Prolapse Flashcards
When does a prolapse occur?
When weakness of the supporting structures allows the pelvic organs to protrude within the vagina
What is prolapse exacerbated by?
Menopause
What types of prolapse are there?
Cystocele - when the bladder drops/sags into the anterior vaginal wall
Cystourethrocoele - when bladder and associated urethra protrude into vaginal wall
Rectocele - bulge of the front wall of rectum into posterior vagina
Enterocele - when small bowel pushes into the upper posterior vaginal wall
Uterine prolapse - protrusion of uterus down into the vagina, taking with it the cervix and upper vagina, if the woman has had a hysterectomy the vaginal vault may also prolapse
Describe first degree prolapse
The lowest part of the prolapse descends half way down the vaginal axis
Describe second degree prolapse
The lowest part of prolapse extends to level of introitus, and through the introitus on straining
Describe third degree prolapse
The lowest part extends through the introitus and outside the vagina (uterus and vagina everted)
What risk factors are there?
Increasing age Menopause Multiparity Vaginal deliveries Obesity Spina bifida Smoking Connective tissue disease
What symptoms are associated?
May be asymptomatic Dragging sensation Sensation of pressure, heaviness Feeling of a lump coming down Dyspareunia Backache Urinary symptoms with cystocele: frequency, urgency, incontinence, retention if urethra kinked Symptoms with rectocele: constipation, difficulty with defecation
How is it managed?
If asymptomatic and mild - no treatment needed
Conservative: weight loss, pelvic floor muscle exercises, stop smoking and straining (reducing intra abdominal pressure)
Ring pessary - useful in those who decline/unfit for surgery
Surgery
How do pessaries work?
Usually ring shaped, placed between the posterior symphysis pubis and posterior aspect of the vagina
They affect sexual function
Change every 6 months
When is surgery useful?
If symptoms are severe, woman is sexually active and pessaries failed
The type of prolapse repair depends on type of prolapse
Excise redundant tissue and strengthen supports
How is marked uterine prolapse treated?
Hysterectomy - with or without sacrospinous fixation
How is post hysterectomy vault prolapse treated?
Sacrocolpopexy - using a strip of synthetic mesh to lift the top of the vagina and hold it in place
What examinations should be done?
Bimanual to exclude pelvic masses
Examine for prolapse with the woman in the left lateral position using a Sims speculum
Inspect anterior and posterior walls for atrophy and descent
If no obvious prolapse ask woman to strain or stand
Arrange urodynamic studies if urinary incontinence
