Pelvic organ prolapse

Question 1

what is prolapse?

Answer 1

Protrusion of an organ or structure beyond its normal anatomical confines.

Question 2

What is a female POP?

Answer 2

the descent of the pelvic organs towards or through the vagina.

Question 3

prevalence?

Answer 3

2% for symptomatic prolapse to 50% for asymptomatic prolapse.

Question 4

In the UK, pelvic organ prolapse accounts for 20% of women on the waiting list for major?

Answer 4

gynaecological surgery

Question 5

what does the pelvic floor consist of?

Answer 5

all the soft tissue structures that close the space between the pelvic bones.

Question 6

what is maintained if the pelvic floor is normal?

Answer 6

pelvic viscera will be maintained in their position both at rest and in periods of increased intra-abdominal pressure.

Question 7

what are the 3 distinct layers of the pelvic floor

Answer 7

Endo-pelvic Fascia
Pelvic Diaphragm
Urogenital Diaphragm

Question 8

describe the Endo-pelvic Fascia?

• what ligaments are present

Answer 8

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).

Question 9

describe the pelvic diaphragm?

Answer 9

layer of striated muscles with its fascial coverings (Levator ani & coccygeus).

Question 10

describe the Urogenital Diaphragm?

Answer 10

the superficial & deep transverse perineal muscles with their fascial coverings.

Question 11

endometriosis- pelvic fascia - describe the connective tissue?

Answer 11

does not stretch or attenuate instead it breaks.

Question 12

Utero-sacral/ Cardinal Complex ligament palpated?

Answer 12

down traction on the Cervix and if intact allows limited side-side movement of the cervix.

Question 13

how does the Utero-sacral/ Cardinal Complex tend to break?

Answer 13

medially (around the cervix)

Question 14

Utero-sacral/ Cardinal Complex lies medially to? (5)

Answer 14

Uterus, Cervix, Lateral Vaginal Fornices & Pubocervical & Rectovaginal Fascia.

Question 15

Utero-sacral/ Cardinal Complex lies laterally to?

Answer 15

the sacrum & fascia overlying the Piriforms muscle.

Question 16

Pubocervical Fascia - what kind of fibre?

• what does it do?

Answer 16

Trapezoidal Fibro-muscular tissue

• Provide the main support of the anterior vaginal wall.

Question 17

Pubocervical Fascia - centrally merges with?

Answer 17

Base of Cardinal ligaments & Cervix

Question 18

Pubocervical Fascia - lies laterally with?

Answer 18

Arcus Tendineus Fascia Pelvis (White line).

Question 19

Pubocervical Fascia lies distally to?

Answer 19

Urogenital Diaphragm (under SP).

Question 20

where do the Pubocervical Fascia tend to break at?

Answer 20

lateral attachments or immediately in front of the cervix.

Question 21

Rectovaginal Fascia - made of what tissue?

Answer 21

Fibro-musculo- elastic tissue.

Question 22

where does the Rectovaginal Fascia tend to break?

upper vs lower defect

Answer 22

If upper defect: Enterocele.

If lower defect: perineal body descent & Rectocele.

Question 23

Rectovaginal Fascia - lies centrally to?

Answer 23

merge with the Base of Cardinal/ uterosacral ligaments & peritoneum.

Question 24

Rectovaginal Fascia - laterally fuses with?

Answer 24

fascia over the levator ani.

Question 25

Rectovaginal Fascia - joins firmly to what distally ?

Answer 25

Perineal Body.

Question 26

Endopelvic Support - level 1 - what 2 ligaments

Answer 26

Utero-sacral ligaments | Cardinal ligaments

Question 27

Endopelvic Support - level 2?

Answer 27

Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia

Question 28

Endopelvic Support - level 3?

