Prolapse of the uterus and vagina Flashcards
What is a prolapse?
Decent of the uterus and/or vaginal walls beyond normal anatomical confines
Why does a prolapse occur?
As a result of weakness in the supporting structures. Behind the vaginal walls, the bladder, urethra, rectum and small bowel descend and produce a form of herniation.
Is prolapse common?
It is extremely common and is present to variable degrees in most older porous women.
How are the types of prolapse classified?
Anatomically according to the site of the defect and the pelvic viscera that are involved
What is a urethrocoele?
A prolapse of the lower anterior vaginal wall, involving the urethra only.
What is a cystocoele?
A prolapse of the upper anterior vaginal wall, involving the bladder. Often there is an associated prolapse of the urethra, in which case the term cystourethrocoele is used.
What is an apical prolapse?
Prolapse of the uterus, cervix and upper vagina. If the uterus has been removed, the vault or top of the vagina, where the uterus used to be, can itself prolapse
What is an enterocoele?
Prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel
What is a rectocoele?
Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum
What grading system is used to grade prolapses?
There are many but the pelvic organ prolapse (POP) scoring system of the international continence society (ICS) is widely used
What examination conditions need to be stated when examining a prolapse?
Position of the patient, at rest or straining and whether traction is employed
What is a grade 0 prolapse in the ICS POP scoring system?
No descent of pelvic organs during straining
What is a grade 1 prolapse in the ICS POP scoring system?
Leading surface of prolapse does not descend below 1cm above the hymenal ring
What is a grade 2 prolapse in the ICS POP scoring system?
Leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring
What is a grade 3 prolapse in the ICS POP scoring system?
Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion
What is a grade 4 prolapse in the ICS POP scoring system?
Vagina completely everted (complete procidentia)
What are the causes of a prolapse?
Vaginal delivery and pregnancy; congenital factors; menopause; chronic predisposing factors; iatrogenic factors
How does a vaginal delivery cause a prolapse?
Due to mechanical injuries and denervation of the pelvic floor, which contribute to subsequent prolapse.
What are the increased risks associated with a vaginal delivery that causes a prolapse?
Large infants, prolonged second stage and instrumental delivery
What congenital factors can increase the risk of a prolapse?
Abnormal collagen metabolism e.g. Ehlers-Danlos syndrome.
How does menopause increase the risk of a prolapse?
It is thought to be due to the deterioration of collagenous connective tissue that occurs following oestrogen withdrawal.
What chronic predisposing factors increase the risk of a prolapse?
Prolapse is aggravated by any chronic increase in intra-abdominal pressure, resulting factors such as obesity, chronic cough, constipation, heavy lifting or pelvic mass
What iatrogenic factors increase the risk of a prolapse?
Pelvic surgery may also influence the occurrence of urogenital prolapse, for example hysterectomy or continence procedures
What are the signs and symptoms of a prolapse?
Symptoms are often absent, but a dragging sensation or the sensation of a lump are common, usually worse at the end of the day or when standing.
What are some additional signs and symptoms of a severe prolapse?
It can interfere with intercourse, may ulcerate and cause bleeding or discharge.
What are the symptoms specific to a cystourethrocoele?
Urinary frequency and incomplete bladder emptying.
What should you ask the patient to do when examining a prolapse?
Sometimes they are visible exteriorly, but ask the patient to bear down to demonstrate prolapse.
How can you tell the difference between a rectocoele and a enterocoele on examination?
A finger in the rectum will be seen to bulge into a rectocoele but not into a enterocoele, which does not contain rectum.
What investigations would you do for a prolapse?
To look for a cause you would do a pelvic ultrasound
How can you prevent a prolapse?
Prevention involves recognition of obstructed labour and the avoidance of an excessively long second stage. Pelvic floor exercises after childbirth are encouraged
What is the aim of prolapse management?
Treatment must be to alleviate symptoms and small prolapses often require no treatment. This can be done with pessaries
When are pessaries used?
In the women who are unwilling or unfit for surgery
What are pessaries?
They act like an artificial pelvic floor, placed in the vagina to stay behind the symphysis pubis and in the front of the sacrum.
What is the most common type of pessary used?
The most commonly used is the ring pessary, but the shelf pessary is more effective in severe forms of prolapse
How often are pessaries changed?
They are changed every 6-9 months
Is there any additional treatment that may be needed with a pessary?
Postmenopausal women may require oestrogen replacement, either topical oestrogen or as standard HRT, to prevent ulceration
What are the negatives of a pessary?
Occasionally, they can cause pain, urinary retention of infection, or fall out
What are the two surgical options for a uterine prolapse?
A vaginal hysterectomy or a hysteropexy (better)
What are the negatives about a vaginal hysterectomy for a uterine prolapse?
Alone, it often fails to address the underlying deficiencies in pelvic support that cause uterovaginal prolapse.
What is a hysteropexy?
The uterus and the cervix are attached to the sacrum using a bifurcated non-absorbable mesh.
Why is a hysteropexy effective?
Because it restores the length of the vagina without compromising calibre
What is the two surgical treatment options for a vaginal vault prolapse?
Sacrocolpepxy or sacrospinus fixation
What is a sacrocolpepxy?
Fixes the vault to the sacrum using a mesh.
What are the complications of a sacrocolpepxy?
Mesh erosion and haemorrhage
What is a sacrospinus fixation?
It is performed vaginally and suspends the vault to the sacrospinus ligament
What are the complications of a sacrospinus fixation?
Nerve or vessel injury, infection and buttock pain.
What are the comparisons between a sacrocopepcy and a sacrospinus fixation?
A sacrospinus fixation is less effective but recovery is faster
What is the surgical treatment of a vaginal wall prolapse?
Anterior and posterior repairs are used for the relevant prolapse but, as several prolapses may occur in one patient, these operations are often combined
