Pelvic Organ Prolapse in Women Flashcards
What is the definition of a prolapse?
Protrusion of an organ or structure beyond its anatomical confines
What is a female POP?
Descent of the pelvic organs towards or through the vagina
Describe the endo-pelvic fascia
Fibromuscular component can stretch
CT does not stretch or attenuate instead it breaks
What is the function of the pubocervical fascia?
Provides main support of the anterior vaginal wall
Tends to break at lateral attachments or immediately in front of cervix
Where does the utero-sacral ligament tend to break?
Medially - around the cervix
Where does rectovaginal fascia tend to break?
Centrally
If upper defect - enterocele
If lower defect - perineal body descent and rectocele
What are the levels of endopelvic support?
1 - uterosacral and cardinal ligaments
2 - pubocervical
3 - urogenital diaphragm and perineal body
What are pregnancy and vaginal birth risk factors for POP?
Forceps delivery
Large baby >4500gm
Prolonged second stage
Parity is strongest risk factor
Advancing age and obesity
What previous surgeries are a risk factor for POP?
Continence procedures
Burch colposuspension (25% of women need prolapse surgery after)
Hysterectomy - vaginal vault prolapse
What are some other risk factors of POP?
Hormonal factors
Quality of connective tissue
Constipation
Occupation with heavy lifting
Exercise - weight lifting, high impact aerobics and long distance running
What is a urethrocele?
Prolapse of lower anterior vaginal wall involving the urethra only
What is a cystocele?
Prolapse of upper anterior vaginal wall involving the bladder
What is a uterovaginal prolapse?
Prolapse of uterus, cervix and upper vagina
What is an enterocele and rectocele?
Enterocele - prolapse of posterior vaginal wall usually containing loops of small bowel
Rectocele - prolapse of lower posterior vaginal wall where rectum bulges forwards into vagina
What are typical vaginal symptoms for pelvic organ prolapse?
Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
What are some urinary symptoms for women with pelvic organ prolapse?
Urinary incontinence, frequency/ urgency, weak or prolonged urinary stream/ hesitancy/ incomplete emptying and manual reduction of prolapse to start or complete voiding
What are some bowel symptoms for women with pelvic organ prolapse?
Incontinence of flatus/ liquid/ solid stool, feeling of incomplete emptying or straining, urgency, digital evacuation, splinting or pushing around vagina to start defecation
How is POP assessed?
Examination to exclude pelvic mass
Record position - left lateral, lithotomy or standing
QoL
Baden-Walker-Halfawt grading
POPQ score
What are the stages of pelvic floor evaluation?
Stage 0 - TVL - 2cm
Stage 0-4
Stage 4 - more than TVL -2cm
What investigations are used for POP?
USS/ MRI - identify fascial defects/ measure levator ani thickness
Urodynamics - concurrent UI
IVU or renal USS
What can be done for prevention of POP?
Avoid constipation
Effective management chronic chest pathology
Smaller family size
Improvements in antenaral and intrapartum care
Describe physiotherapy for POP
Pelvic floor muscle training - increase strength and bulk but no role in advanced cases
Perineometer, vaginal cones and electrical stimulation
Why is silicone advantageous for pessaries?
Long shelf life, resistance to autoclaving + repeated cleaning, non-absorbent, inertness and hypoallergenic nature
Describe vaginal pessaries vs surgery
After 1 year after successful pessary treatment is as effective as surgery
What is the aim of surgical treatment?
Relieve symptoms, restore/ maintain bladder and bowel function and vaginal capacity for sexual function
What needs to be remembered in surgical treatment?
Prophylactic antibiotics, thromboembolic prophylaxis and post-op urinary vs SPC
