Prolapse

Question 1

what are the anatomical supports to the upper 3rd of vagina and cervix?

Answer 1

Transverse cervical ligament (cardinal) - to sides

Uterosacral ligament - to sacrum

Question 2

what are the anatomical supports to the lower 3rd of vagina?

Answer 2

Levator ani muscles - largest in pelvic floor

Perineal body

Question 3

define the following in trems of thee process that cuases it:

Urethrocoele

Answer 3

Prolapse of lower anterior vaginal wall, involving the urethra only

Question 4

define the following in trems of thee process that cuases it:
Apical

Answer 4

Prolapse of uterus, cervix and upper vagina

If uterus has been removed, the vault can itself prolapse

Question 5

define the following in trems of thee process that causes it:
Enterocoele

Answer 5

Prolapse of upper posterior wall of vagina - pouch of Douglas
Pouch usually contains small loops of bowel

Question 6

define the following in trems of thee process that cuases it:
Rectocoele

Answer 6

Prolapse of lower posterior wall of vagina

Involves anterior wall of the rectum

Question 7

define the following in trems of thee process that cuases it:
Cystocoele

Answer 7

Prolapse of upper anterior vaginal wall, involving the bladder
Associated prolapse of urethra = cystourethrocoele

Question 8

what are the presenting symptoms of prolapse?

Answer 8

Often asymptomatic

General Dragging sensation, vaginal lump (may be able to see or feel)

Cystourethrocoele: Urinary frequency, incomplete emptying, frequent UTIs. (incontinence?)

Rectocoele: Occasional difficulty in defaecating - incomplete emptying, constipation, lower back pain.

Discharge: if level 3 prolapse and rubbing on clothes -> ulcer that discharges

Worst at end of day or when standing up

Question 9

what is the aetiology and risk factors of prolpase?

Answer 9

Most common: Obstetric factors - Vaginal delivery AND pregnancy
- damages and denervation of pelvic floor
- macrosomic infants, prolonged 2nd stage and
instrumental delivery, high parity

Congenital factors
- Ehlers-Danlos Syndrome

Menopause
- Atrophy of connective tissue after oestrogen
withdrawal

Iatrogenic:
- Pelvic surgery e.g. hysterectomy
- Continence procedures: stress incontinence surgery
can cause urge incontinence

Increased intra-abdo pressure:
o Obesity, Chronic cough, Constipation, Heavy lifting, Pelvic mass

Question 10

what are some complications of prolapse?

Answer 10

Severe prolapse may interfere with intercourse

May ulcerate and cause bleeding and discharge

Stress incontinence common

Question 11

which speculum is prefered for ivx of a prolapse?

Answer 11

Sims - you can see both walls of vagina if:

1. retract posterior wall with sim’s to see anterior prolapse
2. retract anterior wall with sim’s to see posterior prolapse

Question 12

how does one differeentiate between recto and enterocele?

Answer 12

Finger in rectum will bulge into rectocoele and not enterocoele

Question 13

differentials for a prolapse?

Answer 13

large polyp

vaginal cysts

Question 14

when investigating prolapse, you must always check for what else?

Answer 14

Stress incontinence

Question 15

after physical ivx what other ivx can be done in prolapse?

Answer 15

Pelvic USS if mass suspected

MSU - for UTI

Urodynamic testing if incontinence primary complaint

Question 16

how is prolapse managed?

Answer 16

Conservative:
A. Weight loss, stop smoking + treat chronic cough, avoid constipation, avoid heavy lifting,
B. Pelvic floor exercise - can be physio guided

1. Ring pessary
   - if dont want surgery or unfit
   - shelf pessary if severe
   - change 6-9 months
   - + Estrogen replaement postmenopausal

• Atrophic changes: Estrogen replaement
  2. Surgery (if severe or conservative fails)

Uterine prolapse

• hysterectomy : per vaginal
• hysteeropexy

Vaginal prolapse:
Wall lifting
- Sacrocolpopexy - abdo approach
- Sacrospinous fixation ; less eeffective - vaginal approach

Pelvic floor repair
- Anterior (cys) and posterior (recto) colporrhaphy (repairs)

Question 17

name some cavaets of pessaries?

Answer 17

pain
urinary retention
infection
fall out

Question 18

name some side effects of surgical management of prolapse?

Answer 18

mesh erosion /haemorrhage - sacrocolpopexy

• Sacrospinous fixation : buttock pain, infection, nerve injury

Question 19

what examinations do we do for prolapse?

Answer 19

General - BMI

Abdo exam - scars from hysterectomy

Sims speculum

Bimanual - Is there uterine descent? Is there descent on straining or coughing? Is there urinary leakage on straining or coughing?

Vaginal exam - ideally done with patient standing to assess descent

Question 20

how are pessaries maintained?

Answer 20

Pessaries should be changed or removed, cleaned and reinserted regularly to reduce this risk, ideally every 6 months.

can have sex

Question 21

what is the difference between Urge incontinence and overactive bladder?

Answer 21

Overactive bladder is urgency that occurs with or without incontinence and commonly with frequency and nocturia. suggestive of UI but is not UI

UI - there are episodes of incontinence preceded by urge

Question 22

what are neurological causes of voiding difficulty - acutee/chronic retention?

Answer 22

Central (suprapontine)
Cerebrovascular accident
Parkinson disease

Spinal
Spinal cord injury
Multiple sclerosis

Peripheral
Prolapsed intervertebral disc
Peripheral autonomic neuropathies (e.g., diabetic)

Question 23

list other causes of voiding difficulty - acute/chronic retention?

Answer 23

Medications can cause voiding difficulties, the most common example being epidural or spinal anaesthesia during labour.

Mechanical obstruction

neurological

Question 24

you want to tell a patient with incontinence to keep a bladder diary. what does this entail?

Answer 24

This is a recording of times and volumes of urine passed, leakage and pad usage along with fluid intake, degree of urgency and degree of incontinence.

It is recommended that this is kept for a minimum of 3 days on both working and leisure days.

It will highlight triggers for incontinence episodes related to lifestyle that may be adjustable, such as high caffeine intake.

Question 25

in urodynamics, what does a low flow rate suggest?

Answer 25

poor action of the detrusor muscle, or an outflow obstruction

should at least be 15ml/s

Question 26

what does urodynamic testing involve?

Answer 26

a range of tests:

1. Cystometry
2. Video cystourethrography - contrast is placed in bladder via catheter and monitored via xray during cystometry.
   can also help show anatomical anomalies – such as diverticula and fistula, stress incontinence

Question 27

what does cystometry involve?

Answer 27

Cystometry measures bladder pressure during filling and voiding using pressure catheters inserted in the bladder (intravesical pressure) and the rectum (intraabdominal pressure).

Question 28

what is continuous incotinence?

Answer 28

constant urinary leakage

Question 29

how would you ivx and manage a fistula?

Answer 29

Cystoscopy and dye test

examine under anaesthetic

Question 30

how would you ivx a fistula?

Answer 30

Cystoscopy and dye test

examine under local anaesthetic

Question 31

what is the most common cause of fistula?

Answer 31

Prolonged labour

Question 32

what are some complications of incontinence?

Answer 32

lifestyle changees -> housebound if severe

psychosocial problems

kidney issues - if recurrent utis