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Repro > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

Define female pelvic organ prolapse

A

Descent of pelvic organs towards or through vagina

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2
Q

What is the rate of pelvic organ prolapse?

A

12-30% multiparous women

2% nulliparous

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3
Q

The pelvic floor consists of 3 layers working as one functional unit. Name the 3 layers

A

Endopelvic fascia
Pelvic diaphragm
Urogenital diaphragm

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4
Q

The endopelvic fascia is a fibrous connective tissue surrounding visceral structures. Which structures does it cover?

A

Uterosacral ligaments
Rectovaginal fascia
Pubocervical fascia

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5
Q

The pelvic diaphragm is a layer of striated muscle made up of which muscles?

A

Levator ani

Coccygeus

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6
Q

What does the urogenital diaphragm consist of?

A

The superficial and deep transverse perineal muscles with their fascial coverings

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7
Q

Which ligament is the cardinal ligament?

A

Uterosacral ligament

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8
Q

The uterosacral ligament is medial to which structures

A

Uterus, cervix, lateral fornices of vagina, pubocervical and rectovaginal fascia

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9
Q

The uterosacral ligament is lateral to which structures?

A

Sacrum

Fascia covering the piriformis

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10
Q

Where does the uterosacral ligament tend to break?

A

Medially

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11
Q

What shape is the pubocervical fascia?

A

Trapezoid

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12
Q

What structure does the pubocervical fascia mainly provide support to?

A

Anterior wall of vagina

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13
Q

What merges with the pubocervical fascia centrally?

A

Cardinal ligaments and cervix

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14
Q

What is lateral to the pubocervical fascia?

A

Arcus tendineus fascia of pelvis

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15
Q

What is distal to the pubocervical fascia?

A

Urogenital diaphragm

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16
Q

Where does the pubocervical fascia most commonly tend to break?

A

Immediately in front of cervix

Or at lateral attachments

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17
Q

How is a break in the pubocervical fascia immediate to the cervix treated?

A

Midfascial ligation

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18
Q

How does a midfascial ligation affect lateral defects?

A

Will further disrupt

Pubocervical fascia defects -> 3 defects due to 3 attachments

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19
Q

What type of tissue is the rectovaginal fascia?

A

Fibromuscular ELASTIC tissue

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20
Q

What structures does the rectovaginal fascia fuse with centrally?

A

Base of uterosacral ligament and peritoneum

21
Q

Which fascia does the rectovaginal fascia fuse with laterally?

A

Fascia covering the levator ani

22
Q

To which structure does the rectovaginal fascia merge with distally?

A

Perineal body

23
Q

Where does the rectovaginal fascia tend to break?

A

Centrally

24
Q

Which organ prolapse does an upper defect in the rectovaginal fascia lead to?

A

Enterocele

25
Q

Which organ prolapse doe a lower defect in the rectovaginal fascia lead to?

A

Rectocele

Perineal body descent

26
Q

Describe the 3 levels of endopelvic support

A

Level I - Uterosacral ligaments
Level II- Para vagina to arcus tendinous fascia - Pubocervical and rectovaginal fascia
Level III- Urogenital diaphragm, perineal body

27
Q

Name 7 Risk factors for pelvic organ prolapse

A 
Pregnancy and vaginal birth
Previous pelvic surgery
Hormonal factors
Quality of Connective Tissue
Constipation
Occupation with heavy lifting
Exercise - weight lifting, high impact aerobics, long distance running ; urogenital prolapse
28
Q

What factors associated with pregnancy and vaginal birth in particular pose a risk of pelvic organ prolapse?

A 
Forceps delivery
Large baby - obstructed labour
Prolonged second stage labour
Advanced age
Obesity
29
Q

Which pelvic surgeries increase risk of subsequent pelvic organ prolapse?

A

Burch culposuspension

Hysterectomy

30
Q

Which defect and prolapse is associated with burch colposuspension?

A

Defect in posterior vaginal wall

Leads to increased risk of rectocele and enterocele

31
Q

Define urethrocele

A

Prolapse of lower anterior vaginal wall involving the urethra only

32
Q

Define cystocele

A

Prolapse of upper anterior vaginal wall involving bladder

33
Q

Define uterovaginal prolapse

A

Prolapse of uterus, cervix and upper vagina - Apical

34
Q

Define Enterocele

A

Prolapse of upper posterior vaginal wall involving small loops of bowel

35
Q

Define rectocele

A

Prolapse of lower posterior vaginal wall involving rectum bulging forward - Posterior

36
Q

Symptoms of prolapse can be categorised into which 3 groups

A

Vaginal
Bowel
Urinary

37
Q

Vaginal symptoms of prolapse

A 
Sensation of bulge or protusion
Visible bulge or protrusion
Pressure
Heaviness
Difficulty inserting tampons
38
Q

Urinary symptoms of prolapse

A

Urinary incontinence
Frequency/Urgency
Weak/prolonged urinary stream or hesistancy
Feeling of incomplete emptying
Manual reduction of prolapse necessary to start or complete void

39
Q

Bowel symptoms of prolapse

A

Incontinence of flatus/liquid/solid stool
Feeling of incomplete emptying/straining
Urgency
Digital evacuation to complete defecation
Splinting/ pushing around vagina or perineum to start/complete defecation

40
Q

Assessment of pelvic organ prolapse

A

Examination
Quality of life
Objective assessment - Baden-Walker Halfway grading, POPQ score

41
Q

What is the gold standard for objective assessment of pelvic organ prolapse?

A

POPQ score

42
Q

Stages of Pelvic Floor Evaluation

A 
Stage 0		(TVL – 2 cm )
Stage I		(< - 1cm)
Stage II		(> - 1cm < + 1cm)
Stage III		(> _ 1cm but  + TVL – 2cm )
43
Q

Investigations for Pelvic Organ Prolapse

A

Ultrasound
Urodynamics - urinary incontinence or occult stress incontinence
IVU or Renal Ultrasound - if suspected ureteric obstruction

44
Q

Purpose of IVU or Renal US in investigating POP?

A

If suspected ureteric obstruction

45
Q

Prevention of POP

A

Prompt management and prevention of constipation
Manage chronic chest pathology (COPD)
Smaller family size
Improve antenatal and intrapartum care
No evidence for pelvic floor training postnatal to prevent but logical conclusion to advise anyway

46
Q

Treatment for pelvic organ prolapse

A

Physiotherapy- pelvic floor training
Pessaries
Surgery

47
Q

Aims of surgery in treatment of pelvic organ prolapse

A

Relieve symptoms
Restore and maintain bladder and bowel function
Maintain vaginal capacity for sexual function

48
Q

Risk and considerations for surgery

A

Prophylactic antibiotics
Thrombo-embolic prophylaxis
Post-operative urinary vs SPC (suprapubic catheter)

Repro (12 decks)

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