Structural Abnormalities

Question 1

cystocele etiology, RF, and sxs

Answer 1

• anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus
• pelvic floor injury during childbirth
• RF: genetics, prior prolapse surgery, connective tissue dz, pregnancy, vaginal delivery, parity, advanced age, obesity, menopause, DM, race
• sxs: vaginal bulge or fullness, pressure, heaviness, worse with valsalva
  
  • concurrent urinary incontinence
  • incomplete emptying (retention, straining to void (obstruction)
• examine in lithotomy position and standing
• pt must push up bladder in order to void

Question 2

cystocele dx and tx

Answer 2

• Dx: POP-Q (pelvic organ prolapse quantification), US or MRI, Q-tip test, voiding cystourethrogram, cystometrogram
• tx: pessary, anterior vaginal colporrhaphy, tension-free vaginal tape procedure
• prophylaxis: kegel exercises (strengthen levator ani and perianal mm.), estrogen tx after menopause

Question 3

uterine prolapse etiology, RF, sxs

Answer 3

• etiology: loss of normal ligamentous support (cervix protrudes from introitus), risk increases postmen.
• RF: older, multigravid, any condition that increases intra-abdominal pressure (obesity, chronic cough, constipation, repetative lifting)
• sxs: vaginal fullness or mass (worse after long standing, late in the day)
  
  • lower abdominal aching, low back pain, urinary incontinence, “sitting on a ball”
  • soft, reducible mass on pelvic exam (examine in both lithotomy and standing)
• complications: chronic decubitus ulceration of vaginal epithelium in procidentia

Question 4

uterine prolapse dx and tx

Answer 4

• dx: POP-Q (pelvic organ prolapse quantification), Q-tip test, cystourethroscopy, cystometrogram, anoscopy, colonoscopy, anal manometry, or transanal US
• tx: conservative management (weight reduction, smoking cessation, kegels), vaginal pessary (best for older, postmenopausal women), vaginal hysterectomy with sacrospinous ligament suspension (for severe prolapse), colpocleisis (vagina is surgically obliterated)
• Most accompanied by cystocele, rectocele, or enterocele

Question 5

rectocele etiology, RF, sxs

Answer 5

• etiology: prolapse of posterior vaginal wall and rectum
• RF: pelvic floor injury during childbirth
• sxs: prolonged, excessive use of laxatives or frequent enemas (constipation)
  
  • introital bulging, concurrent fecal incontinence, constipation, low back pain, dyspareunia
  • left decubitus position for detection
• complications: hemorrhoids

Question 6

rectocele dx, tx

Answer 6

• dx: POP-Q (pelvic organ prolapse quantification), anal manometry, transanal US, MRI, colonoscopy, defocography, EMG
• tx: nonsurgical (use of meds: laxatives, EST), posterior colporrhaphy (repair of posterior fascial defects), colpocleisis (closure) or colpectomy (removal) of the vagina if not sexually active

Question 7

ovarian torsion

Answer 7

• associated with ovarian cysts or neoplasm (torsion of normal ovaries is common in children)
• sxs: sudden onset of unilateral lower quadrant pain, nausea, TTP
• dx: WBC normal, B-hCG negative, US (ovarian mass, free fluid in the pelvis), +/- doppler US to check blood flow to ovaries
• tx: rapid surgical exploration