Pelvic organ prolapse Flashcards
What is a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines
What is female pelvic organ prolapse?
Descent of pelvic organs towards or through the vagina
Are nulliparous or multiparous women more likely to get pelvic organ prolapse?
Multiparous
What is the pelvic floor?
The bottom surface of the pelvic cavity
What is the purpose of the pelvic floor?
Keeps pelvic viscera in position at rest and when there is increased intra-abdominal pressure
What are the 3 layers of the pelvic floor?
Endo-pelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the endo-pelvic fascia?
Network of fibro-muscular connective tissue that has a hammock-like configuration and surrounds various visceral structures
What structures male up the endo-pelvic fascia?
Uterosacral ligaments
Pubocervical fascia
Rectovaginal fascia
What is the pelvic diaphragm?
Layer of striated muscles with fascial coverings
What structures make up the pelvic diaphragm?
Levator ani
Coccygeus
What is the urogenital diaphragm?
Superficial and deep transverse perineal muscles with their fascial coverings
What is the anatomical position of the utero-sacral ligament?
Medial to the uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
Lateral to sacrum and fascia overlying piriformis muscle
How can the utero-sacral ligament be palpated?
Down traction on the cervix
What does the utero-sacral ligament provide?
Limited side-side movement of the cervix
Which part of the utero-sacral ligament tends to break?
Medial part
Why is it important that the ligament normally breaks medially?
Allows the surgeon to access it vaginally
What are the 3 supports of the pubocervical fascia?
Centrally - merges with the base of cardinal ligaments and cervix
Laterally - arcus tendineus fascia pelvis
Distally - Urogenital diaphragm
Where does the pubocervical fascia tend to break?
Lateral attachments or immediately in front of cervix
What tissue makes up the rectovaginal fascia?
Fibro-musculo-elastic tissue
What are the 3 supports for the rectovaginal fascia?
Centrally merge with base of the cardinal/uterosacral ligaments and peritoneum
Laterally fuses with fascia over levator ani
Distally attaches firmly to the perineal body
Where does the rectovaginal fascia tend to break?
Centrally
If upper defect - enterocele
If lower defect - perineal body descent and rectocele
What is enterocele?
Descent of the small intestine into the vagina
What is rectocele?
Protrusion of the rectum into the vagina
What are risk factors of pelvic organ prolapse?
Forceps delivery of vaginal birth Large baby - over 4500 grams Prolonged second stage of labour Advancing age Obesity Previous pelvic surgery Hormonal factors Constipation Occupation with heavy lifting Some forms of exercise
What pelvic surgery increases risk of pelvic organ prolapse?
Continence procedures
Hysterectomy
What is 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 uterovaginal prolapse?
Term used to describe prolapse of the uterus, cervix, and upper vagina
What are typical vaginal symptoms in women with pelvic organ prolapse?
Sensation of bulge or protrusion Seeing or feeling bulge or protrusion Pressure Heaviness Difficulty inserting tampons
What are typical urinary symptoms in women with pelvic organ prolapse?
Urinary incontinence
Frequency/urgency
Weak or prolonged urinary stream/feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
What are typical bowel symptoms in women with pelvic organ prolapse?
Incontinence of flatus or liquid stool
Feeling of incomplete emptying
Urgency
Digital evacuation to complete defecation
What is the gold standard assessment of pelvic organ prolapse?
POPQ score
What investigations can be done into pelvic organ prolapse?
USS or MRI to allow identification of fascial defects
Urodynamics
IVU or renal USS
How can pelvic organ prolapse be prevented?
Avoid constipation
Effective management of chronic chest pathology
Smaller family size
Improvements in antenatal and intra-partum care
How can pelvic organ prolapse be treated?
Physiotherapy - pelvic floor muscle training
Surgical treatment
What are factors of pelvic floor muscle training that make it an effective option?
Increase pelvic floor strength and bulk leading to decreased tension on ligaments
Improves cases of mild prolapse
Effecting in young women who have not completed their family
What are negative factors of pelvic floor muscle training?
No role in advanced diseases
Cannot treat fascial defects
