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WCS > PFD 1 Anatomy, Prolapse, Surgical Treatment, Terminology > Flashcards

PFD 1 Anatomy, Prolapse, Surgical Treatment, Terminology 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.

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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.

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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.

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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.

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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
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38
Q

What are the treatments for Pelvic Organ Prolapse?

A
  • Watchful waiting
  • Lifestyle interventions
  • PFMT
  • Pessaries
  • Surgery
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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
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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
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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48
Q

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

A

Laparoscopic and vaginal hysterectomies

Compared to abdominal hysterectomies.

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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.

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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.

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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.

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52
Q

What characterizes a Total Laparoscopic Hysterectomy (TLH)?

A

Entire operation laparoscopic, remove uterus vaginally

This method emphasizes a laparoscopic approach.

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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.

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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.

81
Q

Is the uterus a cause of prolapse?

A

No, the uterus is not a cause of prolapse.

82
Q

What is a hysterectomy?

A

Hysterectomy is not itself a prolapse correction surgery.

83
Q

What are hysteropexies?

A

Hysteropexies are prolapse procedures that suspend the uterine cervix or isthmus without removal of the uterus.

84
Q

Define apical prolapse procedures.

A

Apical prolapse procedures include:
* Sacrocolpopexy (SCP)
* Sacral colpoperineopexy
* Sacrocervicopexy (SCerP)

85
Q

What is the purpose of SCP and SCerP?

A

SCP and SCerP bridge the vagina or cervix to the anterior longitudinal ligament of the sacrum at the level of S1-S2 using a graft.

86
Q

What is Uterosacral ligament suspension USLS for?

A

Uterosacral ligament suspension.
Suspension of vaginal Apex to unilateral or bilateral uterosacral ligament using suture

87
Q

What is iliococcygeus fixation?

A

Iliococcygeus fixation suspends the vaginal apex to the parietal fascia of the iliococcygeus muscle through a transvaginal approach.

88
Q

True or False: Sacrospinous ligament fixation requires entry into the peritoneal cavity.

A

False, sacrospinous ligament fixation can be performed without entry into the peritoneal cavity.
Suspension of vaginal Apex to unilateral or bilateral sacrospinous ligaments

89
Q

What are the types of uterine preservation prolapse procedures?

A

Types include:
* Sacrohysteropexy
* Uterosacral hysteropexy
* Sacrospinous hysteropexy
* Anterior abdominal wall hysteropexy
* Manchester procedure

Hysteropexy is our prolapse procedures that suspend uterine cervix or isthmus without removal of uterus

90
Q

What is anterior vaginal repair?

A

Anterior vaginal repair is a specific repair of the anterior vaginal wall fibromuscular layer.
Anterior repair options are with or without graft and para vaginal repair

91
Q

What is anterior colporrhaphy?

A

Anterior colporrhaphy is defined as midline plication of the fibromuscular layer of the anterior vaginal wall for anterior wall repair.

92
Q

What does posterior colporrhaphy involve?

A

Posterior colporrhaphy involves midline plication of the vaginal fibromuscular layer.

93
Q

What are types of obliterative prolapse repairs

A

Colpocleisis with and without hysterectomy and of vaginal vault
Obliterative procedures result in a narrow, short vagina without an internal opening when the uterus is absent (colpocleisis with hysterectomy or colpocleisis of vaginal vault). In colpocleisis without hysterectomy where the uterus is left in place (Le Fort variation), tunnels for uterine or cervical drainage are ensured. Colpocleisis is always accomplished by ome type of attachment of the fibromuscular layers of the anterior and posterior vaginal walls to one another.

94
Q

What is sacrocolpopexy?

A

Sacrocolpopexy (SCP) is suspension of the vaginal apex to the anterior longitudinal ligament of the sacrum using a graft.

95
Q

What is the goal of sacrospinous ligament fixation?

A

Suspension of the vaginal apex to the unilateral or bilateral sacrospinous ligament(s) (SSLF).

96
Q

What is the Manchester procedure?

A

The Manchester procedure involves shortening or amputation of the uterine cervix with preservation of the uterine body.

97
Q

What is the definition of obliterative prolapse repairs?

A

Obliterative procedures result in a narrow, short vagina without an internal opening.

98
Q

What does levator plication aim to achieve?

A

Levator plication aims to narrow the vaginal caliber by approximating the anterior levator ani muscles.

99
Q

What is the primary focus of perineal repair?

A

Approximation of the muscular tendon components of the perineal body.

May be performed with posterior vaginal repair. Components include deep and superficial transverse peroneal muscles bulbospongiosus muscle external anal sphincter and puborectalis muscle

100
Q

What is the purpose of graft reinforcement in anterior vaginal repair?

A

To improve mechanical strength of an anterior repair.

