pelvic relaxation Flashcards
RF for prolapse
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
prolapse is usually relieved in what position
v. Relieved by lying down
when does prolapse worsen? (this is the KEY to dx)
throughout the day
associated symptoms
i. Urinary stress incontinence–> UTI
ii. Urinary retention
iii. Defecatory dysfunction
iv. Sexual dysfunction
v. Vaginal discharge or bleeding
grades of prolapse
- 0: no prolapse
- 1: halfway to the hymen/introitus
- 2: at the hymen/introitus
- 3: halfway out of the hymen
- 4: total prolapse (procidentia)
pessaries are most helpful for
mild to moderate prolapse
what must a pessarie be used with
i. Must be used with topical estrogen to prevent vaginal ulceration in postmenopausal women
a good pessarie fit
visible at the entroitis or easily able to take out
after placement you should recheck pessarie in
once checked when would you instruct the pt to return to the office ?
ii. Check pessary 2-7 days after placement
Return every 3 months for exam
If 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
Vaginal Vault Prolapse is the result of
Downward displacement of vaginal apex due to loss of apical support
sxs associated with prolapse of the vaginal vault
c. Pelvic pressure, bearing down sensation, inguinal discomfort, dyspareunia, low back pain
d. Symptoms are progressively worse
vaginal vault prolapse is usually due to
e. Due to repetitive increases in intra-abdominal pressure
usually always follow hysterectomy
Hc and physical associated with vaginal vault prolapse
i. Urinary incontinence
ii. Causes of increased intra-abdominal pressure
iii. Speculum exam with straining
iv. Standing vaginal exam
v. Biospy to exclude vaginal neoplasm in severe chronic prolpase with ulceration
vaginal vault tx for prolapse
h. Surgical repair
i. Temporary use of pessaries for symptomatic pts
j. Surgical techniques
surgical techniques for vaginal vault
Colpectomy (removal of vagina)
Colpopexy (suspension of vaginal apex)
III. Uterine Prolapse is usually due to
b. Usually due to injury to endopelvic fascia and relaxation of musculature of the pelvic floor
Herniation of bowel and lining of peritoneal cavity through cul-de-sac/ pouch of Douglas
Enterocele
enteroceles are usually seen with
rectocele
Cystocele is due to
a. Downward displacement of bladder due to defect in anterior vaginal wall
Q tip test is used to evaluate
c. Q-tip test to evaluate bladder neck mobility
determine an abnormal urethrovesical angle.
IV. Cystocele
Procedure of choice is vaginal hysterectomy for this type of prolapse
uterine
post operative care for surgical repair of prolapse involves
i. Ambulation
ii. Bladder drainage
iii. Bowel function
iv. Pelvic rest for 4-6 weeks
which pessary
is used for severe prolapse
cube
which pessari is used for rectocele
Gehrung
which pessary is used for mild prolapse
ring
which pessary is used for mod to severe prolapse
gellhorn (difficult to insert)
donut (used for urinary retention and perineal supprt)
inflatoball (easiest to insert)
Cervix prolapses and brings along the anterior margin of the cul-de-sac
pulsion enterocele
Cervix prolapses and brings along the anterior margin of the cul-de-sac
traction enterocele
traction enteroceles are usually preceded by
cystocele or rectocele
which enterocele is usually followed by rectocele or cystocele
pulsion
