally merges with base of cardinal ligaments and peritoneum.
Laterally fuses with fascia over the levator ani.
Distally it firmly attaches to the perineal body.
What sort of tissue is the rectovaginal fascia?
Fibro-musculo-elastic tissue.
Where does the rectovaginal fascia tend to break?
Centrally - upper then enterocele and if lower defect the perineal body descent and rectocele.
What are the 3 levels of endopelvic support?
Level I - uterosacral ligaments & cardinal ligaments.
Level II - Para-vagina to Arcus tendineus fascia: pubocervical/rectovaginal fascia.
Level III - Urogenital diaphragm & perineal body
What are the risk factors for Pelvic Organ Prolapse?
Pregnancy - forceps delivery, large baby, prolonged second stage. Advancing Age Previous pelvic surgery Obesity Hormonal factors Quality of connective tissue Occupation with heavy lifting Exercise
What is Burch Colposuspension?
Procedure to fix the lateral vaginal fornices to the ipsilateral iliopectineal ligaments. May leave a potential defect in the posterior vaginal wall which predisposes to enterocele and rectocele formation .
What is a urethrocele?
Prolapse of the lower anterior vaginal wall involving urethra only.
What is a cystocele?
Prolapse of the upper anterior vaginal wall involving the bladder.
What is a uterovaginal prolapse?
Prolapse of the uterus, cervix and upper vagina.
What is an Enterocele?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel.
What is a rectocele?
Prolapse of the lower posterior wall of vagina involving the rectum bulging forwards into vagina.
What are the typical symptoms of women with pelvic organ prolapse?
- Sensation of a bulge/protrusion
- Seeing or feeling a bulge/protrusion
- Pressure
- Heaviness
- Difficulty inserting tampons/sex
- Urinary incontinence
- Frequency/urgency
- Weak or prolonged urinary stream
- Hesitancy
- Incomplete emptying
- Manual reduction of prolapse to start voiding
- Incontinence of flatus, liquid or solid stool
- Straining
- Digital evacuation to complete defecation.
- Splinting/pushing on the vagina or perineum to start or complete defecation.
How is POP assessed?
Examination to exclude pelvic mass Record position of examination Quality of life Baden-walker-Halfawy Grading POPQ score (gold standard)
What investigations do you carry out for POP?
Ultrasound scan
MRI
Urodynamics
IVU or Renal USS
How is POP prevented?
Avoid constipation
Effective management of chronic chest conditions
Smaller family size!
improvements in antenatal and intra-partum care.
How is POP treated?
Pelvic Floor muscle training - increase pelvic floor strength and bulk.
Pessaries - devices used to hold organs in place.
Surgery
What is the advantage of using a silicone pessary?
Long shelf life Resistance to autoclaving/repeated cleaning Non-absorbent to secretions and odours Inertness Hypoallergenic nature
What are the aims of POP surgical treatment?
Relieve symptoms
Restore/maintain bladder and bowel function
Maintain vaginal capacity for sexual function.
