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Year 3 - Repro and Anaesthetics > Pelvic Organ Prolapse (POP) > Flashcards

Pelvic Organ Prolapse (POP) Flashcards

1
Q

what is a prolapse?

A

Protrusion of an organ or structure beyond its normal anatomical confines

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2
Q

what is the definition of a female POP?

A

refers to the descent of the pelvic organs towards or through the vagina

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3
Q

how common is a female POP?

A

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

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4
Q

lThe indication of 7-14% of hysterectomies is PROLAPSE

what is a hysterectomy?

A

surgical operation to take out a woman’s uterus

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5
Q

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

A

pressure

bottom

normal

increased

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6
Q

picutre showing all the dynamic organs in pelvic floor

A
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7
Q

Pelvic Floor = 1 Functional Unit

what are the three distinct layers?

A

Endo-pelvic Fascia

Pelvic Diaphragm

Urogenital Diaphragm

These 3 layers do not parallel each other and vary in strength & thickness from place to place

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8
Q

what is the Endo-pelvic Fascia?

A

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)

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9
Q

what is the pelvis diaphragm?

A

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

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10
Q

what is the urogenital diaphragm?

A

the superficial & deep transverse perineal muscles with their fascial coverings

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11
Q

Endo-pelvic Fascia:

Fibro-muscular component can ______ (Uteroscarals)

Connective tissue does not stretch or attenuate instead it ______

A

stretch

breaks

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12
Q

what makes up the Endo-pelvic Fascia?

A

Uteroscaral ligaments

Pubocervical Fascia

Rectovaginal Fascia

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13
Q

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)

A

Medially

Laterally

Easily palpated

limited

cervix

medially

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14
Q

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 _______

A

anterior

Cardinal

lateral

cervix

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15
Q

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 & ________
A

Centrally

Laterally

Distally

Enterocele

Rectocele

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16
Q

what is the endopelvic support and the different levels?

A

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

17
Q

what are the risk factors for POP?

A
  • Pregnancy and Vaginal birth - Forceps Delivery, Large baby (> 4500 gm), Prolonged Second Stage
  • Advancing Age
  • Obesity
  • Previous Pelvic surgery
18
Q

what previos pelvic surgeries may increase the risk of POP?

A

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

19
Q

what are some other risk factros fo POP?

A

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

20
Q

Traditional Classification of Prolapse:

Depends on the ____ of the defect and the presumed ______ _____ that are involved

A

site

pelvic viscera

21
Q

what is a Urethrocele?

A

Prolapse of the lower anterior vaginal wall involving the urethra only

22
Q

what is a Cystocele?

A

Prolapse of the upper anterior vaginal wall involving the bladder

23
Q

what is a Uterovaginal prolapse?

A

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

24
Q

what is an Enterocele?

A

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

25
Q

what is a Rectocele?

A

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

26
Q

what are the Typical symptoms in women with pelvic organ prolapse - Vaginal?

A

Sensation of a bulge or protrusion

Seeing or feeling a bulge or protrusion

Pressure

Heaviness

Difficulty in inserting tampons

27
Q

what are the Typical symptoms in women with pelvic organ prolapse – Urinary?

A

Urinary Incontinence

Frequency/Urgency

Weak or prolonged urinary stream/Hesitancy/Feeling of incomplete emptying

Manual reduction of prolapse to start or complete voiding

28
Q

what are the Typical symptoms in women with pelvic organ prolapse – Bowel?

A

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

29
Q

what is the assessment of POP?

A

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

30
Q

PELVIC FLOOR EVALUTATION

whata re the different stages?

A
  • 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 )

31
Q

what investigations can be used?

A

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).

32
Q

what is the prevention?

A

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

33
Q

how cna phyisotherapy help POP?

A

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

34
Q

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?

A

Long Shelf-life

Resistance to autoclaving and repeated cleaning

Non-absorbent towards secretions and odors

Inertness

Hypoallergenic nature

35
Q

Vaginal Pessaries Vs Surgery

A

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

36
Q

Surgical treatment - what is the aim and what do you ened to remember?

A

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
37
Q

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

A

3

one

pelvic floor muscles

fascial

50

10

Pelvic

floor

PFMT (pelvis floor muscle training)

Surgical

Year 3 - Repro and Anaesthetics (50 decks)

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