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Obstetrics and Gynaecology > Prolapse of the uterus and vagina > Flashcards

Prolapse of the uterus and vagina Flashcards

1
Q

What is a prolapse?

A

Decent of the uterus and/or vaginal walls beyond normal anatomical confines

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2
Q

Why does a prolapse occur?

A

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.

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3
Q

Is prolapse common?

A

It is extremely common and is present to variable degrees in most older porous women.

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4
Q

How are the types of prolapse classified?

A

Anatomically according to the site of the defect and the pelvic viscera that are involved

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5
Q

What is a urethrocoele?

A

A prolapse of the lower anterior vaginal wall, involving the urethra only.

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6
Q

What is a cystocoele?

A

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.

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7
Q

What is an apical prolapse?

A

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

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8
Q

What is an enterocoele?

A

Prolapse of the upper posterior wall of the vagina. The resulting pouch usually contains loops of small bowel

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9
Q

What is a rectocoele?

A

Prolapse of the lower posterior wall of the vagina, involving the anterior wall of the rectum

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10
Q

What grading system is used to grade prolapses?

A

There are many but the pelvic organ prolapse (POP) scoring system of the international continence society (ICS) is widely used

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11
Q

What examination conditions need to be stated when examining a prolapse?

A

Position of the patient, at rest or straining and whether traction is employed

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12
Q

What is a grade 0 prolapse in the ICS POP scoring system?

A

No descent of pelvic organs during straining

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13
Q

What is a grade 1 prolapse in the ICS POP scoring system?

A

Leading surface of prolapse does not descend below 1cm above the hymenal ring

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14
Q

What is a grade 2 prolapse in the ICS POP scoring system?

A

Leading edge of prolapse extends from 1cm above to 1cm below the hymenal ring

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15
Q

What is a grade 3 prolapse in the ICS POP scoring system?

A

Prolapse extends 1cm or more below the hymenal ring but without complete vaginal eversion

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16
Q

What is a grade 4 prolapse in the ICS POP scoring system?

A

Vagina completely everted (complete procidentia)

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17
Q

What are the causes of a prolapse?

A

Vaginal delivery and pregnancy; congenital factors eg Ehler-Danlos syndrome; menopause; chronic increase in intra-abdominal pressure eg obesity, chronic cough, constipation, heavy lifting or pelvic mass

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18
Q

How does a vaginal delivery cause a prolapse?

A

Due to mechanical injuries and denervation of the pelvic floor, which contribute to subsequent prolapse.

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19
Q

What are the increased risks associated with a vaginal delivery that causes a prolapse?

A

Large infants, prolonged second stage and instrumental delivery

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20
Q

What congenital factors can increase the risk of a prolapse?

A

Abnormal collagen metabolism e.g. Ehlers-Danlos syndrome.

21
Q

How does menopause increase the risk of a prolapse?

A

It is thought to be due to the deterioration of collagenous connective tissue that occurs following oestrogen withdrawal.

22
Q

What chronic predisposing factors increase the risk of a prolapse?

A

Prolapse is aggravated by any chronic increase in intra-abdominal pressure, resulting factors such as obesity, chronic cough, constipation, heavy lifting or pelvic mass

23
Q

What iatrogenic factors increase the risk of a prolapse?

A

Pelvic surgery may also influence the occurrence of urogenital prolapse, for example hysterectomy or continence procedures

24
Q

What are the signs and symptoms of a prolapse?

A

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.

25
Q

What are some additional signs and symptoms of a severe prolapse?

A

It can interfere with intercourse, may ulcerate and cause bleeding or discharge.

26
Q

What are the symptoms specific to a cystourethrocoele?

A

Urinary frequency and incomplete bladder emptying.

27
Q

What should you ask the patient to do when examining a prolapse?

A

Sometimes they are visible exteriorly, but ask the patient to bear down to demonstrate prolapse.

28
Q

How can you tell the difference between a rectocoele and a enterocoele on examination?

A

A finger in the rectum will be seen to bulge into a rectocoele but not into a enterocoele, which does not contain rectum.

29
Q

What investigations would you do for a prolapse?

A

To look for a cause you would do a pelvic ultrasound

30
Q

How can you prevent a prolapse?

A

Prevention involves recognition of obstructed labour and the avoidance of an excessively long second stage. Pelvic floor exercises after childbirth are encouraged

31
Q

What is the aim of prolapse management?

A

Treatment must be to alleviate symptoms and small prolapses often require no treatment. This can be done with pessaries

32
Q

When are pessaries used?

A

In the women who are unwilling or unfit for surgery

33
Q

What are pessaries?

A

They act like an artificial pelvic floor, placed in the vagina to stay behind the symphysis pubis and in the front of the sacrum.

34
Q

What is the most common type of pessary used?

A

The most commonly used is the ring pessary, but the shelf pessary is more effective in severe forms of prolapse

35
Q

How often are pessaries changed?

A

They are changed every 6-9 months

36
Q

Is there any additional treatment that may be needed with a pessary?

A

Postmenopausal women may require oestrogen replacement, either topical oestrogen or as standard HRT, to prevent ulceration

37
Q

What are the negatives of a pessary?

A

Occasionally, they can cause pain, urinary retention of infection, or fall out

38
Q

What are the two surgical options for a uterine prolapse?

A

Vaginal hysterectomy with or without vaginal sacrospinous fixation
Vaginal sacrospinous hysteropexy
Manchester repair

39
Q

What are the negatives about a vaginal hysterectomy for a uterine prolapse?

A

Alone, it often fails to address the underlying deficiencies in pelvic support that cause uterovaginal prolapse.

40
Q

What is a hysteropexy?

A

The uterus and the cervix are attached to the sacrum using a bifurcated non-absorbable mesh.

41
Q

Why is a hysteropexy effective?

A

Because it restores the length of the vagina without compromising calibre

42
Q

What is the two surgical treatment options for a vaginal vault prolapse?

A

Vaginal sacrospinous fixation

Sacrocolpepxy

43
Q

What is a sacrocolpepxy?

A

Fixes the vault to the sacrum using a mesh.

44
Q

What are the complications of a sacrocolpopexy?

A

Mesh erosion and haemorrhage

45
Q

What is a sacrospinus fixation?

A

It is performed vaginally and suspends the vault to the sacrospinus ligament

46
Q

What are the complications of a sacrospinus fixation?

A

Nerve or vessel injury, infection and buttock pain.

47
Q

What are the comparisons between a sacrocolpopexy and a sacrospinus fixation?

A

A sacrospinus fixation is less effective but recovery is faster

48
Q

What is the surgical treatment of a vaginal wall prolapse?

A

Anterior wall: anterior repair without mesh

Posterior wall: posterior vaginal repair without mesh

Obstetrics and Gynaecology (27 decks)

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