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PFD 1 Flashcards

1
Q

What is the common risk percentage for surgical correction of POP?

A

12.6%

POP stands for pelvic organ prolapse.

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2
Q

What stage of POP is associated with a higher risk for recurrence?

A

POP stage 3 or 4

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3
Q

What are obstetrical factors that increase the risk of POP?

A
  • Higher parity
  • Larger birth weight
  • Age > 30
  • Forceps delivery
  • Vaginal delivery
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4
Q

What lifestyle factors increase the risk of POP?

A
  • Higher BMI
  • Increased physical activity
  • Smoking has a protective effect
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5
Q

What are the unmodifiable factors that increase the risk of POP?

A
  • Higher age
  • Ethnicity (black is protective)
  • Comorbidity
  • Urinary incontinence
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6
Q

Which factors were found not to be risk factors for POP?

A
  • Hormone replacement therapy
  • Pulmonary disease
  • Hysterectomy
  • Constipation
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7
Q

What social factor is considered protective against POP?

A

High education

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8
Q

What pelvic floor factors are associated with increased risk of POP?

A
  • Levator defect
  • Increased levator hiatal area on Valsalva
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9
Q

What contradictory results were found in relation to BMI?

A

BMI is a risk factor for primary POP but not for recurrence

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10
Q

What is the relationship between age and risk for POP?

A
  • Younger risk for POP recurrence
  • Older risk for primary POP development
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11
Q

What are the primary POP risk factors identified in the study?

A
  • Age
  • Birthweight
  • Levator defect
  • Delivery mode
  • Parity
  • Levator hiatal area
  • Smoking is protective
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12
Q

What are the POP recurrence risk factors identified in the study?

A
  • Younger age
  • Higher POP stage
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13
Q

What is the function of the bladder neck support system?

A

provides continince via the bladder nack support system and sphinteric closure system

Most surgical approaches improve bladder neck support

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14
Q

What is essential for PF bladder neck support in relation to stress continence?

A

Muscle control and residual innervation

Must have residual innervation for muscle control

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15
Q

What are the major components of the urethral support system?

A
  • Anterior vagina
  • Endopelvic fascia
  • Arcus tendineus fasciae pelvis
  • Levator ani muscles

These components work together to provide support to the urethra.

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16
Q

What role does the levator ani muscle play in urinary support?

A

Type 1 fibers maintains constant tone for urogenital hiatus closure

Puborectalis and pubococcygeous muscles are predominantly Type I fibers.

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17
Q

How much pressure is exerted by a hard cough?

A

150 cm H2O

This pressure results in 10mm urethral displacement.

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18
Q

What happens to the urethra during an increase in abdominal pressure?

A

Anterior wall deforms toward posterior wall

This helps to close the urethral lumen and prevent leakage.

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19
Q

What is a consequence of loss of supporting tissues?

A

Leakage

Study shows women with SUI have reduced tissue stiffness.

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20
Q

What effect does denervation have on ligaments?

A

Leads to viscoelastic ligament behavior

Prolapse has viscoeleastic changes

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21
Q

What types of damage can occur to urethral support?

A
  • Paravaginal defect
  • Levator ani muscle contractility
  • Denervation

These factors impact urethral support.

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22
Q

How does aging affect striated muscle in the elderly?

A

Takes 35% longer to develop the same force

Maximum force diminished by approximately 35%.

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23
Q

What is the clinical assessment method for stress urinary incontinence?

A

Have patient cough and measure leakage

Cough while holding PFM contraction to check if leakage reduces.

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24
Q

What anatomical structures contribute to the sphincter closure system?

A
  • Urethral striated muscles
  • Urethral smooth muscle
  • Vascular elements within submucosa

All contribute equally to resting urethral closure pressure.

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25
Q

What is the role of the sphincter closure system?

A

Detrussor smooth muscle surrounds proximal urethra, Striated urethra sprinter made up of T1 fibers provide constant and volutray tone. Urethrovaginaial spinter and compressor urethrea compress lumen

It is involved in the function of the sphincter closure system.

