Structural abnormalities Flashcards
The most commonly involved organs in pelvic organ prolapse
bladder, vaginal vault, uterus, rectum, and intestines
Pelvic organ prolapse can be classified based on severity using
the Baden-Walker system into stages 0–4, with stage 4 the most severe
cystocele
the bladder prolapses through the anterior vaginal wall
sx cystocele
urinary incontinence or retention and a sensation of pelvic pressure or of the protrusion of tissue through the vagina
Patients often describe feeling as though something is falling out of their vagina
dyspareunia
pressure but not pain
dx cystocele
made clinically
complications cystocele
urinary retention, urinary tract infections, ulcerations, and vaginal bleeding
conservative therapy cystocele
weight loss in patients who are obese, reduction in straining (e.g., heavy weightlifting, chronic coughing, constipation), and Kegel exercises, which strengthen the pelvic floor muscles that provide support to the pelvic organs. Pessaries are another nonsurgical treatment option. They are removable devices that can be inserted into the vagina to provide support to the pelvic organs
when is surgical tx considered for cystocele
symptomatic patients who have not improved with conservative treatment or have declined conservative treatment
surgical options cystocele
reconstructive vs obliterative
reconstructive - performed more often. There are vaginal and abdominal approaches to pelvic organ prolapse surgery. Two common vaginal-approach repair techniques include uterosacral ligament suspension and sacrospinous ligament suspension. Women undergoing transvaginal apical suspension who require repair of anterior or posterior vaginal wall prolapse should have colporrhaphy performed. Cystoceles require anterior colporrhaphy. Hysterectomy is often performed at the time of apical prolapse repair because it reduces the risk of recurrence
obliterative - removing or closing off at least a portion of the vaginal canal. Patients who wish to have sexual intercourse should not have obliterative pelvic organ prolapse surgery. Obliterative surgeries have a low risk of recurrence or perioperative complications but eliminate the possibility of vaginal intercourse or evaluation of the cervix and uterus, such as during a Pap smear
if pts wish to have sexual intercourse after surgery for cystocele, which should they NOT have
obliterative
which surgery for cystocele is performed more often
reconstructive
What are the risk factors for pelvic organ prolapse?
Increased parity, advancing age, obesity, and increased intra-abdominal pressure
cystocele is often due to
pelvic floor injury during childbirth
common causes of cystocele
genetic predisposition, prior prolapse surgery, and connective tissue diseases (Ehlers danlos –> joint hyper mobility)
RF cystocele
pregnancy, vaginal delivery, advanced age, obesity, multiparity, menopause, and diabetes mellitus
in order to void with cystocele, what do pts commonly have to do
Patients usually will push up the bladder in order to void
PE cystocele
vaginal bulge, especially when examined in a standing position. Internal examination reveals anterior fullness of the vaginal wall
Transabdominal ultrasound cystocele
funnel-shaped bladder
Ovarian torsion
complete or partial rotation (twisting) of an ovary on its ligamentous support, which can lead to impaired blood flow to the ovary.
Adnexal torsion refers to the twisting of both the ovary and the fallopian tube
is ovarian/adnexal torsion a gynecologic emergency
yes
when does ovarian torsion MC occur
reproductive age women
the most important risk factor for ovarian torsion
the presence of an ovarian mass, particularly masses larger than 5 cm
sx ovarian torsion
acute onset of moderate or severe pelvic pain and the presence of an ovarian mass. Most patients have nausea and vomiting and do not have vaginal bleeding
causes ovarian torsion
ovarian cysts, ovarian malignancies, and polycystic ovary syndrome
strenuous exercise or acutely increased abdominal pressure
definitive diagnosis of ovarian torsion
direct visualization of a rotated ovary at the time of surgical intervention
what must you rule out for ovarian torsion
ectopic or regular pregnancy
what may occur due to necrosis of fallopian tube
leukocytosis
keep in mind that ovarian torsion rarely if ever causes hemorrhage – so hemoglobin should be fine
what is the best imaging study to assess for ovarian torsion
pelvic US
US findings ovarian torsion
affected ovary being enlarged and rounded relative to the unaffected ovary due to edema from vascular and lymphatic engorgement, ovarian masses, and decreased or absent flow within the ovary.
