Prolapse of the uterus and vagina Flashcards
3 levels of pelvic supports
Uterus + vagina suspended from pelvic side walls by endopelvic fascial attachments that support the vagina at 3 levels
Level 1
- cervix + upper third vagina supported by cardinal (transverse cervical) and uterosacral ligaments
- attached to cervix and suspend uterus from the pelvic side wall and sacrum
Level 2
- mid-portion vagina attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls
Level 3
- lower-third vagina supported by levator ani muscle and perineal body in the perineum
- levator ani + associated fascia = pelvic diaphragm
Types of uterovaginal prolapse
Urethrocoele = prolapse of lower anterior vaginal wall, involving urethra only
Cystocoele = prolapsed of upper anterior vaginal wall, involving bladder, often associated with prolapse of urethra (cystourethrocoele)
Apical prolapse = prolapse of uterus, cervix, upper vagina
Enterocoele = prolapse of upper posterior wall of vagina → resulting pouch usually contains loops of small bowerl
Rectocoele = prolapse of the lower posterior wall of vagina, involving anterior wall of the rectum
Baden-Walker classification to grade prolapse
Female genital prolapse types summary
Urethrovaginal prolapse epidemiology
Half of all parous women have some degree of prolapse and 10–20% seek medical attention.
Causes of urethrovaginal prolapse
Vaginal delivery and pregnancy = parous, large infants, prolonged second stage, instrumental delivery
Congenital = Ehler-Danlos Syndrome (abnormal collagen metabolism)
Chronic predisposing factors = chronic increased intra-abdominal pressure (obesity, chronic cough, constipation, heavy lifting, pelvic mass)
Iarogenic = pelvic surgery (e.g. hysterectomy), continence procedures
Menopause
Clinical features of urethrovaginal prolapse
Hx
- sx often absent
- dragging sensation/lump sensation
- worse at end of day or when standing up
- back pain unusual
- severe prolapse = interferes with intercourse, ulcerate, bleeding, discharge
- cystourethrocoele = urinary frequency and incomplete bladder emptying, stress incontinence
- Rectocoele = asx but can cause difficulty defecating
- some women have to reduce prolapse with fingers to enable passing of urine or stool
Examination
- abdominal examination
- large prolapse visible from outside
- smaller prolapse requires speculum
- finger in butt (differentiate recto vs entero)
- mistaken for large polyps and vaginal cysts
- stress incontinence = prolapse temporarily reduced by asking patient to strain/cough
Ix
usually none (clinical ddx)
consider pelvic USS if pelvic mass suspected
Urodynamic testing if urinary incontinence is principal complaint
Vaginal prolapse (mx guide)
shelf pessary for major prolapse but cannot have penetrative sex
Genital prolapse at a glance
Genital prolapse at a glance
Urogenital prolapse: PassMed + QuesMed
n urogenital prolapse there is descent of one of the pelvic organs resulting in protrusion on the vaginal walls. It probably affects around 40% of postmenopausal women
Types
Anterior vaginal wall:
- Cystocele: bladder (may lead to stress incontinence)
Urethrocele: urethra
- Cystourethrocele: both bladder and urethra
Posterior vaginal wall:
- Enterocele: small intestine
- Rectocele: rectum
Apical vaginal wall
- Uterineprolapse: uterus
- Vaginal vault prolapse: roof of vagina (common after hysterectomy)
Risk factors
- increasing age
- multiparity, vaginal deliveries
- obesity
- spina bifida
Presentation
- sensation of pressure, heaviness, ‘bearing-down’
- urinary symptoms: incontinence, frequency, urgency
Management
- if asymptomatic and mild prolapse then no treatment needed
- conservative: weight loss, pelvic floor muscle exercises
- ring pessary
- surgery
Surgical options
- cystocele/cystourethrocele: anterior colporrhaphy, colposuspension
- uterine prolapse: hysterectomy, sacrohysteropexy
- rectocele: posterior colporrhaphy