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26
Q

True or False: Urethral support operations cure stress incontinence implicating urethral hypermobility as the cause.

A

False

The fact that operations cure stress incontinence does NOT implicate hypermobility.

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27
Q

What is the effect of age-related deterioration on urethral musculature?

A

Loss of urethral closure, due to deteroriation of muscle and neuologica injury limited improvement with PFMT.

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28
Q

What is the relationship between nerve dysfunction and stress incontinence?

A

Nerve dysfunction accompanies stress incontinence

Improving muscle coordination during a cough can eliminate SUI.

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29
Q

What is a potential cause of decreased urethral closure pressure after vaginal birth?

A

Pelvic nerve damage

This may result in delayed conduction in the pudendal nerve.

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30
Q

What do Allen EMG studies indicate regarding SUI?

A

Increased motor unit potential (MUP) indicates neurologic injury. When > 120% change in MUP SUI chances increase.

Antepartum vs postpartum changes show correlation with SUI.

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31
Q

What does the narrative review conclude about PFMT in the treatment of POP?

A

1A evidence/recommendation for PFMT in treatment of POP in the general female population

Based on the ICI 2017 guidelines.

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32
Q

What do the NICE guidelines (2019) recommend for women with symptomatic POP-Q stage I or II?

A

Consider a program of supervised PFMT for at least 16 weeks as a first option

If beneficial, advise women to continue PFMT.

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33
Q

What is the recommended frequency and intensity of PFMT sessions?

A

1–2 sessions a week with 8–12 close to maximum contractions

Intensity of contraction is the main factor.

34
Q

What did the review find about predictors of success for PFMT in women with POP?

A

Young age and having ≥ 1 indicators of obstetric trauma

Many factors such as PFM function were not included in the analysis.

35
Q

List the clinical recommendations for effective PFMT for POP.

A
  • Provide proper information about pelvic floor and exercise physiology
  • Teach proper PFM contraction technique
  • Use validated outcome measures
  • Offer individual/group training with a therapist
  • Teach strategies to reduce IAP during daily activities
  • Use motivational strategies for adherence
  • Follow general principles for strength training
  • Register adherence to training
  • Assess PFM variables before and after treatment
  • Recommend a suitable maintenance program

IAP: intra-abdominal pressure.

36
Q

What is the prevalence of Pelvic Organ Prolapse (POP) based on symptoms?

A

1-31%
on pelvic exam up to 50%
*Symptoms and exam up to 65%

Varies based on research and reporting.

37
Q

What are some contributing factors to Pelvic Organ Prolapse?

A
  • Childbirth
  • Constipation
  • Strenuous work
  • Heavy lifting
  • Congenital connective tissue weakness
  • Obesity
  • Menopause
  • Chronic increased intra-abdominal pressure
  • Iatrogenic causes
38
Q

What are the treatments for Pelvic Organ Prolapse?

A
  • Watchful waiting
  • Lifestyle interventions
  • PFMT
  • Pessaries
  • Surgery
39
Q

What are the two mechanisms by which PFMT prevents and treats POP?

A
  • Knack and voluntary contractions to prevent descent
  • Behavioral modifcations for PF descent
  • Regular strength training to improve firmness and support
40
Q

What anatomical changes are associated with PFMT?

A
  • Constriction of levator hiatus
  • Elevation and stabilization of pelvic floor
  • Lifting of bladder
  • Hypertrophy of targeted muscles
41
Q

What is the evidence for PFMT in the prevention of POP?

A

No primary prevention studies; 2 studies for secondary prevention showed positive short-term effects
evidence is lacking

Significant differences maintained through 2-year follow-up.

42
Q

What is the evidence for early intervention of PFMT in the peripartum period?

A

Very low quality evidence that structured PFMT reduces POP symptoms at 6-12 months postpartum

Moderate quality evidence showed no change in POP stage.

43
Q

What is the evidence for PFMT in treatment of POP in the general female population?

A

Dose-response relationship with more intensive and supervised programs showing better results

Variation in exercises and lack of standardization noted.

44
Q

What is the evidence for PFMT pre- and post-POP surgery?