101
Q

True or False: Anterior vaginal repair with graft is the same as anterior vaginal repair without graft.

A

False, anterior vaginal repair with graft includes the use of implanted graft material.

102
Q

What is the purpose of the sacrohysteropexy procedure?

A

Suspension of the uterine cervix or isthmus to the anterior longitudinal ligament of the sacrum using a graft.

103
Q

What is a key requirement during uterine suspension?

A

Assessment of ureteral patency with cystoscopy is mandatory due to a high prevalence of ureteral injury.

104
Q

sacral colpoperineopexy:

A

extension of the posterior vaginal graft attachment down to the perineal body for the purpose of perineal support should NOT be called perineopexy to avoid confession of perineal support

105
Q

Sacrocervicopexy (SCerP):

A

suspension of the uterine cervix to the anterior longitudinal ligament of the sacrum using a bridging graft Any route of hysterectomy can be followed by SCP

106
Q

uterosacral ligament suspension

A

POP procedure
Can be performed at the time of a hysterectomy because the USLs can be easily identified

107
Q

Sacrohysteropexy (SHP):

A

Suspension of the uterine cervix or isthmus to the anterior longitudinal ligament of the sacrum using a graft, with possible incorporation of the graft into the anterior and/or posterior vaginal walls, with preservation of the uterine body

108
Q

Anterior abdominal wall hysteropexy

A

Suspension of the uterine cervix or isthmus and possibly the fibromuscular layer of the anterior vaginal wall to the anterior abdominal wall, with or without utilization of a graft, with preservation of the uterine body

109
Q

Uterosacral hysteropexy (USHP)

A

suspension of the uterine cervix or isthmus to the unilateral or bilateral USL(s) using suture with preservation of the uterine body

110
Q

Sacrospinous hysteropexy (SSHP)

A

Suspension of the uterine cervix or isthmus to the unilateral or bilateral SSL(s) using suture with preservation of the uterine body

111
Q

What is the pelvic diaphragm composed of?

A

Levator ani and coccygeus muscles attached to inner surface of minor pelvis and pubococcygeus

112
Q

What are the sub-portions of the pubococcygeus muscle?

A

pubourethralis, pubovaginalis, puboanalis, and puborectalis known collectively as pubovisceralis

113
Q

What is the primary function of the normal levator ani?

A

Maintains tone in the upright position to support the pelvic viscera

114
Q

What effect does voluntary squeezing of the puborectalis have?

A

May increase tone to outer increased intra-abdominal pressure

115
Q

What is the urogenital diaphragm?

A

Musculofascial structure over the anterior pelvic outlet below the pelvic diaphragm

116
Q

What muscles are found on the inferior aspect of the urogenital diaphragm?

A

Superficial ischiocavernosus and bulbocavernosus muscles bridge gap between inferior pubic rami and peroneal body

117
Q

What does the perineal body connect?

A

Pyramidal fibromuscular structure in the midline between anus and vagina

118
Q

What occurs to the perineal body during childbirth?

A

It distends and then recoils

119
Q

What happens due to acquired weakness of the perineal body?

A

Gives rise to elongation and predisposes to defects such as rectocele and enterocele

120
Q

What is the endopelvic fascia?

A

System of connective tissue supporting the bladder, urethra, vagina, and uterus attached to pelvic walls

121
Q

What are the components of the endopelvic fascia?

A

A mesh-like group of collagen fibers interlaced with elastin, smooth muscle cells, fibroblasts, and vascular structures

122
Q

What do anterior supports connect?

A

Urethra, bladder, and vagina extending to the arcus tendineus of the pelvic fascia

123
Q

What role do pubourethral ligaments play?

A

Support urethra and keep vesical neck closed

124
Q

What is paracolpium?

A

Middle supports of connective tissue surrounding the vagina that fuses with the pelvic wall and fascia laterally

125
Q

What is the structure of the urethra?

A

A complex tubular structure extending below the bladder to the external meatus

126
Q

What are the muscular elements within the urethra?

A

Smooth muscle contiguous with trigone and detrusor

127
Q

What is the role of circular muscle in the urethra?

A

Constraining the lumen

128
Q

What is the outer layer of the urethra formed by?

A

Muscle of the striated urogenital sphincter

129
Q

What type of fibers are mainly found in the distal urethral muscles?

A

Slow-twitch fibers

130
Q

What is the urethral mucosa derived from?

A

Urogenital sinus

131
Q

What changes does the urethral mucosa undergo?

A

Hormonal sensitivity and undergoes changes with stimulation

132
Q

What does the mechanism of continence require?

A

Quiniscent bladder, functioning musculofascial supports, and functional urethral sphincter mechanism

133
Q

What is the hammock hypothesis in relation to continence?

A

The urethra is compressed on the hammock during increased intra-abdominal pressure.

WCS (6 decks)

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