Pelvic Organ Prolapse Flashcards

1
Q

What does the word prolapse refer to

A
  • Falling or slipping of the viscous
  • Protrusion of an organ or structure beyond its normal anatomical confines
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2
Q

What is female pelvic organ prolapse (POP)

A
  • refers to the descent of the pelvic organs towards or through the vagina
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3
Q

Incidence of POP

A
  • 12-30% of multiparous women
  • 2% of null parous
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4
Q

Prevalence of POP

A
  • 2% symptomatic prolapse to 50% asymptomatic prolapse
  • Leading cause of hysterectomies
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5
Q

What is the pelvic floor

A
  • The bottom of the abdomino-pelvic cavity (box)
  • Consists of all the soft tissue structures that close the space between the pelvic bones
  • If normal, pelvic viscera maintained in position both at rest and during increased intra-abdominal pressure
  • The pelvic floor is 1 functional unit
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6
Q

What are the layers of the pelvic floor

A
  • 3 distinct layers - do not parallel each other and vary in strength and thickness
  • Endopelvic fascia
  • Pelvic diaphragm
  • Urogenital diaphragm
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7
Q

Describe the endopelvic fascia layer of the pelvic floor

A
  • Network of fibro-muscular connective tissue that has a ‘hammock-like’ configuration and surrounds the various visceral structures (uterosacral ligaments/pubocervical fascia/rectovaginal fascia)
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8
Q

Describe the pelvic diaphragm layer of the pelvic floor

A
  • Layer of striated muscle with its fascial coverings (levator ani & coccygeus)
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9
Q

Describe the urogenital diaphragm layer of the pelvic floor

A
  • The superficial & deep transverse perineal muscles with their fascial coverings
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10
Q

How do the components of the endopelvic fascia act

A
  • Fibro-muscular component can stretch (uterosacrals)
  • Connective tissue does not stretch or attenuate - breaks
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11
Q

What forms the utero-sacral/cardinal complex

A
  • Medially to uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia
  • Laterally to the sacrum & fascia overlying the piriforms muscle
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12
Q

What are the features of the utero-sacral/cardinal complex

A
  • Easily palpated by down traction on the cervix and if intact allows limited side-side movement of the cervix
  • Tends to break medially (around the cervix)
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13
Q

What is the anatomy of the pubocervical fascia

A
  • Trapezoidal fibro-muscular tissue: provide the main support of the anterior vaginal wall
  • Centrally - merges with the base of the cardinal ligament & cervix
  • Laterally - arcus tendinous fascia pelvis
  • Distally - urogenital diaphragm
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14
Q

Where does the pubocervical fascia tend to break

A
  • 3 support = 3 defects
  • Tends to break at lateral attachments or immediately in front of cervix
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15
Q

What is the anatomy of the rectovaginal fascia

A
  • Fibro-musculo - elastic tissue
  • Centrally - merge with the base of cardinal/uterosacral ligaments & peritoneum
  • Laterally - fuses with fascia over the levator ani
  • Distally - firmly to the perineal body
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16
Q

Where does the rectovaginal fascia tend to break

A
  • Centrally
    • If upper - enterocele
    • If lower - perineal body descent & rectcocele
17
Q

What are the levels of endopelvic support

A
  • Level I
    • Utero-sacral ligaments
    • Cardinal ligaments
  • Level II
    • Paravagina to argus tendinous fascia: pubocervical/rectovaginal fascia
  • Level III
    • Urogenital diaphragm
    • Perineal body
18
Q

What are the risk factors for POP

A
  • Pregnancy and vaginal birth
  • Advancing age
  • Obesity
  • Previous pelvic floor surgery
  • Others
19
Q

What are specific risk factor of pregnancy for POP

A
  • forceps delivery
  • Large baby (>4500g)
  • Prolonged second stage
  • Parity - strongest risk factor with adjusted relative risk of 10.9
    • Increase with parity but slows after 2
20
Q

What previous pelvic floor surgery is a risk of POP

A
  • Continence procedures while elevating the bladder neck may lead to other defects in the pelvic compartments
  • Burch colposuspension - can leave defects with predispose to rectocele and enterocele formation
21
Q

What are some other risk factors of POP

A
  • Hormonal factors
  • Quality of connective tissue
  • Constipation
  • Occupation with heavy lifting
  • Exercise
    • Weight lifting, high impact aerobic and long-distance running
22
Q

What is the traditional classification of POP

A
  • Urethrocele - prolapse of the lower anterior vagina involving the urethra only
  • Cystocele - prolapse of the upper anterior vaginal wall involving the bladder
  • Uterovaginal prolapse - prolapse of the uterus, cervix and upper vagina
  • Enterocele - prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
  • Rectocele - prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
23
Q

What is the current classification of POP

A
  • Anterior vaginal wall prolapse
    • Cystocele
    • Due to breaking of the pubocervical fascia centrally
  • Posterior vaginal wall prolapse
    • Rectocele
    • Rectovaginal fascia broken
  • Apical prolapse
    • Uterine prolapse (not anterior or posterior) - just comes down
    • Enterocele
24
Q

What are the vaginal symptoms of POP

A
  • Sensation of bulge or protrusion
  • Seeing or feeling a bulge of protrusion
  • Pressure
  • Heaviness
  • Difficulty inserting tampons
25
Q

What are the urinary symptoms of POP

A
  • Urinary incontinence
  • Frequency/urgency
  • Weak or prolonged urinary stream/hesitancy/feeling of incomplete emptying
  • Manual reduction of prolapse to start of complete voiding
26
Q

What are the bowel symptoms of POP

A
  • 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
27
Q

How is POP assessed

A
  • Examination to exclude pelvic mass
  • Record the position of examination: left vs lithotomy vs standing
  • Quality of life
28
Q

What scoring systems are used to objectively assess POP

A
  • Baden-Walker-Halfway Grading
  • POPQ score
29
Q

What is the POP score

A
30
Q

Investigations of POP

A
  • USS/MRI - allow identification of fascial defects/measurements of levator any thickness
  • Urodynamics - concurrent UI to exclude occult SI
  • IVU or renal USS - if suspicion of ureteric obstruction
31
Q

Prevention of POP

A
  • Avoid constipation
  • Effective management of chronic chest pathology (COAD & asthma)
  • Smaller family size
  • Improvements in antenatal and intrapartum care
32
Q

What is the physiotherapy treatment of POP

A
  • Pelvic floor muscle training (PFMT) - stages 1 & 2
    • Increase the pelvic floor strength & bulk –> relieves tension on ligaments
    • For women who have not yet completed their family
    • Cannot treat fascial defects
  • Can be supplemented with the use of perineometer and biofeedback, vaginal cones and electric stimulation
33
Q

Other treatment of POP

A
  • Pessaries - usually silicone
  • Surgery - function not anatomy
    • Relive symptoms
    • Restore bladder and bowel function
    • Maintain vaginal capacity for sexual function
34
Q

What should be remembered in surgery for POP

A
  • Propjhylactic antibiotics
  • Thrombo-embolic prophylaxis
  • Postoperative urinary vs SPC