Urogenital Prolapse Flashcards
Definition of urogenital prolapse
Descent of uterus and/or vaginal walls beyond normal anatomical confines. Genitourinary prolapse occurs when the normal support structures for organs inside the woman’s pelvis (uterus, bladder and lower bowel/rectum) are weakened and no longer effective.
Incidence of urogenital prolapse
Effects around 40% of postmenopausal women. In primary care in the UK, 8.4% of women reported vaginal bulge or lump, on examination prolapse is present in up to 50% of women. 1 in 10 women need a surgical procedure and re-operation rate is 19%
What are the three levator ani muscles, what is their function
Levator ani muscles: puborectalis, pubococcygeus, iliococcygeus
* The levator ani forms a bowl-shaped muscle filling the pelvic outlet and supporting the pelvic organs- the urogenital hiatus allows the passage of urethra, vagina and rectum
What are the THREE layers of supporting ligaments (and fascia) which support the uterus, vagina, other organs
- Level 1 (apical support by uterosacral ligaments)- attach the cervix to the sacrum- this is important in support the vaginal walls. DEFECTS in level 1 can lead descent of the uterus within the vagina (must be reattached during hysterectomy)
- Level 2 (vaginal fascia)- Provided by the anterior, posterior, pubocervical or rectovaginal fascia- results in the vagina lying flat at rest. DEFECTS in level 2 result in prolapse of the vaginal wall into the vaginal lumen (anterior or posterior vaginal prolapse)
- Level 3 (perineal body)- Provided by the fascia of the posterior vagina (attached to the caudal end of the perineal body.) Perineal body is the mass of tissue that is torn or cut during childbirth. Point of attachment for the posterior vaginal fascia, fibres of the levator ani and transverse perineal muscles. DEFECTS of the perineal body cause development of lower posterior wall prolapse (also predisposes anterior prolapse since vaginal opening will be bigger)
Classification of urogenital prolapse
- Urethrocele- Prolapse of lower anterior vaginal wall, involving the urethra only
- Cystocoele- Prolapse of the upper anterior part of the vaginal wall, involving the bladder (cystourethrocele is the associated prolapse of the urethra)
- Apical prolapse- Prolapse of the uterus, cervix and upper vagina (or vault if uterus is removed)
- Enterocoele- Prolapse of the upper posterior wall of the vagina whereby pouch usually contains small loops of bowel
- Rectocele- Prolapse of the lower posterior wall of the vagina and involves anterior wall of the rectum
Staging of pelvic organ prolapse
Pelvic organ prolapse- Quantification (POP-Q)
Staging of pelvic organ prolapse
Pelvic organ prolapse- Quantification (POP-Q)
Risk factors for pelvic organ prolapse
Childbirth, ageing, post-menopausal, following pelvic surgery, increased abdominal pressure, congenital, ethnicity
- Vaginal delivery and pregnancy: Prolapse is uncommon in nulliparous women. Vaginal delivery leads to mechanical injuries and denervation of the pelvic floor. Risk is increased with foetal macrosomia, prolonged second stage and instrumental delivery
- Congenital factors- abnormal collagen metabolism e.g Ehlers-Danlos
- Menopause- leads to deterioration of connective tissue after oestrogen withdrawal
- Chronic predisposing factors: Obesity, chronic cough, constipation, heavy lifting, pelvic mass
- Iatrogenic factors: Pelvic surgery (hysterectomy), continence procedures (colposuspension may predispose to rectocele and enterocele formation)
Presentation of urogenital prolapse
- May be asymptomatic
- Dragging sensation, sensation of a lump
- Worst at the end of the day or when standing up. Severe prolapse may interfere with intercourse. May also ulcerate and cause bleeding and discharge
- Cystourethrocele- may present with urinary frequency and incomplete bladder emptying
- Rectocele- commonly asymptomatic, occasionally difficulty defaecating
- Stress incontinence is commonly concomitant
- Some women will have to reduce prolapse with their fingers to enable passing of urine or stool
OE (Requires abdominal examination and bimanual (exclude masses):
* Ask patient to ‘bear down’ to demonstrate prolapse
* Finger placed into the rectum will bulge into a rectocele but NOT an enterocele (may otherwise be confused)
* Large prolapse will be visible from the outside
* Sim’s speculum- allows separate inspection of anterior and posterior walls
Investigations for urogenital prolapse
Perform a history and examination (sims speculum) to:
* Assess and record the presence and degree of prolapse of the anterior, central and posterior vaginal compartments of the pelvic floor, using the POP-Q system
* Assess the activity of the pelvic floor muscles
* Assess for vaginal atrophy
* Rule out a pelvic mass or other pathology
Do not routinely perform imaging if prolapse is detected on physical examination
Can consider: Urodynamic assessment and functional test of lower bowel- Endoanal ultrasound, Rectal manometry, Flexible sigmoidoscopy, Defecating proctogram
What needs to be taken into account when determining the management of urogenital prolapse
The woman’s preferences, site of prolapse, lifestyle factors, comorbidities including physical or cognitive impairment, age, desire for childbearing
What lifestyle advice should be given to women with urogenital prolapse
- Losing weight if the woman has a BMI greater than 30kg/m2
- Minimising heavy lifting
- Preventing or treating constipation
Management of urogenital prolapse
- Consider vaginal oestrogen for women with prolapse and signs of vaginal atrophy (consider an oestrogen-releasing ring if they have physical or cognitive impairment)
- Consider a vaginal pessary alone or in conjunction with pelvic floor muscle training:
- Offer women using pessaries an appointment in a pessary clinic every 6 months
- Sex is NOT POSSIBLE with a shelf-pessary. Other side-effects include unpleasant discharge, irritation, UTI
- Offer surgical intervention for women whose symptoms have not improved or who have declined non-surgical treatment (do not offer surgery to prevent incontinence in women without incontinence)
Surgical management of urogenital prolapse
Uterine prolapse:
* Vaginal hysterectomy, with or without sacrospinous fixation (of remaining vaginal vault) with sutures: 65% rate of reduction in symptoms. Will need to stay in hospital for 1-2 days
* Vaginal sacrospinous hysteropexy with sutures: 55% improval rate
* Manchester repair (also called the Fothergill operation- shortening of the cervix to support the uterus).
* Sacro-hysteropexy with mesh: stay in hospital for 1 or 2 days after keyhole surgery or 2 to 3 days after open surgery
Vaginal vault prolapse:
* Vaginal sacrospinous fixation with sutures
* Sacrocolpopexy with mesh.
What is a colposleisis
offered if the woman does not intend to have penetrative sex or they are at high surgical risk (the procedure involves closure of the vagina)
