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OBG: prolapse, incontinence, fertility > Prolapse > Flashcards

Prolapse Flashcards

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1
Q

What is the overall structure and function of the pelvic floor?

A

consists of muscular and fascial structures that provide support to the pelvic viscera and the external openings of the vagina, urethra and rectum

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2
Q

What are 5 key ligaments / muscles to be aware of when it comes to pelvic anatomy?

A
  1. Round ligament
  2. Cardinal ligament
  3. Uterosacral ligament
  4. Levator ani
  5. Perineal muscle
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3
Q

How do the uterus and vagina relate to the rest of the pelvic anatomy?

A

they are suspended from pelvic side walls by endopelvic fascial attachments that support the vagina at three levels

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4
Q

What is level 1 of vaginal support?

A

the cervix and upper third of the vagina are supported by the cardinal (transverse cervical) and uterosacral ligaments. these are attached to the cervix and suspend the uterus from the pelvic sidewall and sacrum respectively

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5
Q

What is level 2 of vaginal support?

A

the mid-portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls.

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6
Q

What is level 3 of vaginal support?

A

he lower third of the vagina is supported by the levator ani muscles and the perineal body. The levator ani, together with its associated fascia, is termed the pelvic diaphragm.

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7
Q

What is the normal axis of the vagina and what does it lie in relation to?

A

normally lies in horizontal plane, flat on the levator muscles and the perineal body

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8
Q

Why is the normal lie of the vaginal important?

A

protects it during coughing and other activities that increase intra-abdominal pressure

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9
Q

Why is it important to know the different levels of support of the vagina?

A

damage at different levels of vaginal support causes different types of prolapse

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10
Q

What are 5 types of causes of prolapse?

A
  1. Pregnancy and vaginal delivery
  2. Congenital factors
  3. Menopause
  4. Chronic predisposing factors
  5. Iatrogenic factors
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11
Q

Why can vaginal delivery result in prolapse?

A

may cause mechanical injuries and denervation of the pelvic floor

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12
Q

What are 3 factors that increase the risk of vaginal delivery causing prolapse?

A
  1. Large babies
  2. Prolonged second stage
  3. Intrumental delivery (particularly forceps)
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13
Q

What are is an example of congenital factor that can predispose to prolapse?

A

abnormal collagen metabolism in Ehlers-Danlos syndrome

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14
Q

What is thought to cause increase prolapse incidence following the menopause?

A

may be due to deterioration of collagenous connective tissue that occurs following oestrogen withdrawal

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15
Q

What do chronic predisposing factors to prolapse have in common?

A

chronic increase in intra-abdominal pressure

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16
Q

What are 5 chronic predisposing factors to prolapse?

A
  1. Obesity
  2. Chronic cough
  3. Constipation
  4. Heavy lifting
  5. Pelvic mass
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17
Q

What are 2 examples of iatrogenic factors that can influence the occurrence of prolapse?

A
  1. Hysterectomy
  2. Continence procedures
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18
Q

How can previous hysterectomy predispose to prolapse?

A

Associated with susbequent vaginal vault prolapse (particularly when indication for the surgery was prolapse)

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19
Q

How can continence procedures predispose to prolapse?

A

although elevating the bladder neck, they may lead to defects in other pelvic compartments (Burch colposuspension may predispose to rectocele and enterocele formation)

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20
Q

What is an example of a continence procedure that can predispose to prolapse, and which types of prolapse can it lead to?

A

Burch colposuspension (repositioning muscles that connect bladder to the urethra)

  • may predispose to rectocele and enterocele formation
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21
Q

What is the definition of prolapse?

A

protrusion of the uterus and/or vagina beyond normal anatomical confines. Bladder, urethra, rectum, bowel also often involved

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22
Q

How common is prolapse believed to be?

A

difficult to define as many women don’t seek help; probably extremely common and present in varying degrees in most older parous women

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23
Q

What are the 4 key types of prolapse?

