pelvic organ prolapse Flashcards
def
the descent of pelvic organs towards or through the vagina
o In the UK, pelvic organ prolapse accounts for 20% of women on the waiting list for major gynaecological surgery
o 7-14% of hysterectomies is due to prolapse.
anatomy of pelvic floor
Endo-pelvic floor ( 3 distinct layers)
Endo-pelvic fascia: network of fibro-muscular connective-type tissue surrounds the various visceral structures
Pelvic Diaphragm
Urogenital Diaphragm:the superficial & deep transverse perineal muscles
vary in strength but function in one unit
Endo-pelvic fascia
Fibromuscular can stretch, connective tissue breaks
o Tend to break medially (around the cervix).
Utero Sacral/ cardinal complex
pubocervical
fibromuscular
-– provide the main support of the anterior vaginal wallTend to break at lateral attachments or immediately in front of the cervix
Rectovaginal fascia fibromuscular elastic o Tends to break Centrally: ♣ If upper defect: Enterocele. ♣ If lower defect: perineal body descent & Rectocele.
Endo pelvic support
level I:
Utero-sacral ligaments
cardinal ligaments
level2:
Para vagina to arcus tendineus fascia: pubocervical/ rectovaginal fascia
level 3:
Urogenital diaphragm
perineal body
risk for POP
pregnancy and vaginal birth
forceps delivery
large baby
prolonged second stage
advancing age
obesity previous pelvic surgery continence procedures burch colposuspension other risk factors hormonal factors quality of connective tissue occupation with heavy lifting constipation
traditional classification of prolapse
o Urethrocele: Prolapse of the lower anterior vaginal wall involving the urethra only.
o Cystocele: Prolapse of the upper anterior vaginal wall involving the bladder.
o Uterovaginal prolapse. This term is used to describe prolapse of the uterus, cervix and upper vagina.
o Enterocele: Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
o Rectocele: Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
Typical symptoms
o Pressure
Vaginal prolapse
Heaviness/sensation of fullness
o Difficulty in inserting tampons
o Other presentations depend on where/what it is
♣ E.g. feel like sitting on a golf ball
Urinary bladder prolapse
o Urinary Incontinence
o Frequency/ Urgency
o Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
o Manual reduction of prolapse to start or complete voiding
bowel prolapse
o Incontinence of flatus, or liquid or solid stool
o Feeling of incomplete emptying/ Straining
o Urgency
o Digital evacuation to complete defecation
o Splinting, or pushing on or around the vagina or perineum, to start or complete defecation
Assessment of POP
examination to exclude pelvic mass
-quality of life
objective assessment
POPQ score (gold standard)
stage prolapse 1 to IV
investigation
clinical diagnosis
o No investigation is required for diagnosis – a clinical diagnosis
o USS / MRI: Allow identification of fascial defects/ measurement of levator ani thickness (research only).
♣ Only done if symptoms don’t match the clinical picture (e.g. prolapse is inside pelvis)
-urodynamics
IVU intravenous urogram or renal USS
prevention
avoid constipation
effective management of chronic chest pathology
smaller family size
treatment
conservative
• Pelvic floor muscle (PFM) exercises
o Pelvic floor muscle training (PFMT):
♣ First-line management of stage I & II prolapse
♣ Increase the pelvic floor strength & bulk relieve the tension on the ligaments
♣ Younger women who have not yet completed their family.
♣ No role in advanced cases.
♣ Cannot treat fascial defects.
o may be supplemented with the use of a perineometer and biofeedback, vaginal cones and electrical stimulation
o (perineometer – an instrument for measuring the strength of voluntary contractions of the pelvic floor muscles)
Pessaries
-made from silicone
o doesn’t solve prolapse completely, it reduces pressure symptoms
Some pessaries allow intercourse, some don’t
surgery
-♣ Relieve symptoms,
♣ Restore/maintain bladder & bowel function
Maintain vaginal capacity for sexual function if needed by the patient
o 3 points about surgery to remember:
♣ Prophylactic antibiotics
♣ Thrombo-embolic prophylaxis
♣ Postoperative urinary vs suprapubic catheter.
• SPC usually done in severe distension + pain
summary
prolapse occurs due to progressive weakness of pelvic floor muscles followed by breakdown in fascial support
• Affect 50% of multiparous women with 10% symptomatic.
• Assessment is multi-dimensional including pelvic examination, assessment of pelvic floor, symptom bother & impact on QoL.
• Management would be tailored to patients needs and would include Pelvic floor muscle therapy conservative & surgical management.
