Prolapse Flashcards
what are the anatomical supports to the upper 3rd of vagina and cervix?
Transverse cervical ligament (cardinal) - to sides
Uterosacral ligament - to sacrum
what are the anatomical supports to the lower 3rd of vagina?
Levator ani muscles - largest in pelvic floor
Perineal body
define the following in trems of thee process that cuases it:
Urethrocoele
Prolapse of lower anterior vaginal wall, involving the urethra only
define the following in trems of thee process that cuases it:
Apical
Prolapse of uterus, cervix and upper vagina
If uterus has been removed, the vault can itself prolapse
define the following in trems of thee process that causes it:
Enterocoele
Prolapse of upper posterior wall of vagina - pouch of Douglas
Pouch usually contains small loops of bowel
define the following in trems of thee process that cuases it:
Rectocoele
Prolapse of lower posterior wall of vagina
Involves anterior wall of the rectum
define the following in trems of thee process that cuases it:
Cystocoele
Prolapse of upper anterior vaginal wall, involving the bladder
Associated prolapse of urethra = cystourethrocoele
what are the presenting symptoms of prolapse?
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
what is the aetiology and risk factors of prolpase?
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
what are some complications of prolapse?
Severe prolapse may interfere with intercourse
May ulcerate and cause bleeding and discharge
Stress incontinence common
which speculum is prefered for ivx of a prolapse?
Sims - you can see both walls of vagina if:
- retract posterior wall with sim’s to see anterior prolapse
- retract anterior wall with sim’s to see posterior prolapse
how does one differeentiate between recto and enterocele?
Finger in rectum will bulge into rectocoele and not enterocoele
differentials for a prolapse?
large polyp
vaginal cysts
when investigating prolapse, you must always check for what else?
Stress incontinence
after physical ivx what other ivx can be done in prolapse?
Pelvic USS if mass suspected
MSU - for UTI
Urodynamic testing if incontinence primary complaint
how is prolapse managed?
Conservative:
A. Weight loss, stop smoking + treat chronic cough, avoid constipation, avoid heavy lifting,
B. Pelvic floor exercise - can be physio guided
- 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)
name some cavaets of pessaries?
pain
urinary retention
infection
fall out
name some side effects of surgical management of prolapse?
mesh erosion /haemorrhage - sacrocolpopexy
- Sacrospinous fixation : buttock pain, infection, nerve injury
what examinations do we do for prolapse?
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
how are pessaries maintained?
Pessaries should be changed or removed, cleaned and reinserted regularly to reduce this risk, ideally every 6 months.
can have sex
what is the difference between Urge incontinence and overactive bladder?
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
what are neurological causes of voiding difficulty - acutee/chronic retention?
Central (suprapontine)
Cerebrovascular accident
Parkinson disease
Spinal
Spinal cord injury
Multiple sclerosis
Peripheral
Prolapsed intervertebral disc
Peripheral autonomic neuropathies (e.g., diabetic)
list other causes of voiding difficulty - acute/chronic retention?
Medications can cause voiding difficulties, the most common example being epidural or spinal anaesthesia during labour.
Mechanical obstruction
neurological
you want to tell a patient with incontinence to keep a bladder diary. what does this entail?
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.
in urodynamics, what does a low flow rate suggest?
poor action of the detrusor muscle, or an outflow obstruction
should at least be 15ml/s
what does urodynamic testing involve?
a range of tests:
- Cystometry
- 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
what does cystometry involve?
Cystometry measures bladder pressure during filling and voiding using pressure catheters inserted in the bladder (intravesical pressure) and the rectum (intraabdominal pressure).
what is continuous incotinence?
constant urinary leakage
how would you ivx and manage a fistula?
Cystoscopy and dye test
examine under anaesthetic
how would you ivx a fistula?
Cystoscopy and dye test
examine under local anaesthetic
what is the most common cause of fistula?
Prolonged labour
what are some complications of incontinence?
lifestyle changees -> housebound if severe
psychosocial problems
kidney issues - if recurrent utis