A
  1. Cystocele
  2. Uterine (apical) prolapse
  3. Eneterocele
  4. Rectocele
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24
Q

What is a cystocele?

A

prolapse of anterior vaginal wall, involving bladder. Often associated prolapse of urethra in which case term cysto-urethrocele is used

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25
What is meant by uterine (apical) prolapse?
term used to describe prolapse of uterus, cervix, and upper vagina
26
What type of prolapse can occur if the uterus has been removed?
the vault aka top of vagina, where uterus used ot be, can itself prolapse (vaginal vault prolapse)
27
What is the definition of enterocele?
prolapse of **upper** **posterior** **wall** of vagina; resulting pouch often contains loops of **bowel**
28
What is a rectocele?
prolapse of lower posterior wall of the vagina, involving the anterior wall of the rectum
29
What are 3 things that must be described when giving a measurement of the extent of a prolapse?
1. Position of patient 2. At rest or straining 3. Whether traction is employed
30
What are the 3 degrees of the Baden-Walker classification of urogenital prolapse?
1. **First degree:** the lowest part of the prolapse descends halfway down the vaginal axis to the introitus 2. **Second degree:** the lowest part of the prolapse extends to the level of the introituse and through the introitus on straining. 3. **Third degree:** the lowest part of the prolapse extends through the introitus and lies outside the vagina
31
What is meant by procidentia?
third degree uterine prolapse
32
What are 5 of the most common general symptoms of prolapse?
1. **dragging** sensation, discomfort, and **heaviness** within the pelvis 2. feeling of ‘a **lump** coming down’ 3. **dyspareunia** 4. difficulty in **inserting tampons** 5. discomfort and **backache**.
33
What are 3 symptoms of prolapse specific to a cysto-urethrocele?
1. Urinary urgency and frequency 2. Incomplete bladder emptying 3. Urinary retention or reduced flow where the urethra is kinked by descent of the anterior vaginal wall
34
What are 2 symptoms of prolapse specific to rectoceles?
1. Constipation 2. Difficulty with defecation (may digitally reduce to defecate)
35
What are 2 things that can cause prolapse symptoms to become worse?
1. Prolonged standing 2. Towards end of day
36
What are secondary symptoms that can occur in grade 3 or 4 of prolapse?
Mucosal ulceration and lichenification, resulting in vaginal bleeding and discharge
37
What is the best position in which to carry out an examination for prolapse?
Left lateral position using a Sims speculum (can additionally perform supine with Cisco speculum)
38
What are 4 things that should be carried out in examination of a prolapse?
1. Exclude pelvic masses with bimanual examination 2. Check walls in turn for descent and atrophy 3. If absolutely necessary, **volsellum** may be applied to cervix so traction will demonstrate severity of uterine prolapse (causes marked discomfort) 4. Asses pelvic floor muscle strength
39
What is a Volsellum?
forceps used to grasp cervical lips to visualise cervix or during vaginal hysterectomy
40
What is the Modified Oxford system for grading pelvic floor muscle strength? Give the grades 0-5
system of grading using **vaginal palpation** of pelvic floor muscles * 0: no contraction * 1: flicker * 2: weak * 3: moderate * 4: good (with lift) * 5: strong
41
Why is it important to assess quality of life in women with prolapse and how can this be done?
* can have big effect: social, psychological, occupational, sexual * self-completion questionnaires e.g. Vaginal Symptoms module of International Consultation on Incontinence Questionnaire (ICIQ-VS)
42
What are 5 investigations to consider in prolapse?
1. USS - exclude pelvic or abdominal masses (if suspected clinically) 2. Urodynamics - if urinary incontinence present 3. ECG - to assess fitness for surgery 4. CXR - " 5. FBC + U&E - "
43
What are 2 approaches to the management of prolapse?
conservative and surgical
44
What are 6 things that can contribute to prevention of pelvic organ prolapse (POP)?
1. Reduction of prolonged labour 2. Reduction of trauma caused by instrumental delivery 3. Encouraging persistence with postnatal pelvic floor exercises 4. Weight reduction 5. Treatment of chronic constipation 6. Treatment of chronic cough (including smoking cessation)
