Pelvic Organ Prolapse Flashcards
What is a female pelvic organ prolapse?
The descent of the pelvic organs towards or through the vagina
What is the incidence of female pelvic organ prolapse?
12-30% of multiparous women
2% of nulliparous women
What are the borders of the utero-sacral or cardinal complex fascia and where does it commonly break?
Medial border- uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia
Lateral border- sacrum and fascia overlying piriformis
Breaks- Tend to break medially around the cervix
What are the borders of the pubocervical fascia and where does it commonly break?
Central border- merge with base of cardinal ligaments and cervix
Lateral border- Arcus tendineus fascia pelvis
Distal border- Urogenital diaphragm
Breaks- Lateral attachments
Immediately in anterior to cervix
What are the borders of the rectovaginal fascia and where does it commonly break?
Central border- merge with base of cardinal complex and peritoneum
Laterally - fuses with fascia over levator ani
Distally- firmly attached to perineal body
Breaks- Tends to break centrally
If upper defect- enterocele, lower defect- rectocele
What are the risk factors for pelvic organ prolapse?
- Pregnancy and vaginal birth
- Forceps delivery
- Large baby (>4500g)
- Prolonged second stage of labour
- Age
- Obesity
- Previous pelvic floor surgery
- Hormonal factors
- Constipation
- Occupation with Heavy Lifting
- Exercise
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 uterovaginal prolapse?
Prolapse of 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 the vagina involving the rectum bulging forwards into the vagina
What is the cause of an anterior wall prolapse?
Breakage of the pubocervical fascia between the bladder and the vagina
What is the cause of a posterior wall prolapse?
Breakage of rectovaginal fascia
What are the vaginal symptoms of pelvic organ prolapse?
- Sensation of a bulge or protrusion
- Seeing or feeling a bulge or protrusion
- Pressure
- Vaginal heaviness
- Difficulty in inserting tampons
What urinary symptoms can present with pelvic organ prolapse?
- Urinary Incontinence
- Frequency/ Urgency
- Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
- Manual reduction of prolapse to start or complete voiding
What gastrointestinal symptoms can present with pelvic organ prolapse?
- Incontinence of flatus, or liquid or solid stool
- Feeling of incomplete emptying/ Straining
- Urgency
- Digital evacuation to complete defecation
- Splinting (pushing on or around the vagina or perineum, to start or complete defecation)
What steps are involved in assessment of pelvic organ prolapse?
- Examination to exclude pelvic mass
- Record the position of examination
- Quality of Life
- Objective assessment with POPQ score
What investigations can be done to check for other problems such as pelvic masses or ureteric onbstruction?
- Ultrasound/MRI
- Urodynamics
- Intravaginal or renal ultrasound
How can pelvic organ prolapses be prevented?
- Avoid constipation.
- Effective management chronic chest pathology (COPD & asthma).
- Smaller family size.
- Improvements in antenatal and intra-partum care (pelvic floor muscle training)
What are the treatment options for pelvic organ prolapse?
Physiotherapy- pelvic floor muscle training
Pessaries
Surgery
What are the aims of pelvic organ prolapse surgery?
- Relieve symptoms
- Restore/maintain bladder & bowel function
- Maintain vaginal capacity for sexual function
What additional measures may be required with pelvic organ prolapse surgery?
- Prophylactic Antibiotics.
- Thrombo-embolic prophylaxis
- Postoperative urinary or supra-pubic catheter