Prolapse Flashcards
Uterovaginal prolapse, rectocele, cystocele
How are the cervix and upper third of the vagina supported?
By the cardinal (transverse cervical) and uterosacral ligaments. They are attached to the cervix and suspend the uterus from the pelvic sidewall and sacrum respectively
How is the mid portion of the vagina supported?
By endofascial condensation (endopelvic fascia) laterally to the pelvic side walls
How is the lower third of the vagina supported?
By the levator ani muscles and the perineal body. The levator ani, together with its associated associated fascia, is termed the pelvic diaphragm
What is the pelvic diaphragm?
The levator ani muscles and its associated fascia
What is the aetiology of prolapse?
- Pregnancy and vaginal delivery
- Congenital factors
- Menopause
- Chronic predisposing factors
- Iatrogenic factors
How does pregnancy and vaginal delivery cause prolapse?
Vaginal delivery may cause mechanical injuries and denervation of the pelvic floor.
Is prolapse common in nulliparous women?
No
What Fx of labour can increase the risk of prolapse?
Large babies, prolonged second stage, and instrumental delivery (particularly forceps)
What congenital factors can increase the risk of prolapse?
Abnormal collagen metabolism e.g. Ehlers-Danlos syndrome
What happens to incidence of prolapse after menopause?
Increases
How does menopause cause prolapse?
Deterioration of collagenous connective tissue following oestrogen withdrawal
What chronic predisposing factors to prolapse exist?
Any chronic increase in intra-abdominal pressure;
- Obesity
- Chronic cough
- Constipation
- Heavy lifting
- Pelvic mass
What iatrogenic factors increase risk of prolapse?
Pelvic surgery;
- Hysterectomy is associated with vaginal vault prolapse (particularly when the indication was prolapse)
- Continence procedures, although elevating the bladder neck, may lead to defects in other compartments
What is prolapse defined as?
Protrusion of the uterus and/or vagina beyond normal anatomical confines. The bladder, urethra, rectum and bowel are also often involved
What is a cystocele?
A prolapse of the anterior vaginal wall, involving the bladder.
What is a cysto-urethrocele?
An anterior wall prolapse involving the bladder and urethra
What is a uterine (apical) prolapse?
Prolapse of the uterus, cervix and upper vagina. If the uterus had been removed, the vault or top of the vagina (where the uterus used to be) can itself prolapse
What is an enterocele?
A prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel
What is a rectocele?
A prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
What is the most common grading system for prolapse?
The Baden-Walker System
Are Sx always present in prolapse?
Often absent
Most common general Sx?
- Dragging sensation, discomfort, and heaviness within the pelvis
- Feeling of ‘a lump coming down’
- Dyspareunia or difficulty inserting tampons
- Discomfort and backache
Sx of cyst-urethrocele
- Urinary urgency and frequency
- Incomplete bladder emptying
- Urinary retention or reduced flow where the urethra is kinked by descent of the anterior vaginal wall
Sx of a rectocele?
- Constipation
2. Difficulty with defecation (may digitally reduce it to defecate)
When do Sx become worse?
Worse when prolonged standing and towards the end of the day.
What can happen in grade 3 or 4 prolapse?
Mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge
Why does a bimanual examination need to be done?
To exclude pelvic masses
How should a vaginal examination be done?
With the woman in the left lateral position, using a Sims’ speculum
What needs to be done on a vaginal examination?
- Check the walls for descent and atrophy
2. Assessment of pelvic floor muscle strength
What effect can Sx have on a woman’s QoL?
Reduce QoL by affecting; Social Psychological Occupational Sexual limitations
Ix to be done
- Sometimes none; clinical diagnosis can be made
- USS to exclude pelvic or abdo masses (if suspected clinically)
- ECG, CXR, FBC and U&E (if appropriate) to assess fitness for surgery
How is fitness for surgery assessed?
- ECG
- CXR
- FBC
- U&E
General Mx of prolapse?
Weight reduction if appropriate
Discourage smoking
Physiotherapy
How to prevent prolapse?
- Reduction of prolonged labour
- Reduction of trauma caused by instrumental delivery
- Encourage persistence with postnatal pelvic floor exercises
- Weight reduction
- Tx of chronic constipation
- Tx of chronic cough (including smoking cessation)
When is physiotherapy used?
Mx of mild prolapse in younger women, who find intravaginal devices unacceptable and are not yet willing to consider definitive surgical Tx
When are pessaries used?
Declines surgery, unfit for surgery, surgery contraindicated
How often should pessaries be changed?
6-9 months
What should be given with pessaries?
Topical oestrogen to reduce the risk of vaginal erosion
Types of pessary?
Ring pessaries
Shelf pessaries
Hodge pessaries
Cube and doughnut pessaries
Most common type of pessary?
Ring pessary
When are shelf pessaries used?
Severe forms of prolapse
Factors influencing Mx of prolapse?
- Severity of Sx
- Extension of the signs
- Age, parity and wish for further pregnancies
- Patient’s sexual activity
- Presence of aggravating Fx such as smoking and obesity
- Urinary Sx
- Other gynae problems such as menorrhagia
Surgery for uterine prolapse?
Hysteropexy (mesh attaches uterus and cervix to sacrum) or vaginal hysterectomy (though 40% recurrence rate)
Surgical Tx for cystocele?
Anterior wall repair
Surgical Tx for rectocele?
Posterior wall repair
Surgical Tx for vault porlpase?
Sacrospinous fixation or sacrocolpopexy