45
What are 2 important aspects of conservative management of prolapse?
1. Physiotherapy - pelvic floor muscle exercise (PFME), biofeedback and vaginal cones 2. Intravaginal devices - pessaries
46
Which group of women is physiotherapy a good option for the management of prolapse?
mild prolapse in younger women, who find intravaginal devices unacceptable and are not yet willing to consider definitive surgical treatment will improve tone in young parous women but unlikely to benefit older women with significant uterovaginal prolapse
47
What are 3 aspects of physiotherapy which can be used to manage prolapse?
1. Pelvic floor muscle exercises (PFME) 2. Biofeedback 3. Vaginal cones
48
When are pelvic floor muscle exercises most effective at treating prolapse?
when taught under direct supervision of a physiotherapist
49
Which group of women are vaginal pessaries a good option to treat prolapse for?
women who declie surgery, who are unfit for surgery, or for whom surgery is contraindicated
50
How frequently should vaginal pessaries be changed?
6 monthly
51
What should be given alongside vaginal pessaries and why?
topical oestrogen to reduce risk of vaginal erosion
52
What are 4 types of vaginal pessaries and which is the most commonly used?
1. Ring pessary - most common 2. Shelf pessary 3. Hodge pessary 4. Cube and doughnut pessaries
53
What size ranges are ring pessaries available in?
available in range of sizes 52-129mm
54
How is a ring pessary used?
ring is placed between the posterior aspect of the symphysis pubis and the posterior fornix of the vagina
55
When is a shelf pessary used for prolapse?
when correctly sized ring pessary will not sit in the vagina and/or when perineum is deficienct
56
Why are shelf pessaries becoming less frequently used?
may be difficult to insert and remove
57
What is Hodge pessary used for?
can be used to correct uterine retroversion (but rarely ever used now)
58
When are cube and doughnut pessaries used?
very rarely - for significant prolapse when others are not retained
59
What are 7 factors that influence the management of prolapse?
1. Severity of symptoms 2. Extension of the signs (asymptomatic grade 1 doesn't require treatment) 3. Age, parity and wish for further pregnancies 4. Patient's sexual activity 5. Presence of aggravating factors such as smoking and obesity 6. Urinary symptoms 7. Other gynae problems such as menorrhagia
60
What does surgery offer when managing prolapse and what does the type depend on?
definitive treatment; depends on patient and type of prolapse
61
What are 3 types of surgical treatment for anterior compartment defects in prolapse?
1. Anterior colporrhaphy (anterior repair) 2. Transvaginal mesh repair 3. Paravaginal repair
62
What 2 types of surgery are available for a posterior compartment defect in prolapse?
1. posterior colpoperineorrhaphy (posterior repair); transvaginal mesh repair; perineal body reconstruction 2. sacrocolpopexy to correct recto/enterocele
63
What are 3 types of surgical management of uterovaginal (apical) prolapse?
1. Vaginal hysterectomy; sacrospinous fixation 2. Manchester repair (or Fothergill repair) 3. Hysteropexy; sacrocolpopexy
64
What are 2 types of surgery available for a vaginal vault prolapse?
1. Sacrospinous ligament fixation 2. Sacrocolpoplexy
65
What type of prolapse is anterior colporrhaphy (anterior repair) used for?
repair of a cysto-urethrocele
66
What does an anterior colporrhaphy (anterior repair) operation involve?
* longitudinal incision made on anterior vaginal wall and vaginal skin separated by dissection from the pubocervical fascia * buttressing sutures are places on the fascia * surplus vaginal skin excised and skin is closed
67
What type of anaesthesia can be used for anterior colporrhaphy?
traditionally regional or general anaesthesia but can also be under local anaesthesia, allowing early mobilisation and discharge home
68
What is the long-term success rate of anterior colporrhaphy?
disappointing - recurrence rates of up to 30% have been reported, may be in part due to failure to identify a co-existing apical defect
69
What is a paravaginal repair used for?