A

Poor evidence; only 1 of 11 studies showed PFMT benefit to surgery with fewer prolapse symptoms. Reoccurance of 30%

Despite evidence, Non-invasive treatments should be considered before surgery.

45
Q

What is the evidence for PFMT on associated conditions in women with POP?

A

Only level 2 evidence found that PFMT can improve sexual function with POP
* imporved bladder symptoms and anorectal symptoms

2 studies found some effect on sexual function.

46
Q

What did studies find regarding bladder symptoms and PFMT?

A

8 studies found improved bladder symptoms with PFMT

5 studies found improved anorectal symptoms.

47
Q

What is the long-term effect of PFMT in the treatment of POP?

A

Limited number of studies; mixed results on long-term effects

Follow-up varied between 6-8 months to 10 years.

48
Q

Which surgical approaches to hysterectomy have a shorter return to activity?

A

Laparoscopic and vaginal hysterectomies

Compared to abdominal hysterectomies.

49
Q

What was observed about UTIs in the different surgical groups?

A

More UTIs in laparoscopic group vs abdominal

Indicates a potential complication of the laparoscopic approach.

50
Q

What are the reasons for performing a hysterectomy?

A
  • Menstrual bleeding
  • Endometriosis/adenomyosis
  • Dysmenorrhea
  • Dyspareunia
  • Prolapse

These are common indications for the procedure.

51
Q

What is the definition of Laparoscopic Assisted Vaginal Hysterectomy (LAVH)?

A

Part laparoscopic and part vaginally, laparoscopic component doesn’t involve division of the uterine vessels

It combines both techniques.

52
Q

What characterizes a Total Laparoscopic Hysterectomy (TLH)?

A

Entire operation laparoscopic, remove uterus vaginally

This method emphasizes a laparoscopic approach.

53
Q

What type of laparoscopic procedures have incisions not exceeding 3mm?

A

Single port laparoscopic and mini laparoscopic

These techniques aim for minimal invasiveness.

54
Q

What are the risks associated with laparoscopic hysterectomy compared to other approaches?

A
  • Higher risk of bladder injury after laparoscopic vs vaginal/abdominal
  • Higher risk of abdominal wall infection with abdominal approach
  • Higher cost for laparoscopic vs vaginal

These factors influence the choice of surgical method.

55
Q

What advantages does vaginal hysterectomy have?

A
  • Quickest return to normal activities
  • Earliest discharge from hospital
  • Shortest operation time
  • Less bleeding and pain meds

These benefits contribute to its preference in certain cases.

56
Q

What advantages does laparoscopic hysterectomy have over abdominal hysterectomy?

A
  • Quicker return to normal activities
  • Less postoperative pain
  • Earlier discharge
  • Improved QOL in first months and 4 years postop

Quality of life improvements are significant.

57
Q

True or False: Robotic assisted hysterectomy has advantages over laparoscopic hysterectomy.

A

False

Robotic assisted has no advantages over laparoscopic and has a longer operation time, more costly.

58
Q

What is a higher risk associated with laparoscopic hysterectomy?

A

Urinary tract injuries

This risk is greater compared to other surgical approaches.

59
Q

What is a common reason to choose an abdominal approach for hysterectomy?

A

Malignancy with other pathology present – endo or adhesions

This indicates a more complex surgical situation.

60
Q

What are the disadvantages of laparoscopic hysterectomy?

A
  • More urinary tract injuries
  • Longer operating time

These factors may affect patient recovery and outcomes.

61
Q

Is robotic perfered over laproscopic ?

A

Robotic assisted – no advantages over laparoscopic and longer operation time, more costly

62
Q

What percentage of women are affected by pelvic organ prolapse (POP)?

A

Up to 8%

This statistic highlights the prevalence of POP among women.

63
Q

What is the lifetime risk of undergoing prolapse surgery?

A

12.6%

Indicates the likelihood of women needing surgical intervention for prolapse at some point in their lives.

64
Q

What is the correlation between the vaginal apex and the anterior vaginal wall?

