Prolapse Flashcards
What is a prolapse?
the descent of the uterus +/- vaginal walls beyond normal anatomical confines
occurs as a result of weakness in supporting structures
extremely common and present in most older parous women
How is the vagina supported at 3 levels?
o Level 1- the cervix and upper ⅓ of vagina are supported by the cardinal (transverse cervical) and uterosacral ligament
these are attached to the cervix and suspend the uterus from the pelvic side wall and sacrum, respectively
o Level 2- the mid-portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls
o Level 3- the lower ⅓ of vagina is supported by levator ani and the perineal body which forms the pelvic floor/diaphragm
What are the types of prolapse?
Urethrocele- prolapse of the lower anterior vaginal wall, involving the urethra only
Cystocoele- prolapse of upper anterior vagina wall, involving the bladder, often there is an associated prolapse of the urethra (cystourethrocoele)
Apical prolapse- prolapse of the uterus, cervix and upper vagina, if the uterus has been removed, the vault or top of the vagina can prolapse
• Enterocoele- prolapse of the upper posterior wall of the vagina, resulting pouch usually contains loops of small bowel
Rectocoele- prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
How are prolapses graded? (Baden-Walker classification)
Stage 0: No descent of pelvic organs during straining
Stage 1: leading surface of prolapse does not descend below 1cm above the hymenal ring
Stage 2: leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring
Stage 3: prolapse extends 1cm or below the hymenal ring but without complete vaginal eversion
Stage 4: vagina completely everted (complete providentia)
What is the aetiology of prolapse?
Vaginal delivery and pregnancy: mechanical injuries and denervation of the pelvic floor (increased for large infants, prolonged 2nd stages and instrumental)
Congenital factors- Ehlers dances (abnormal collagen)
Menopause: oestrogen withdrawal causes deterioration of collagenous connective tissue
Chronic predisposing factors- obesity, chronic cough, constipation, heavy lifting
Iatrogenic factors: pelvic surgery may influence occurrence of urogenital prolapse
What are the clinical features of prolapse?
dragging sensation or sensation of a lump, usually worse at the end of the day or when standing up
• Severe prolapse interferes with intercourse, may ulcerate and cause bleeding or discharge
• A cystourethrocoele can cause urinary frequency and incomplete bladder emptying (stress incontinence)
• A rectocoele often causes no symptoms- but occasionally causes difficulty in defaecating
What are the examinations used for prolapse?
abdominal examination to exclude pelvic masses
large prolapses may be visible from the outside- Sims’ speculum allows separate inspection of the anterior and posterior vaginal walls
• Diagnosis is made clinically- urodynamic testing is required if urinary incontinence is the principal compliant
What are the lifestyle changes advised for prolapse?
Weight reduction
Stop smoking
What are pessaries?
used in women who are unwilling or unfit for surgery
act as an artificial pelvic floor, so place in the vagina behind the pubic symphysis and in front of the sacrum
shelf pessary is better in severe prolapse
changed every 6-9 months, but post-menopausal women may require oestrogen (cream or HRT) to prevent vaginal ulceration
complications include pain, urinary retention, infection or may fall out
What is the surgery for prolapse?
synthetic meshes are used for sacrocolpopexy, hysteropexy and some vaginal operations
it reinforces weak connective tissue, reducing recurrent prolapse risk
complications can occur particularly if inserted through a vaginal incision – mesh extrusion or erosion (mesh protrudes through the vagina)
What is the management for a uterine prolapse?
o Vaginal hysterectomy- traditional surgical treatment, but 40% of women present with subsequent vaginal vault prolapse o Hysteropexy (open or laparoscopic)- uterus and cervix are attached to the sacrum using a bifurcated non-absorbable mesh- restores the length of the vagina without compromising the calibre
What is the management for a vaginal vault prolapse?
o Sacrocolpopexy (open or laparoscopic)- fixes the vault to the sacrum using mesh- complications include mesh erosion and haemorrhage o Sacrospinous fixation (vaginally)- suspends the vault to the sacrospinous ligament- complications include nerve or vessel injury, infection and buttock pain, less effective, but recovery is faster
What is the management for a vaginal wall prolapse?
anterior or posterior ‘repairs’ are used for the relevant prolapse, several prolapses may occur in one patient, these operations are often combined
• Surgery for urodynamic stress incontinence, tension-free vaginal tape (TVT) or transobturator tape (TOT) procedures may be performed at the same time as prolapse repair
