Urogynae Flashcards
Incidence of prolapse
Difficult to estimate prevalence and incidence accurately
1 in 10 (9%) women affected
Lifetime risk of requiring an operation for prolapse or incontinence is 11-19%
7% for POP (RANZCOG)
29% reoperation rate
2/3 in same compartment
Risk factors for POP
Age - (double risk for every decade)
Parity and vaginal delivery - 50% incidence in parous c.f. 2% in nulliparous. Vaginal tears (including episiotomy) are associated with increased risk.
Obesity
Chronic increased intra-abdominal pressure (cough, weight lifting, constipation, occupation)
FHx and genetic risk
Genetic connective tissue disorders
Previous gynae surgery
- Hysterectomy - Recent review suggests that hysterectomy for benign conditions other than prolapse does not seem to be a risk factor for POP
- Sacrospinous fixation and sacrocolpopexy - increased risk of anterior vaginal wall prolapse
- Colposuspension - increased risk of enterocele
What levels of anatomical support of the vagina
Level 1 = Suspension
Uterosacral and cardinal ligaments
Apex or upper third of the vagina
Level 2 = Attachment
Lateral attachment of the vagina in its middle third. Connective tissue which is part of the endopelvic fascia
Level 3 = Fusion
The lower third of the vagina is supported by the fusion of the vaginal endopelvic fascia to the urogenital diaphragm and the perineal body
What use a system like POP-Q?
Used to quantify, describe and stage pelvic support
A standardised means of documenting, comparing and communicating clinical findings with proven inter-observer and intra-observer reliability
For research and audit
To compare post-op
Describe the POP-Q
Aa = anterior vaginal wall 3cm proximal to the external urethral meatus (-3cm to +3cm) Ba = most distal position of the remaining upper anterior vaginal wall (-3cm to + tvl) C = Most distal edge of cervix or vaginal cuff scar (-10cm to +10cm) D = Posterior fornix (n/a if post-hysterectomy) Ap = Posterior vaginal wall 3cm proximal to the hymen (-3cm to +3cm) Bp = Most distal position of the remaining upper posterior vaginal wall (-3cm to + tvl)
gh = Genital hiatus - measured from middle of external urethral meatus to posterior hymen ph = Perineal body - measured from posterior margin to gh to middle of anal opening tvl = Total vaginal length - depth of vagina when point D or C is reduced to normal position
POP-Q staging system
Stage 0 = no prolapse
Aa, Ba, Ap, Bp = -3cm, and C (if post hysterectomy) or D (pre-hysterectomy) equals or nearly equals TVL (- TVL to - (TVL - 2) cm)
Stage I = stage 0 criteria not met and leading edge < -1cm
Stage II = Leading edge > -1cm but < +1cm
Stage III = Leading edge > +1cm but < +(TVL - 2) cm
Stage IV = Leading edge > + (TVL - 2) cm
Eversion of the total length of the vagina
Prevention of POP
Avoidance of increased intra-abdominal pressure may help (no studies to demonstrate a protective effect)
Avoid constipation
Effectively manage chronic chest pathology
Smoking cessation
Antenatal perineal massage, hot packs during second stage - reduce tears, no evidence that reduce POP incidence
No evidence that PFMT presents the development or worsening of POP
McCall’s culdoplasty - done during vaginal hysterectomy
Prophylactic sacrospinous fixation is unnecessary, unless there is marked uterovaginal prolapse making the uterosacral ligaments too weak to provide any support
What is McCall’s culdoplasty
Done during vaginal hysterectomy to prevent subsequent vault prolapse
Obliteration of the posterior cul de sac by a series of sutures from the uterosacral ligament on one side the uterosacral ligament on the other side
Need to reach the highest point of the sac so ensure complete obliteration
Uterosacral ligaments approximated in the midline and fixed to the vault
Also helps maintain vaginal length
Management of POP
Do nothing
Lifestyle advice (wt loss if BMI >30, minimise heavy lifting, preventing or treating constipation)
Topical oestrogen (if atrophy or using pessary)
PT
Pessary
Physiotherapy for POP
Consider supervised PFMT for >16 weeks as a first option for women with symptomatic POP-Q stage 1 or 2 POP
PFMT vs. no active treatment
- Reduces pelvic floor symptoms and specific prolapse symptoms, e.g. bulge
- Does not reduce prolapse severity based on POP-Q
Cochrane
- benefit to 6/12 of supervised exercised, no long term data
- no enough evidence for PFMT as an adjunct to surgery
PT associated with significant improvement in prolapse symptoms
Pessaries
Stretch the vagina wider than the genital hiatus through the pelvic floor –> stay above the level of the pelvic floor
Limited evidence to recommend one type over another
Work best for apical and anterior prolapse
Studies found at 6y only 14% continuing to use
Widened genital hiatus >6cm then likely pessary will fall out
Problems with pessary use
Discuss limitations of sex life and complications
Difficult removal and insertion Neglected pessary - Can erode into the vagina is left too long - Urinary or bowel fistulae - Can become impacted and therefore difficult to remove Vaginal ulceration Urinary retention Infection Bleeding Vaginal discharge Pain and constipation Change of size and/or type of pessary Resort to surgery
