Prolapse and Incontinence Flashcards
What are the 3 levels of vaginal support anatomically?
- Cervix and upper 1/3 of the vaginal are supported by the cardinal (transverse cervical) and uterosacral ligaments. These attach from the cervix to the pelvic sidewalls and sacrum respectively.
- Mid portion of the vaginal is supported by endofascial condensations (endopelvic fascia) laterally to the pelvic side walls.
- Lower 1/3 of the vagina is supported by the levator ani muscle and the perineal body. The levator ani and its fascia are termed the pelvic diaphragm.
What is the pelvic floor, and what pierces through it?
The pelvic floor supports the pelvic organs and is pierced by the urethra and vagina termed the urogenital hiatus and rectum – the rectal hiatus. Between these two hiatuses lies a fibrous node known as the perineal body which joins the pelvic floor to the perineum.
Describe the levator ani muscle?
The levator ani muscle forms a broad muscular sheath and forms the main part of the pelvic floor; it is formed by the puborectalis, pubococcygeus, and iliococcygeus muscle. It attaches to the pubic bone anteriorly, ischial spines posteriorly, and the tendinous arch of levator ani laterally. It is innervated by the nerve roots S2, 3 and 4.
• Puborectalis loops around the anal canal to provide both faecal and urinary continence and must relax to allow for micturition or defecation.
• Pubococcygeus this is the main constituent of the levator ani and some of its fibres loops down around the prostate and vagina (levator prostate and pubovaginalis)
• Iliococcygeus thin muscle fibres comes from the ischial spine and attach posteriorly at the coccyx
Describe the coccygeus muscle
The coccygeus muscle arises from the ischial spine and runs to the inferior sacrum and coccyx; their fleshy fibres lie on and attach to the sacrospinous ligament.
What are the risk factors for prolapse?
Advancing Age
Menopause – low oestrogen causes atrophy of collagenous connective tissue
Parity
Connective tissue diseases such as Ehlers-Danlos
Smoking
Any chronic condition that increases intra-abdominal pressure e.g. chronic cough, obesity, constipation, heavy lifting and pelvic masses
Surgery – hysterectomy and continence procedures
How are prolapses classified?
Cystocele – prolapse of the anterior vaginal wall involving the bladder. If urethra involved, then cysto-urethrocele.
Uterine-apical prolapse – uterus, cervix and upper vagina
Enterocele – upper posterior wall of the vagina. Resulting pouch can contain bowel loops
Rectocele – lower posterior wall of the vagina involving the anterior wall of the rectum
Vaginal vault prolapse - prolapse of the superior portion of the vagina following a hysterectomy
Describe the grading of a prolapse?
Grading – Baden-Walker classification
Grade 1 – prolapse descends halfway down the vaginal axis to the introituse
Grade 2 – prolapse descends to the level of the introituse and through it when straining
Grade 3 – prolapse descends through the introituse and lies outside the vagina
Describe how a prolapse usually presents and its clinical features
Asymptomatic
Obvious prolapse
Pain and backache
Digitation – having to hold fingers on an area to prevent prolapse when on toilet
Bleeding or discharge
Dyspareunia or Apareunia – inability to have sex
Difficulty inserting tampons
Urinary symptoms e.g. frequency, urgency, incomplete bladder emptying
Constipation and difficulty defecation
High grade may result in ulceration, bleeding and discharge
How should a prolapse be investigated and examined?
Full gynae examination USS for pelvic masses Urodynamics if incontinence Assess pelvic floor strength Assessment for surgery
What should be considered when deciding whether to manage prolapses conservatively or with surgery?
Decision of which management to use should consider symptoms, age, parity, wish for further pregnancies and sexual activity.
Describe conservative management options for prolapse
If its not bothering them this is generally the best course of action
Weight loss and cessation of smoking
Treat underlying illnesses such as chronic cough and constipation
Pelvic floor exercises and physio
Pessaries to reduce prolapse – easy and effective with minimal side effects
Types of pessary: ring, shelf and cube and doughnut
Describe different surgical options for treating prolapse
• Anterior compartment defect – anterior repair (anterior colporrhaphy) usually for cysto-urethrocele or paravaginal repair (abdominal approach).
• Posterior compartment defect – posterior repair (posterior colporrhaphy) for rectocele or deficient perineum
• Uterovaginal prolapse
a. Hysterectomy
b. Sacrohysteropexy (If patient wishes to preserve uterus)
• Vaginal vault prolapse
a. Sacrospinous ligament fixation
b. Sacrocolpoplexy
What are the complications of prolapse surgery
Recurrent prolapse Haemorrhage and vault haematoma Vault infection DVT New incontinence Ureteric or bladder injury
Which nerves are involved in controlling continence?
S2, 3 and 4 – pudental nerve and parasympathetic controlling detrusor pressure and somatic nerves controlling the external sphincter
T12 – L2 – sympathetic controlling the internal sphincter
How does the level of the sphincters of the bladder effect continence?
Sphincters of the bladder normally lie above the pelvic floor and so are subject to intra-abdominal pressure however if they fall below this it can lead to incontinence.
