Prolapse Flashcards
What is prolapse?
Weakness of supporting structures allows pelvic organs to protrude through the vaginal wall
What are associations with weakness leading to prolapse?
Prolonged labour Trauma from instrumental delivery Lack of postnatal pelvic floor exercise Obesity Chronic cough Constipation
Prolapse is exacerbated by menopause and is not danger to health
What are the types of prolapse?
Cystocele Cystourethrocele Rectocele Enterocele Uterine prolpase
What is cystocele? Symptoms?
Anterior wall of vagina and the bladder attached to it bulge
Residual urine within cystocele may cause frequency and dysuria
Associated with urethral prolapse (cystourethrocele)
What is rectocele? Symptoms?
Lower posterior wall which is attached to rectum may bulge through weak elevator ani
Often symptomless but may have to reduce herniation prior to defaecation by putting a finger in the vagina or pressing on the perineum
What is enteocele?
Bulges of upper posterior vaginal wall may contain loops of intestine from the pouch of Douglas
What is uterine prolapse?
Protrusion of the uterus downwards into the vagina taking with it the cervix and upper vagina.
If woman has had hysterectomy, the vaginal vault is left and may also prolpase
How are prolapsed graded?
First degree:
Lowest part of prolapse descends halfway down the vaginal axis into the introitus
Second degree:
Lowest part of the prolapse extends to the level of the introitus and through the introitus on straining
Third degree:
Lowest part of prolapse extends through introitus and outside vagina
Procidentia - uterus lies outside the vagina (fourth degree)
What are symptoms of prolapse?
Dragging sensation Pressure Feeling of a lump coming down Dyspareunia Backache Heaviness Bearing-down
Cystocele Urinary urgency ad frequency Incontineny Incomplete bladder emptying Urinary retention if urethra is kinked
Rectocele
Constipation
Difficulty defamation
What examination for prolapse?
Bimanual to exclude pelvic masses
Examine for prolapse with woman in left lateral position using Sim’s speculum
Inspect anterior and posterior walls for atrophy and descent
If no obvious prolapse ask woman to strain or stand or cough
What is conservative management for prolapse?
Weight loss Stop smoking Stop straining Pelvic floor exercises Physiotherapy
What other management for prolapse?
Pessaries useful in those who decline surgery, are unfit for surgery or if surgery is CI
What information about pessaries?
Affect sexual function
Should be changed every 6 months and if woman is post-menopausal, topical oestrogen is useful to prevent vaginal erosion
Ring pessaries placed between posterior aspect of pubic symphysis and posterior fornix of vagina
Gelhorn pessary is shaped like a mushroom
Indications for surgery?
Symptoms are severe
Sexually active
Pessaries have failed
What is surgical management for cystocele?
Anterior colporrhaphy
Colposuspension