Counselling around POP surgery
Goals
- Restore anatomy and relieve symptoms
- Maintain or restore bowel and/or bladder function
- Maintain vaginal length and capacity for sexual function
Discuss above
Do not offer surgery to prevent incontinence in women having surgery for prolapse who do not have incontinence
Risk of post-op urinary incontinence in those having anterior or middle compartment prolapse repair
Up to 29% of women will require an additional operation following primary prolapse surgery
Post-op advice
Avoid heavy lifting, strenuous exercises, prolonged straining etc. for 3 months
Sex can be resumed at 6 weeks
Surgery for recurrent prolapse
Recurrence can be contributed to by:
- Poor surgical technique
- Genetic predisposition to POP
- Continued unhealthy lifestyle - straining, obesity
Direct recurrence = at site of previous surgery
Indirect recurrence = no previous surgery was carried out there
Management
- Pessary
- Surgery - Risk of failure increases with repeat surgery, can be more challenging because of distorted planes, mesh has been suggested but awaits more robust evidence
Complications of anterior repair
Bleeding - Infiltration with LA + vasoconstrictive agent to limit Bladder or urethral injury - Can cause fistula if not detected at time Infection - Wound, UTI Initial voiding dysfunction Occult stress UI may be unmasked Failure and recurrence of prolapse
Steps of anterior repair
DVT prophylaxis, IV antibiotics, prep and drape
Submucosal infiltration of local anaesthetic
Midline incision in vaginal epithelium
Bladder is dissected off the overlying vaginal skin using sharp and blunt dissection - in avascular plane
Vesico-vaginal fascia is plicated in the midline using delayed absorable sutures - interrupted sutures or purse-string
Close the vagina with vicryl 2/0
Cystoscopy to ensure ureteric patency and no intravesical sutures
Insert:
- IDC
- Vaginal pack 12-24h
Success rates up to 100% reported
Recurrence rates up to 43% reported
Steps of posterior repair
DVT prophylaxis, IV antibiotics, prep and drape
Submucosal infiltration of local anaesthetic
Midline incision in vaginal epithelium
Rectum is dissected off the overlying vaginal skin using sharp and blunt dissection - in avascular plane
Rectovaginal fascia is plicated using 2/0 vicryl or PDS sutures
Close the vagina with vicryl 2/0
Commonly performed with a perineorrhaphy
- perineal muscles may need to be approximated from each side of rebuild the perineal body
- Perineum sutured with subcut 3/0 vicryl rapide
Do PR to check no sutures placed into the rectum
IDC +/- pack
Vaginal hysterectomy steps
Grasp cervix (with Vulsellum)
Infiltration with LA + vasoconstrictive agent
Circumferential incision made around the cervix
Continue reflection posterior, opening the Pouch of Douglas between the cut uterosacral ligaments
- Can use blunt dissection to reflect
Sims speculum inserted posteriorly though the peritoneum to guard rectum
Can use finger posteriorly and around uterus to identify anatomy and open vesico-uterine peritoneal reflection
Standard 3 pedicle hysterectomy
- Uterosacral and cardinal ligaments are clamped, divided and ligatured.
- Followed by the uterine vessels
- Finally the tubo-ovarian and round ligaments
Culdoplasty then performed
- Sutures tied in the midline and brought through the posterior part of the vault, to be tied after closing the vault
Peritoneum is closed keeping all pedicles extraperitoneal
If anterior repair required, carry out now
Close vault
Culdoplasty sutures then tied
If posterior repair required and planned, carry out at the end along with sacrospinous fixation if appropriate
SACROSPINOUS HYSTEROPEXY
Entails sacrospinous fixation of the back of the cervix and uterosacral ligaments using permanent sutures (usually ethibond)
2 permanent, or slowly absorbable, sutures are passed through the right sacrospinous ligament, 2cm medial to the ischial spine, using Miya hook or similar
PR needed to exclude rectal perforation
Approaches - vaginal, or abdominal
Bleeding
- Haematoma can develop in rectovaginal space or ischiorectal fossa
Occult SUI might be unmasked
Right buttock pain
- 1 in 20 patients
- Usually subsides within 3 months with the absorption of PDS
Comparison with vaginal hysterectomy
- No significant difference in outcome
- Significant reduction in blood loss and operating time
Need for repeat surgery for recurrent POP is low
MANCHESTER REPAIR
No longer used
Attempted to preserve fertility in patient’s with POP
Cervical amputation followed by approximating and shortening the cardinal ligaments anterior to the cervical stump and elevating the uterus
SACROHYSTEROPEXY
Attach the back of the cervix to the sacral promontory using a piece of prolene mesh
Peritoneum over sacral promontory is opened to reach the anterior longitudinal ligament
Prolene mesh is attached to the posterior aspect of the cervix with permanent sutures secured at the level of insertion of the uterosacral ligaments
