Pelvic organ prolapse Flashcards
what is prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines.
What is a female POP?
the descent of the pelvic organs towards or through the vagina.
prevalence?
2% for symptomatic prolapse to 50% for asymptomatic prolapse.
In the UK, pelvic organ prolapse accounts for 20% of women on the waiting list for major?
gynaecological surgery
what does the pelvic floor consist of?
all the soft tissue structures that close the space between the pelvic bones.
what is maintained if the pelvic floor is normal?
pelvic viscera will be maintained in their position both at rest and in periods of increased intra-abdominal pressure.
what are the 3 distinct layers of the pelvic floor
Endo-pelvic Fascia
Pelvic Diaphragm
Urogenital Diaphragm
describe the Endo-pelvic Fascia?
- what ligaments are present
network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
describe the pelvic diaphragm?
layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
describe the Urogenital Diaphragm?
the superficial & deep transverse perineal muscles with their fascial coverings.
endometriosis- pelvic fascia - describe the connective tissue?
does not stretch or attenuate instead it breaks.
Utero-sacral/ Cardinal Complex ligament palpated?
down traction on the Cervix and if intact allows limited side-side movement of the cervix.
how does the Utero-sacral/ Cardinal Complex tend to break?
medially (around the cervix)
Utero-sacral/ Cardinal Complex lies medially to? (5)
Uterus, Cervix, Lateral Vaginal Fornices & Pubocervical & Rectovaginal Fascia.
Utero-sacral/ Cardinal Complex lies laterally to?
the sacrum & fascia overlying the Piriforms muscle.
Pubocervical Fascia - what kind of fibre?
- what does it do?
Trapezoidal Fibro-muscular tissue
- Provide the main support of the anterior vaginal wall.
Pubocervical Fascia - centrally merges with?
Base of Cardinal ligaments & Cervix
Pubocervical Fascia - lies laterally with?
Arcus Tendineus Fascia Pelvis (White line).
Pubocervical Fascia lies distally to?
Urogenital Diaphragm (under SP).
where do the Pubocervical Fascia tend to break at?
lateral attachments or immediately in front of the cervix.
Rectovaginal Fascia - made of what tissue?
Fibro-musculo- elastic tissue.
where does the Rectovaginal Fascia tend to break?
upper vs lower defect
If upper defect: Enterocele.
If lower defect: perineal body descent & Rectocele.
Rectovaginal Fascia - lies centrally to?
merge with the Base of Cardinal/ uterosacral ligaments & peritoneum.
Rectovaginal Fascia - laterally fuses with?
fascia over the levator ani.
Rectovaginal Fascia - joins firmly to what distally ?
Perineal Body.
Endopelvic Support - level 1 - what 2 ligaments
Utero-sacral ligaments
Cardinal ligaments
Endopelvic Support - level 2?
Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia
Endopelvic Support - level 3?
Urogenital Diaphragm
Perineal body
Risk factors of POP? (4)
Pregnancy and Vaginal birth - Forceps Delivery Large baby (> 4500 gm) Prolonged Second Stage - Advancing Age - Obesity
strongest RISK FACTOR OF POP?
Parity
how can previous pelvic procedure effect POP?
Continence procedures - ELEVATES BALDDER NECK
- Burch colposuspension
- hysterectomy
WHAT IS Burch colposuspension?
by fixing the lateral vaginal fornices to the ipsilateral iliopectineal ligaments, leaves a potential defect in the posterior vaginal wall, which predisposes to rectocele and enterocele formation
Other Risk Factors for POP?
- Hormonal factors
- Quality’ of Connective Tissue
- Constipation
- Occupation with Heavy Lifting
- Exercise
- Weight lifting, high-impact aerobics and long-distance running increase the risk of urogenital prolapse.
what is a Urethrocele prolapse?
Prolapse of the lower anterior vaginal wall involving the urethra only.
what is a cystocele prolapse?
Prolapse of the upper anterior vaginal wall involving the bladder.
what is a Uterovaginal prolapse?
This term is used to describe prolapse of the uterus, cervix and upper vagina.
what is a Enterocele prolapse?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
what is a Rectocele prolapse?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
Typical symptoms in women with pelvic organ prolapse - Vaginal (5)
- Sensation of a bulge or protrusion
- Seeing or feeling a bulge or protrusion
- Pressure
- Heaviness
- Difficulty in inserting tampons
Typical symptoms in women with pelvic organ prolapse – Urinary
- Urinary Incontinence
- Frequency/ Urgency
- Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
- Manual reduction of prolapse to start or complete voiding
Typical symptoms in women with pelvic organ prolapse – Bowel (5)
- 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
Assessment of POP (3)
- Examination to exclude pelvic mass
- Record the position of examination: left lateral Vs - Lithotomy Vs Standing.
Quality of Life
Objective Assessment: (3)
Baden- Walker- Halfawy Grading
POPQ Score
Others
gold standard test?
POPQ Score
Pelvic floor evaluation values? ( 0,1,2,3,5)
Stage 0(TVL – 2 cm )
Stage I(< - 1cm)
Stage II (> - 1cm < + 1cm)
Stage III (> _ 1cm but + TVL – 2cm )
Investigations for POP (3)
- why do them
USS / MRI: Allow identification of fascial defects/ measurement of Levator ani thickness (research only).
Urodynamics: concurrent UI or to exclude Occult SI.
IVU or Renal USS (if suspicion of ureteric Obstruction).
Prevention of prolapse (4)
Avoid constipation.
Effective management chronic chest pathology (COAD & asthma).
Smaller family size.
Improvements in antenatal and intra-partum care: Antenatal and post-natal pelvic floor muscle training.
Treatment of POP - Pelvic floor muscle training (PFMT): - WHY?? (5)
- Increase the pelvic floor strength & bulk relieve the tension on the ligaments
- cases of mild prolapse.
- younger women who have not yet completed their family.
- No role in advanced cases.
- Cannot treat fascial defects.
Education about pelvic floor exercises may be supplemented with the use of ? (4)
perineometer
biofeedback, vaginal cones and electrical stimulation.
what are pessaries made from?
silicone, Lucite, rubber or plastic.
why is silicone advantageous ? (5)
- Long Shelf-life
- Resistance to autoclaving and repeated cleaning
- Non-absorbent towards secretions and odors
- Inertness
- Hypoallergenic nature.
do women prefer surgery of pessary?
pessary
exclusions for POP surgery? (2)
- Previous POP surgery
- Unable to retain pessary for 2 weeks.
with getting surgery - what will you see at 12 months?
No significant difference in bowel, urinary, sexual symptoms
At I year follow-up successful pessary treatment is as effective as ?
surgery
Aim of surgical treatment for POP (3)
- Relieve symptoms,
- Restore/maintain bladder & bowel function and
- Maintain vaginal capacity for sexual function.
treatment for POP (3) - what should you remember
- Prophylactic Antibiotics.
- Thrombo-embolic prophylaxis.
- Postoperative Urinary Vs SPC.
Prolapse occur due to progressive …?
weakness of the pelvic floor muscles followed by breakdown in fascial support.
How man women are affected and what % are asymptomatic
50% of multiparous women with 10% symptomatic.
