Pelvic Relaxation Flashcards
1
Q
Pelvic organ prolapse
A
- Pelvic organs supported through complex pelvic floor musculature, fascia, nervous system
- Site-specific fascial defects result in anterior, apical, or posterior vaginal segment weakness and herniation
- Common in women
- Pelvic organs supported by uterosacral/cardinal ligament complex, levator ani muscles, endopelvic fascia
- Ligaments attach pelvic organs to bony pelvis
2
Q
Risk factors for pelvic organ prolapse
A
- Multiparity
- Operative vaginal delivery
- Obesity
- Advanced age
- Prior pelvic surgery
- Estrogen deficiency
- Neurogenic dysfunction of pelvic floor
- Connective tissue disorders
- Chronic increased intra-abdominal pressure
3
Q
clinical manifestations of pelvic organ prolapse
A
- Pelvic pressure/heaviness
- Protrusion of tissue from vagina
- Sitting on a lump
- Low backache or heaviness
- Relieved by lying down
- Less noticeable in the morning
- Worsens throughout the day
4
Q
Associated symptoms
A
- Urinary stress incontinence
- Urinary retention
- Defecatory dysfunction
- Sexual dysfunction
- Vaginal discharge or bleeding
5
Q
physical examination
A
- Dorsal lithotomy position
- Can also examine pt in standing position
- Visual/speculum exam of each vaginal support area separately
- Examine patient relaxed and when bearing down
- Rectovaginal exam
6
Q
graded scale of pelvic organ prolapse
A
- Graded scale 0-4
- 0: no prolapse
- 1: halfway to the hymen
- 2: at the hymen
- 3: halfway out of the hymen
- 4: total prolapse (procidentia)
7
Q
POP managment
A
- Mild prolapse treated with pelvic floor exercises, physical therapy, behavioral modification
- Moderate prolapse may benefit from a vaginal pessary
- Poor surgical candidates may also use pessaries
- Surgery preferred for severe prolapse
8
Q
Vaingal pessaries: indications
A
- Useful alternative to surgery
- Symptomatic pelvic relaxation
- Temporary use before surgery
- Most effective with mild to moderate prolapse
- May be used for cervical prolapse occurring during pregnancy
9
Q
vaginal pessaries: use
A
- Must be used with topical estrogen to prevent vaginal ulceration
- Type and size of pessary fitted individually
- Goal is largest pessary the patient can wear comfortably
- She likes to get the women on topical estrogen for a couple weeks before starting the pessary so that they don’t get ulcers
10
Q
Vaginal pessaries
A
- Ensure fit before patient leaves office
- Visible at introitus but will not descend past the hymen with bearing down
- Returns to prior position with relaxation
- Comfortable with walking, squatting, sitting, and bearing down
- Check pessary 2-7 days after placement
- Ask about comfort, urinary incontinence, bowel movements, vaginal bleeding or discharge
- Instruct patient how to remove, clean, replace pessary at least weekly
- Return every 3 months for exam
- Vaginal mucosal ulceration may occur
- Stop using pessary 2-3 weeks
- Continue topical estrogen therapy
- Antibiotics may be needed if large ulceration or does not heal
- Increase cleaning interval
- Leave pessary out overnight
- Can cause nasty infection if neglected
11
Q
pelvic organ prolapse types
A
- Vaginal Vault
- Uterus
- Cystocele/Urethrocele
- Rectocele/Enterocele
12
Q
vaginal vault prolapse
A
- Downward displacement of vaginal apex due to loss of apical support
- Usually follows hysterectomy
- Pelvic pressure, bearing down sensation, inguinal discomfort, dyspareunia, low back pain
- Symptoms are progressively worse
- Due to repetitive increases in intra-abdominal pressure
- Prolapse leads to chronic vaginal discharge and bleeding from chronic ulceration
- History and physical exam
- Urinary incontinence
- Causes of increased intra-abdominal pressure
- Speculum exam with straining
- Standing vaginal exam
- Biospy to exclude vaginal neoplasm in severe chronic prolpase with ulceration
- Surgical repair
- Temporary use of pessaries for symptomatic pts
- Surgical techniques
- Colpectomy (removal of vagina)
- Colpopexy (suspension of vaginal apex)
13
Q
uterine prolapse
A
- Descent of uterus and cervix down the vaginal canal
- Usually due to injury to endopelvic fascia and relaxation of musculature of the pelvic floor
- Multipariy, gravity, loss of estrogen, repetitive increase intra-abdominal pressure contribute
- Asymptomatic prolapse does not require treatment
- Kegel exercises of little value
- May be helpful in preventing prolapse
- Pessaries may be useful
- Temporarily
- With vaginal estrogen therapy
- Most patients have defects of pelvic support in more than one location
- Procedure of choice is vaginal hysterectomy
14
Q
cystocele
A
- Downward displacement of bladder due to defect in anterior vaginal wall
- Inspect vagina at rest and with Valsalva
- Q-tip test to evaluate bladder neck mobility – put qtip in the urethra and have the patient strain
- Usually occur with other defects
- Treatment with pessary or surgery in symptomatic patients
- The Q-tip test is an office test to evaluate the adequacy of anatomic support to the bladder neck and to determine an abnormal urethrovesical angle. It may be part of a pelvic exam to evaluate incontinence, but is not commonly done by internists.
- With the patient in the supine position, the urethral meatus is cleaned with providone-iodine and a cotton swab (Q-tip) is introduced into the urethra to the bladder. The cotton tip should be well lubricated with anesthetic cream so that discomfort is avoided. The cotton swab is then gently pulled back out of the bladder until some resistance is encountered. At this point, the cotton tip is at the level of the urethrovesical junction.
- In a normal patient, the angle of the Q-tip is less than 30 degrees from the horizontal, and will remain at this angle when the patient strains. In patients with inadequate bladder neck support and stress incontinence, the Q-tip angle generally exceeds 30 degrees from the horizontal.
15
Q
urethrocele
A
- Downward displacement of urethra due to a midline defect in suburethral fascia
- History and physical exam similar to cystocele
- Usually occur with other defects
- Treatment is surgical repair