Mesh then attached to the anterior aspect of the sacral promontory with permanent suture or screw tacks
Sacrocolpopexy - vaginal vault is attached to the sacral promontory using mesh
Abdominal or laparoscopic approach
Low recurrence rate
Use of mesh is associated with potential risk of mesh erosion and infection
Prevention of post-hysterectomy vault prolapse
12% of hysterectomies performed for POP will have vault prolapse (c.f. 2% for other indications)
McCall culdoplasty at the time of vaginal hysterectomy is effective in preventing subsequent PHVP
Suturing the cardinal and uterosacral ligaments to the vaginal cuff is effective in preventing PHVP following both abdominal and vaginal hysterectomies
SSF at the time of vaginal hysterectomy should be considered when the vault descends to the introitus during closure
ABOUT SACROSPINOUS FIXATION
Aims to fix the vaginal vault to the right sacrospinous ligament
- Maintains horizontal position of the upper vagina on standing
- Avoid rectosigmoid on the left
Long term success rates >90%
Recurrence rate of vault prolapse - 5-7% reported
Risk of anterior vaginal wall prolapse
- Because of exaggerated retroversion
Associated with dyspareunia
- Best avoided in women who are sexually active
Right buttock pain - 1 in 20 women, usually subsides within 3 months with absorption of PDS
Bleeding from pudendal vessels will require suturing and may require laparotomy to ligate the internal iliac artery
Surgical steps of sacrospinous fixation
If doing pelvic floor repair:
- Do before anterior repair
- Do after posterior repair
Submucosal infiltration
Vaginal incision with sharp dissection in the vascular plane between the rectum and vaginal mucosa
Adequate mobilisation of rectovaginal fascia from the vaginal epithelium with attention to haemostasis
Enter the rectovaginal space and pararectal fossa
Dissection taken up to the level of the ischial spine (uni or bilaterally)
Palpate right sacrospinous ligament
Sutures (PDS) passed through the ligament using appropriate technique and instrumentation, to prevent neurovascular injury - Suture should be passed 2cm medial to the ischial spine to avoid injury to the pudendal nerve and vessels as they curve around the ischial spine. Encircling the full thickness of the ligament is avoided
Haemostasis
Retrovaginal plication of fascia
Close vagina
PR exam to exclude rectal perforation
SACROCOLPOPEXY
Support vaginal vault by fixing it to the sacral promontory using a piece of mesh (or rectus sheath fascia)
Can perform abdominally or laparoscopically
Division of adhesions and handling of tissue as may be required
Traction and counter traction techniques by use of vaginal probes and forceps to facilitate dissection of peritoneum and bladder from vaginal vault with attention to tissue planes, integrity of bladder and haemostasis
Retroperitoneal dissection from the vaginal vault to sacral promontory between the large bowel and right ureter to allow clear exposure of sacral promontory and retroperitoneal space
Mesh is attached over the vagina and retroperitoneally to sacral promontory
- Tension free fashion
Closure of peritoneum from sacrum to vaginal vault
Cystoscopy to exclude bladder or ureteric injury
PR to exclude rectal injury
Haemostasis and closure
Outcomes of sacrocolpopexy
Bleeding
- Especially from the pre-sacral venous plexus and sacral artery
Injury to the right ureter and sigmoid colon
Infection
Mesh erosion and infection (rare, decreased erosion rates <3% compared to vaginal mesh surgery)
Gold standard for post-hysterectomy vaginal vault prolapse
Success rates from 93-100% reported
Backward displacement of the vagina exposes the anterior vaginal wall to increased intra-abdominal pressure
Sacrocolpopexy vs. SSF
Good long term results
Procedure of choice in younger, sexually active patients
Significantly lower rates of recurrent vault prolapse, dyspareunia and post-op SUI. This is not reflected in significantly lower reoperation rates or higher patient satisfaction.
SSF - Earlier recovery, cheaper, quicker. Increased dyspareunia
COLPOCLEISIS
Obliterate the vagina either partially or totally Precludes sexual activity Can perform under LA Usually reserved for frail Direct recurrence 3% Need endometrial sampling prior
Mesh erosion
- incidence
- symptoms
1-2% of midurethral slings
10-12% of operations where TVM is used for prolapse
In some cases, erosion is asymptomatic
May cause bleeding, discomfort, awareness by either or both partners during sex
Tender or exposed area may be treated with Ovestin, or require minor procedure to relieve symptoms
Evidence for mesh
Posterior and apical compartment - No evidence to support use of mesh
Anterior compartment - polypropylene mesh anterior vaginal wall repair associated with significantly improved subjective outcome without difference in dyspareunia. But higher operating time, blood loss, indirect recurrence and de novo SUI. Mesh exposure in 10%, with 6.8% requiring surgical intervention.
Can access mesh via national MDT by approved practitioners on case-by-case basis or under ethics-approved trial
