POP & Urinary Incontinence Flashcards
What is a prolapse?
Protrusion of an organ or structure beyond its normal anatomical confines.
What is a female POP?
Refers to the descent of the pelvic organs towards or through the vagina
Either within the vagina but beyond it’s anatomical confines or beyond the vagina (exteriosistation)
Why must the abdomino-pelvic cavity walls be of sufficient flexibility?
To withstand changes in volumes of these organs and also pressure changes within the cavity
If the pelvic floor is normal all the pelvic viscera will be what?
Maintained in their position both at rest and in periods of increased intra-abdominal pressure
What are the 3 distinct anatomical layers of the pelvic floor (function as one unit)?
Endo-pelvic Fascia: 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).
Pelvic Diaphragm: layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
Urogenital Diaphragm: the superficial & deep transverse perineal muscles with their fascial coverings.
These 3 layers do not parallel each other and vary in strength & thickness from place to place.
What is the endopelvic fascias components?
Fibro-muscular component can stretch (Uteroscarals)
Connective tissue does not stretch or attenuate instead it breaks.
Where does the uterosacral/cardinal complex tend to break?
Medially (around the cervix)
Easily palpated by down traction on the Cervix and if intact allows limited side-side movement of the cervix.
Where does the pubocervical fascia tend to break?
Tend to break at lateral attachments or immediately in front of the cervix
What defects/breaks can be seen in the rectovaginal fascia?
Tends to break Centrally:
If upper defect: Enterocele.
If lower defect: perineal body descent & Rectocele.
What are the common risk factors of POP?
- Pregnancy and vaginal birth
- Higher the parity the higher the risk
- Forceps delivery
- Large baby (>4500gm)
- Prolonged second stage
- Advancing age
- Obesity
Is previous pelvic surgery a risk factor for POP?
Yeah…
Continence procedures, while elevating the bladder neck, may lead to defects in other pelvic compartments:
Burch colposuspension- Potential defect in the posterior vaginal wall - predisposes to rectocele and enterocele formation
What are some other risk factors for POP?
Hormonal factors (age and then drop in oestrogen level)
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)
Prolapses are traditionally classified depending on the site of the defect and the presumed pelvic viscera that are involved. What are these classifications?
Urethrocele: Prolapse of the lower anterior vaginal wall involving the urethra only.
Cystocele: Prolapse of the upper anterior vaginal wall involving the bladder.
Uterovaginal prolapse. This term is used to describe prolapse of the uterus, cervix and upper vagina.
Enterocele: Prolapse of the upper posterior wall of the vagina usually containing loops of small bowel (apical prolapse-Vagina out totally and bowel dropping into it – vault prolapse)
Rectocele: Prolapse of the lower posterior wall of the vagina involving the rectum bulging forwards into the vagina.
(Implies an unrealistic certainty as to the structures on the other side of the vaginal bulge. This is often a false assumption, particularly in women who have had previous prolapse surgery)
What are the typical vaginal symptoms in a woman with pelvic organ prolapse?
Sensation of a bulge or protrusion
Seeing or feeling a bulge or protrusion
Pressure
Heaviness
Difficulty in inserting tampons
What are the typical urinary symptoms in a woman with pelvic organ prolapse?
Urinary Incontinence
Frequency/ Urgency
Weak or prolonged urinary stream/ Hesitancy/ Feeling of incomplete emptying
Manual reduction of prolapse to start or complete voiding
What are the typical bowel symptoms in a woman with pelvic organ prolapse?
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
What scoring system for POP is considered currently as the gold standard?
POPQ-endorsed by the ICS
Stage 1-4
How is POP assessed?
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
What investigations are done for associative symptoms if not just a prolapse (clinical diagnosis only for a prolapse)?
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).
For a pelvic mass why would an USS be done?
USS for exclusion of post menopausal bleeding causes like endometrial cancer or want to exclude a pelvic mass
What can be done as prevention of POP?
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.
Avoid things that will cause sustained increased intra-abdominal pressure
How can physiotherapy be used in the context of prolapse?
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.
In what stages of prolapse is PFMT helpful?
Strengthen the pelvic floor muscles & the muscular components of the endopelvic fascia – improves patients symptoms specifically for Stage 1 or 2 prolapse (limited role if outside vagina-stage 3 & 4)
What are pessaries made of today
Silicone mostly as it is advantageous due to its hypoallergenic nature and it is non absorbent etc
