Pelvic organ prolapse Flashcards
What is a female POP?
Descent of pelvic organs towards or through the vagina
Who is more at risk of POP?
Parous women
What are the 3 layers of the pelvic floor?
Endo-pelvic fascia
Pelvic diaphragm
Urogenital diaphragm
What is the endo-pelvic fascia?
Network of fibre-muscular connective-type tissue that has ‘hammock-like’ configuration and surrounds various visceral structures
What is the pelvic diaphragm?
Layer of striated muscles with its facial coverings (Levator ani & coccygeus)
What makes up the endo-pelvic fascia?
Uterosacral ligaments
Pubocervical fascia
Rectovaginal fascia
What makes up the pelvic diaphragm?
Levator ani
Coccygeus
What is the urogenital diaphragm?
Superficial and deep transverse perineal muscles with their fascial coverings
Where does the uterosacral-cardinal complex tend to break?
Medially (around the cervix)
What does the uterosacral-cardinal complex attach to medially?
Uterus, cervix, lateral vaginal fornices & pubocervical & rectovaginal fascia
What does the uterosacral-cardinal complex attach to laterally?
Sacrum a& fascia overlying piriformis
How is the uterosacral-cardinal complex palpated?
Down traction on acerbic and, if intact, allows limited side-side movement of the cervix
What does the pubocervical fascia do?
Provides the main support of anterior vaginal wall
Where does the pubocervical fascia tend to break?
At lateral attachments of immediately in front of cervix
Where does the pubocervical fascia attach centrally?
Merge with base of cardinal ligaments & cervix
Where does the pubocervical fascia attach laterally?
Arcus tendinous fascia pelvis
Where does the pubocervical fascia attach distally?
Urogenital diaphragm
What type of tissue is the rectovaginal fascia tissue?
Fibro-musculo-elastic tissue
Where does the rectovaginal fascia attach centrally?
Merge with base of cardinal/uterosacral ligaments & peritoneum
Where does the rectovaginal fascia attach laterally?
Fuses with fascia over levator ani
Where does the rectovaginal fascia attach distally?
Firmly to perineal body
Where does the rectovaginal fascia tend to break?
Centrally - if upper defect e.g. enterocele
What are the 3 levels of endopelvic support?
Level I: utero-sacral ligaments and cardinal ligaments
Level II: para-vagina to Marcus tendineus fascia: pubocervical/rectovaginal fascia
Level III: urogenital diaphragm and perineal body
What are the main risk factors of POP?
Pregnancy and vaginal birth: forceps delivery, large baby, prolonged second stage
Advancing age
Obesity
Previous pelvic surgery (continence procedures)
Hormonal factors
Quality of connective tissue
Constipation
Occupation with heavy lifting
Exercise: weight lifting, high-impact aerobics, long-distance running
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 the 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 an apical prolapse the same as?
Enterocele
What are typical vaginal symptoms in women with POP?
Sensation of bulge/ protrusion Seeing or feeling bulge/protrusion Pressure Heaviness Difficulty inserting tampons
What are typical urinary symptoms in women with POP?
UI Frequency/urgency Weak or prolonged urinary stream Hesitancy Feeling of incomplete emptying Manual reduction of prolapse to start or complete voiding
What are typical bowel symptoms in women with POP?
Incontinence of flatus, or liquid/solid stool
Feeling of incomplete emptying/straining
Urgency
Digital evacuation to complete defecation
Splinting/pushing on around vagina/perineum to start/complete defecation
What is the assessment for POP?
Examination - exclude pelvic mass
Record position of exam
QoL effect
Objective assessments
What are the objective assessments used in POP?
Bade-Walking-Halfawy Grading
POPQ score
What is the gold standard objective assessment used in POP?
POPQ score
What is the POPQ score?
Stage 0-VI
Measures 9 points in vagina
What investigations can be done in POP?
USS/MRI
Urodynamics
IVU or renal USS
What are preventions to avoid POP?
Avoid constipation
Effective management chronic chest pathology (COPD/asthma)
Smaller family - less parity!
Antenatal pelvic floor training
What are the treatment options for POP?
Physio: PFMT
Pessaries
Surgery
How does PFMT help POP?
Increase pelvic floor strength/bulk = relieve tension of ligaments
How does prolapse occur?
Progressive weakness of the pelvic floor muscles followed by breakdown in fascial support