Answer 28

Urogenital Diaphragm | Perineal body

Question 29

Risk factors of POP? (4)

Answer 29

``` Pregnancy and Vaginal birth - Forceps Delivery Large baby (> 4500 gm) Prolonged Second Stage - Advancing Age - Obesity ```

Question 30

strongest RISK FACTOR OF POP?

Answer 30

Parity

Question 31

how can previous pelvic procedure effect POP?

Answer 31

Continence procedures - ELEVATES BALDDER NECK - Burch colposuspension - hysterectomy

Question 32

WHAT IS Burch colposuspension?

Answer 32

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

Question 33

Other Risk Factors for POP?

Answer 33

- 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.

Question 34

what is a Urethrocele prolapse?

Answer 34

Prolapse of the lower anterior vaginal wall involving the urethra only.

Question 35

what is a cystocele prolapse?

Answer 35

Prolapse of the upper anterior vaginal wall involving the bladder.

Question 36

what is a Uterovaginal prolapse?

Answer 36

This term is used to describe prolapse of the uterus, cervix and upper vagina.

Question 37

what is a Enterocele prolapse?

Answer 37

Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel

Question 38

what is a Rectocele prolapse?

Answer 38

Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.

Question 39

Typical symptoms in women with pelvic organ prolapse - Vaginal (5)

Answer 39

- Sensation of a bulge or protrusion - Seeing or feeling a bulge or protrusion - Pressure - Heaviness - Difficulty in inserting tampons

Question 40

Typical symptoms in women with pelvic organ prolapse – Urinary

Answer 40

- Urinary Incontinence - Frequency/ Urgency - Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying - Manual reduction of prolapse to start or complete voiding

Question 41

Typical symptoms in women with pelvic organ prolapse – Bowel (5)

Answer 41

- 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

Question 42

Assessment of POP (3)

Answer 42

- Examination to exclude pelvic mass - Record the position of examination: left lateral Vs - Lithotomy Vs Standing. Quality of Life

Question 43

Objective Assessment: (3)

Answer 43

Baden- Walker- Halfawy Grading POPQ Score Others

Question 44

gold standard test?

Answer 44

POPQ Score

Question 45

Pelvic floor evaluation values? ( 0,1,2,3,5)

Answer 45

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

Question 46

Investigations for POP (3) | - why do them

Answer 46

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).

Question 47

Prevention of prolapse (4)

Answer 47

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.

Question 48

Treatment of POP - Pelvic floor muscle training (PFMT): - WHY?? (5)

Answer 48

- 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.

Question 49

Education about pelvic floor exercises may be supplemented with the use of ? (4)

Answer 49

perineometer | biofeedback, vaginal cones and electrical stimulation.

Question 50

what are pessaries made from?

Answer 50

silicone, Lucite, rubber or plastic.

Question 51

why is silicone advantageous ? (5)

Answer 51

- Long Shelf-life - Resistance to autoclaving and repeated cleaning - Non-absorbent towards secretions and odors - Inertness - Hypoallergenic nature.

Question 52

do women prefer surgery of pessary?

Answer 52

pessary

Question 53

exclusions for POP surgery? (2)

Answer 53

- Previous POP surgery | - Unable to retain pessary for 2 weeks.

Question 54

with getting surgery - what will you see at 12 months?

Answer 54

No significant difference in bowel, urinary, sexual symptoms

Question 55

At I year follow-up successful pessary treatment is as effective as ?

Answer 55

surgery

Question 56

Aim of surgical treatment for POP (3)

Answer 56

- Relieve symptoms, - Restore/maintain bladder & bowel function and - Maintain vaginal capacity for sexual function.

Question 57

treatment for POP (3) - what should you remember

Answer 57

- Prophylactic Antibiotics. - Thrombo-embolic prophylaxis. - Postoperative Urinary Vs SPC.

Question 58

Prolapse occur due to progressive ...?

Answer 58

weakness of the pelvic floor muscles followed by breakdown in fascial support.

Question 59

How man women are affected and what % are asymptomatic

Answer 59

50% of multiparous women with 10% symptomatic.