tx ovarian torsion
In premenopausal women, laparoscopy is used to detorse the ovary manually and attempt to conserve it. Ovarian cystectomy is performed if a benign mass is present. However, salpingo-oophorectomy is the recommended treatment in postmenopausal women
RF ovarian torsion
pregnancy and reproductive age
which ovary is MC affected in ovarian torsion
right
PE ovarian torsion
tachycardia or elevated blood pressure associated with severe pain. An abdominal and pelvic exam may be negative for palpable masses
may have low grade fever
what meds can be helpful in preventing ovarian cyst
high-dose estrogen oral contraceptives
Why is the right-sided ovary more likely to torse than the left?
Because the right utero-ovarian ligament is longer than the left and the sigmoid colon is on the left side, so the left ovary has less ability to move and twist
Rectocele
herniation of the terminal rectum into the posterior wall of the vagina, resulting in a collapsible pouch-like fullness that passes into the introitus
RF rectocele
vaginal birth, advancing age, multiparity, genetic disposition, obesity, elevated intra-abdominal pressure, frequent constipation, and use of laxatives
sx rectocele
vaginal fullness, introital bulging with concurrent fecal incontinence, constipation, low back pain, and dyspareunia.
Symptoms are exacerbated by standing or the Valsalva maneuver
dx rectocele
made clinically by the presence of a bulge in the posterior vaginal wall with concurrent symptoms, such as fecal incontinence in a woman with risk factors for rectocele
conservative tx rectocele
high-fiber diet, weight reduction, pessary, Kegel exercises, biofeedback, and electrical stimulation
surgical tx rectocele
posterior colporrhaphy and colpocleisis - if no response to conservative measures
What is the surgical repair of a cystocele called?
Anterior vaginal colporrhaphy
Uterine prolapse
the loss of the normal ligamentous support for the uterus, thereby resulting in the protrusion of the cervix toward or past the introitus
prolapse of the vaginal apex
MC RF uterine prolapse
childbirth and pregnancy
other RF uterine prolapse
aging, chronic cough, constipation, heavy lifting, genetic collagen deficiency, obesity, and previous pelvic surgery
vaginal delivery, menopause, obesity, and tobacco use
sx uterine prolapse
vaginal fullness or a mass, lower abdominal aching, low back pain, urinary incontinence, and sexual dysfunction
Symptoms are often worse after prolonged standing or at the end of the day and are relieved by lying down
as uterine prolapse progresses, women may report
sensation of sitting on a ball
PE uterine prolapse
soft, reducible mass that may be protruding through the introitus
stage 0 uterine prolapse
no prolapse
stage 1 uterine prolapse
the most distal portion of the prolapse is > 1 cm above the level of the hymen; prolapse further than 1 cm from the vaginal introitus
stage 2 uterine prolapse
the prolapse has descended near the introitus; prolapse ≤ 1 cm to the vaginal introitus
stage 3 uterine prolapse
partial protrusion through the introitus; prolapse outside the vaginal introitus but by no more than 1 cm
stage 4 uterine prolapse
complete protrusion through the introitus; prolapse ≥ 1 cm outside the vaginal introitus
conservative tx uterine prolapse
weight reduction, smoking cessation, Kegel exercises and use of a vaginal pessary
surgical tx uterine prolapse
vaginal hysterectomy with sacrospinous ligament suspension, and colpocleisis (An operation in which the vaginal walls are sewn together to fix vaginal vault prolapse in women who are no longer sexually active)
What is the name for the type of prolapse that involves the herniation of the anterior, posterior, and apical compartments simultaneously?
Procidentia
The rate of recurrence of symptoms or the need for repeat surgery for pelvic organ prolapse
30%
uterine prolapse is also known as
uterine procidentia
what is the current standard for staging of pelvic organ prolapse
The Pelvic Organ Prolapse Quantification system
Which ligaments support the uterus and attach the cervix to the posterior surface of the pubic symphysis?
pubocervical ligaments
What is the most commonly encountered form of pelvic organ prolapse?
cystocele