abdominal approach to correct an anterior defect
70
What does a paravaginal repair of an anterior defect involve?
retropubic space is opened through a Pfannenstiel incision and the bladder is swept medially, exposing the pelvic sidewall Lateral sulcus of vagina is elevated and reattached to the pelvic sidewall using interrupted sutures
71
How successful is paravaginal repair of anterior wall prolapse?
cure rate of 70-90% has been reported (may also be done laparoscopically)
72
How commonly is a paravaginal repair of anterior wall prolapse performed?
not commonly done, very invasive
73
What type of prolapse is a posterior colpoperineorrhaphy (posterior repair) used for?
rectocele and deficient perineum
74
What does a posterior colpoperineorrhaphy involve?
repair of a rectovaginal fascial defect and removal of excess vaginal skin perineoplasty is performed by placing deeper sutures into the perineal mscules, building up the perineal body to provide additional support
75
Why must care be taken when removing redundant vaginal skin in a posteior colpoperineorrhaphy?
vaginal narrowing can result in dyspareunia
76
Which type of surgical management of uterovaginal (apical) prolapse is now rarely performed?
Manchester repair (or Fothergill repair)
77
When is vaginal hysterectomy performed?
in cases of significant uterine descent or menstrual problems
78
What does a Manchester repair involve?
cervical amputation followed by approximation and shortening of the cardinal ligaments anterior to the cervical stump; this is combined with an anterior and posterior colporrhaphy
79
When is a hysteroscopy used to repair a uterine prolapse?
if patient wishes to preserve uterus
80
What does a hysteropexy involve?
open or laparoscopic procedure uterus and cervix are attached to sacrum using bifurcated non-absorbable mesh
81
What is a theoretical benefit of hysteropexy when compared with hysterectomy to treat uterine prolapse?
stronger apical support with hysteropexy
82
What does a sacrospinous ligament fixation to repair a vaginal vault prolapse involve? How successful is it?
suturing the vaginal vault to the sacrospinous ligaments, using a vaginal approach 70-85% success rate and low immediate morbidity
83
What is a risk of sacrospinous ligament fixation to treat vaginal vault prolapse?
as vaginal axis is changed by this procedure, there is a risk of postoperative dyspareunia
84
What does sacrocolpopexy to treat vaginal vault prolapse involve?
vault is attached to the sacrum using a non-absorbable mesh, and can be performed either as open procedure or laparoscopically
85
How does sacrocolpoplexy compare with sacrospinous ligament fixation to manage vaginal vault prolapse?
sacrocolpoplexy has a higher success rate, of around 90%, and a better anatomical result than sacrospinous fixation
86
What is a possible complication of sacrocolpoplexy to treat vaginal vault prolapse?
mesh erosion into the vagina, or rarely into the bladder or bowel - possible late complication
87
What proportion of all prolapse surgery is for recurrent defects?
1/3 approximately
88
What is a problem with managing recurrent urogenital prolapse with surgery?
vaginal epithelium may be scarred and atrophic, making surgical correction technically more difficult an increasing the risk of damage to the bladder and bowel
89
Why is the use of synthetic meshes becoming increasingly common for repair of recurrent prolapse?
they may offer more support where endopelvic fascia has proved to be deficient
90
What are 3 possible adverse effects of the use of mesh in urogynaecological surgery that have been raised as concerns?
1. Pain 2. Mesh erosion 3. Sexual dysfunction
91
What are 4 requirements that must be met for the use of mesh in urogynaecological surgery?
1. NICE recommends surgeons have specialist training and carry out sufficient case load to maintain their skills 2. All surgeons should maintain audit data and contribute to national audit databases (such as British Society for Urogynaecology) 3. All surgeons should work within the context of the MDT 4. Patients must be provided with information about risks of surgery and should be made aware of alternative procedures

OBG: prolapse, incontinence, fertility (6 decks)

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