A

There is a correlation between the apex and most prolapsed portion of the anterior vaginal wall. There is a 4.5 cm appical loss with symptom report.

This relationship is critical for understanding the mechanics of prolapse.

65
Q

What is the clinically significant apical support loss measurement associated with symptoms?

A

4.5 cm

This measurement indicates the threshold for significant clinical symptoms related to prolapse.

66
Q

Prolapse surgeries previously corrected only anterior/posterior without apical repair see what type of outcomes?

A

87% of prolapse surgeries were corrected ant/post approach only

This statistic illustrates the historical approach to prolapse surgery.

67
Q

What role does sacrocolpopexy play in prolapse surgery?

A

It uses mesh to support anterior and posterior vagina, decreasing anterior and posterior prolapse.

This technique is significant for comprehensive prolapse repair.

68
Q

What outcomes occur with posterior wall repair in addition to apical repair?

A
  • Higher reports of pain with defecation
  • More fecal incontinence
  • Similar outcomes for constipation and incomplete emptying
    Apical surgery had resolution of posterior prolapse

This highlights the complexities and potential complications of combined surgical approaches.

69
Q

What percentage of women who underwent posterior repair experienced recurrent or persistent posterior prolapse? What % of woman has posteriro prolpase after 1 years with sarcocolpopexy?

A

12% still has recurrent persistant prolpase and a4% underwent another procedure. 8% who underwent sarcocolpopexy has persistne prolapse 1 year after

Indicates the risk of recurrence even after surgical intervention.

70
Q

What is the success rate for resolution of difficult defecation after posterior colporrhaphy?

A

54%
After posterior colporrhaphy – 54% had resolution of difficult defecation, 43% had resolution of constipation, and 36% had resolution of manual evacuation and success rate decreased overtime

This success rate reflects the effectiveness of the procedure for specific symptoms.

71
Q

What is the impact of hysterectomy on pelvic organ support?

A

Disruption of the uterosacral/cardinal ligament complex may weaken pelvic floor supports further.

This suggests caution in performing hysterectomy during prolapse repair.

72
Q

What are the success rates for uterosacral ligament hysteropexy?

A

80% cure rate

This indicates a high success rate for this surgical approach.

73
Q

What is the comparative success rate for abdominal surgery for sacrocolpopexy versus vaginal surgery?

A

Abdominal surgery is 2.4x more successful but riskier.

This highlights the trade-offs between surgical methods.

74
Q

What is the success rate for anterior and apical prolapse in the UPHOLD vaginal mesh hysteropexy study?

A

97%

This indicates a high efficacy of this particular surgical intervention.

75
Q

What is the Michigan four-wall sacrospinous ligament suspension?

A

It accesses the ligament via an apical approach and attaches to anterior and posterior vaginal walls directly to sacrospinous ligament.

This innovative approach aims to reduce anterior wall recurrence.

76
Q

What are the risks associated with synthetic mesh in prolapse surgery?

A
  • Risk of erosion
  • Vaginal mesh exposure

These risks are particularly concerning when attached transvaginally after total vaginal hysterectomy.

77
Q

What is the success rate of PROLift mesh for anterior compartment POP?

A

94% success with no prolapse beyond the hymen
9% of women in the native tissue group had apical prolapse to level of the hymen 6 months postop vs 4% after sacrocolpopexy

This demonstrates the effectiveness of this specific mesh type.

78
Q

What percentage of women without SUI will develop SUI after POP repair?

A

More than 40%

This statistic underscores the potential for new symptoms post-surgery.

79
Q

Fill in the blank: Decreased postoperative SUI is observed with colposuspension versus sacrocolpopexy: _____ vs 44%.

A

24%
Midurethral sling at time of POP repair decreased SUI 1 year post op 27% vs 43%

This reflects the comparative outcomes of different surgical techniques.

80
Q

What is the future direction for graft materials in prolapse surgery?

A

New graft materials from extracellular matrix to promote site-specific tissue remodeling without risk of erosion.

This suggests a focus on enhancing surgical outcomes while minimizing complications.

WCS (2 decks)

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