Pelvic Organ Prolapse (POP) Flashcards
what is a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines
what is the definition of a female POP?
refers to the descent of the pelvic organs towards or through the vagina
how common is a female POP?
It is estimated to affect 12–30% of multiparous and 2% of nulliparous women
Prevalence estimates varying from 2% for symptomatic prolapse to 50% for asymptomatic prolapse
Approximately 50% of parous women will have some degree and only 10–20% of these seek medical help
In the UK, pelvic organ prolapse accounts for 20% of women on the waiting list for major gynaecological surgery
lThe indication of 7-14% of hysterectomies is PROLAPSE
what is a hysterectomy?
surgical operation to take out a woman’s uterus
The abdomino-pelvic cavity is an odd shaped box that contains all the abdominal & pelvic viscera
The walls of this cavity must be of sufficient flexibility to withstand changes in volumes of these organs & also ________ changes within the cavity
The pelvic floor represents the ________ of this box and consists of all the soft tissue structures that close the space between the pelvic bones
If the pelvic floor is _______, all the pelvic viscera will be maintained in their position both at rest and in periods of _________ intra-abdominal pressure
pressure
bottom
normal
increased
picutre showing all the dynamic organs in pelvic floor
Pelvic Floor = 1 Functional Unit
what are the three distinct layers?
Endo-pelvic Fascia
Pelvic Diaphragm
Urogenital Diaphragm
These 3 layers do not parallel each other and vary in strength & thickness from place to place
what is the Endo-pelvic Fascia?
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)
what is the pelvis diaphragm?
layer of striated muscles with its fascial coverings (Levator ani & coccygeus)
what is the urogenital diaphragm?
the superficial & deep transverse perineal muscles with their fascial coverings
Endo-pelvic Fascia:
Fibro-muscular component can ______ (Uteroscarals)
Connective tissue does not stretch or attenuate instead it ______
stretch
breaks
what makes up the Endo-pelvic Fascia?
Uteroscaral ligaments
Pubocervical Fascia
Rectovaginal Fascia
Utero-sacral/Cardinal Complex:
________ to Uterus, Cervix, Lateral Vaginal Fornices & Pubocervical & Rectovaginal Fascia
________ to the sacrum & fascia overlying the Piriforms muscle
______ ________ by down traction on the Cervix and if intact allows _______ side-side movement of the ______
Tend to break _______ (around the cervix)
Medially
Laterally
Easily palpated
limited
cervix
medially
Pubocervical Fascia:
Trapezoidal Fibro-muscular tissue: Provide the main support of the _______ vaginal wall
- Centrally: merge with the Base of _______ ligaments & Cervix
- Laterally: Arcus Tendineus Fascia Pelvis (White line)
- Distally: Urogenital Diaphragm (under SP).
(3 supports = 3 defects)
Tend to break at ______ attachments or immediately in front of the _______
anterior
Cardinal
lateral
cervix
Rectovaginal Fascia:
Fibro-musculo - elastic tissue
_______: merge with the Base of Cardinal/uterosacral ligaments & peritoneum
_______: fuses with fascia over the levator ani
_______: firmly to the Perineal Body
Tends to break Centrally:
- If upper defect: _________
- If lower defect: perineal body descent & ________
Centrally
Laterally
Distally
Enterocele
Rectocele
what is the endopelvic support and the different levels?
Level I: Utero-sacral ligaments and Cardinal ligaments
Level II: Para-vagina to arcus tendineus fascia: Pubocervical/ Rectovaginal fascia
Level III: Urogenital Diaphragm and Perineal body
what are the risk factors for POP?
- Pregnancy and Vaginal birth - Forceps Delivery, Large baby (> 4500 gm), Prolonged Second Stage
- Advancing Age
- Obesity
- Previous Pelvic surgery
what previos pelvic surgeries may increase the risk of POP?
Continence procedures, while elevating the bladder neck, may lead to defects in other pelvic compartments:
- 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 = Overall 25% of women following Burch colposuspension required further surgery for prolapse
One large series reported “vaginal vault prolapse” 9-13 years after hysterectomy, in 11.6% of women who had the hysterectomy for prolapse and in 1.8% of women who had the hysterectomy for their benign disease
what are some other risk factros fo 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
Traditional Classification of Prolapse:
Depends on the ____ of the defect and the presumed ______ _____ that are involved
site
pelvic viscera
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?
This term is used to describe prolapse of the uterus, cervix and upper vagina
what is an Enterocele?
Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel
what is a Rectocele?
Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
what are the Typical symptoms in women with pelvic organ prolapse - Vaginal?
Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
what are the 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
what are the Typical symptoms in women with pelvic organ prolapse – Bowel?
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
what is the assessment of POP?
Examination to exclude pelvic mass
Record the position of examination: left lateral Vs Lithotomy Vs Standing
Quality of Life
Objective Assessment: Baden- Walker- Halfawy Grading, POPQ Score, Others
POPQ Score is endorsed by the ICS & is currently considered the gold standard
PELVIC FLOOR EVALUTATION
whata re the different stages?
- Stage 0 (TVL (total vaginal length) – 2 cm )
- Stage I (< - 1cm)
- Stage II (> - 1cm < + 1cm)
- Stage III (> _ 1cm but <+
TVL – 2cm)
•Stage VI (> + TVL – 2cm )
what investigations can be used?
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).
what is the prevention?
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 has not yet been shown to conclusively reduce the incidence of prolapse, although there are logical reasons to think that it may be protective
how cna phyisotherapy help POP?
Pelvic floor muscle training (PFMT):
- 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 a perineometer and biofeedback, vaginal cones and electrical stimulation
Current Pessaries:
A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage, and pelvic organ prolapse to maintain the location of organs in the pelvic region
Today, pessaries are generally made from a variety of materials including silicone, Lucite, rubber or plastic.
Silicone is advantageous - why?
Long Shelf-life
Resistance to autoclaving and repeated cleaning
Non-absorbent towards secretions and odors
Inertness
Hypoallergenic nature
Vaginal Pessaries Vs Surgery
Prospective observational study: I year FU
Women decision: 48 Surgery Vs 56 Pessary - No significant difference in median parity, HRT, Pre-operative bowel, urinary, sexual symptoms
Exclusions: Previous POP surgery, Unable to retain pessary for 2 weeks
Results: No pessary related complications & no significant postoperative morbidity, At 12 month: No significant difference in bowel, urinary, sexual symptoms
Conclusion: At I year follow-up successful pessary treatment is as effective as surgery
Surgical treatment - what is the aim and what do you ened to remember?
Aim:
- Relieve symptoms,
- Restore/maintain bladder & bowel function and
- Maintain vaginal capacity for sexual function
Remember:
- Prophylactic Antibiotics
- Thrombo-embolic prophylaxis
- Postoperative Urinary Vs SPC
Summary:
The pelvic floor is made from _ distinct anatomical layers but function as ___ unit
Prolapse occur due to progressive weakness of the ______ ______ _______ followed by breakdown in ______ support
Affect __% of multiparous women with __% symptomatic
Assessment is multi-dimensional including ______ examination, assessment of pelvic _____, symptom bother & Impact on QoL
Management would be tailored to patients needs and would include ___________________, Conservative & ________ Management
3
one
pelvic floor muscles
fascial
50
10
Pelvic
floor
PFMT (pelvis floor muscle training)
Surgical
