Urogynaecology Flashcards
In POP-Q: define Aa
On anterior vaginal wall. Located in midline, 3 cm proximal (-3 in absence of prolapse) to the external urethral meatus. Corresponds approximately to external urethral crease. Range of movement will be -3 to +3.
In POP-Q: define Ba
On anterior vaginal wall. Most distal position of any part of the upper anterior vaginal wall between point Aa and the anterior vaginal fornix (or vaginal vault after hysterectomy).
In POP-Q: define C
Superior vagina. Most distal edge of cervix or leading edge of vaginal vault after hysterectomy.
In POP-Q: define D
Superior vagina. Posterior fornix or pouch of Douglas in a woman who still has a cervix. Represents attachment of uterosacral ligaments to the cervix. Its measurements allows differentiating suspensory failure of the uterosacral ligaments from cervical elongation.
In POP-Q: Ap
Posterior vaginal wall. Located in midline 3 cm proximal to hymen (-3 in absence of prolapse). Its range of movement will be -3 to +3.
In POP-Q: Bp
Posterior vaginal wall. Most distal position of any part of upper posterior vaginal wall between point D (or vaginal vault after hysterectomy) and point Ap.
In POP-Q: gh
Measured from middle of external urethral meatus to posterior midline hymen (or the firm tissue of the perineal body if hymen distorted by scarring).
In POP-Q: pb
Measured from posterior margin of the gh to the midanal opening.
In POP-Q: tvl
Greatest depth of vagina when point C or D is reduced to its normal position
In POP-Q: define stage I POP
Leading edge of prolapse not lower than 1 cm above the hymen.
In POP-Q: define stage II POP
Leading edge of prolapse is between -1 and +1 cm in relation to the hymen.
In POP-Q: define stage III POP
Leading edge of prolapse is 1 cm beyond the hymen but without complete eversion
In POP-Q: define stage IV POP
Complete vaginal eversion.
List the risk factors for vesico-vaginal fistula:
○ Hysterectomy (usually supratrigonal and medial to both ureters). Intraoperative risk factors: uterus weight >250g; long operation time; concurrent ureteral injury.
○ Obstructed labour (2% in developing world)
○ Obstetric: instrumental delivery, manual removal of placenta; Caesarean section, peripartum hysterectomy, uterine rupture at term.
○ Pelvic mesh erosion
○ Radiation therapy
○ Inflammation: PID, diverticulitis, IBD.
Describe how you would diagnose a vesico-vaginal fistula:
○ Pelvic examination: Recently formed fistulas may appear as a small, red area of granulation tissue with no visible opening, or an actual hole may be seen.
○ Dye test: Insert bladder catheter and create urethral seal with gauze to prevent bypass leaking.
Insert tampon or vaginal pack into vagina.
Instil bladder with saline mixed with methylene blue dye gradually (60 mL/min).
Check if blue dye has stained tampon/vaginal pack.
If no leakage is seen, ask patient to cough or perform Valsalva manoeuvre.
○ Examination under anaesthesia + dye test.
List your differential diagnoses for a suspect vesico-vaginal fistula:
Pelvic collection / seroma; urinary retention with overflow incontinence; SUI; UTI
List the management options for a vesico-vaginal fistula:
○ Latzko procedure: surgical closure of the fistula via the vagina.
○ Mackenrodt procedure: vaginal approach, especially for high vaginal fistulas. Tissue graft used (Martius/labial fibrofatty; gracilis muscle peritoneum) to reinforce repair.
○ Abdominal approach surgical repair: fistula is excised and bladder and vagina closed. Omental tissue is interposed between the bladder and vagina to separate the suture lines and act as a neovascular pedicle.
○ Post-repair cares: IDC should be left in for 7-14 days Referral to urologist. Cystogram prior to removal of IDC
What is the incidence of POP?
What % will undergo surgery for POP or continence?
204 per 1000 woman years
11-19% will undergo surgery.
What percentage of women who undergo surgery for POP will need re-operation?
30%
List risk factors for POP:
○ Age
○ Parity and vaginal delivery: 4 x increase risk after one child, 11 x increase risk after four or more children delivered vaginally.
○ Postmenopausal oestrogen deficiency.
○ Obesity and chronic increase in intra-abdominal pressure.
○ Neurological: spina bifida, muscular dystrophy.
○ Genetic connective tissue disorders: Marfans, Ehlers-Danlos syndrome.
○ Hysterectomy
Describe the three levels of support for the vagina:
Level I: vertical suspension by the uterosacral and cardinal ligaments.
Level II: lateral attaches of the middle third of the vagina to the paracolpium and paravagina; these connect to the ATFP which in turn connects to the levator ani muscles.
Level III: lower third is supported by fusion of vaginal endopelvic fascia to the perineal body, levator ani and urethra.
What provides somatic innervation to the pelvic floor?
Pudendal nerve (nerve roots S2-S4)
What provides autonomic innervation to the pelvic organs?
Inferior hypogastric plexus
Describe the steps you would take in a physical exam for a woman with POP:
- Abdominal examination: ?masses.
- Vaginal and speculum examination:
- Look for central compartment prolapse.
- Isolate the anterior and posterior walls and look for anterior and posterior wall prolapse.
- Assess maximum descent of prolapse.
- Modified Oxford score for pelvic muscle contraction (0-5)
- Cough test for UI with support / replacement of POP.
What percentage of POP is anterior vaginal wall prolapse?
50%
Posterior vaginal wall prolapse may develop after which urogynaecological procedure and why?
After Burch colposuspension due to change in vaginal axis.
What is a major risk factor for posterior vaginal wall prolapse and what structural supports may have been interrupted to cause this?
Vaginal and perineal tears, poor episiotomy repair.
Rectovaginal septum (vaginal apex to perineal body) and pararectal fascia.
Describe your management options for uterine prolapse:
- Vaginal hysterectomy
- Abdominal sacrohysteropexy
- Sacrospinous fixation
- (Total vagina mesh) - fertility sparing.
- LeFort’s colpocleisis - fragile elderly, not wanting to have sex again.
Pessary if doesn’t want surgery, wants to delay surgery or too frail for surgery.
Briefly describe the vaginal hysterectomy procedure:
Vaginal approach. Circumferential vaginal incision around cervix. Enter peritoneum. Identify uterosacral ligaments. Separate bladder from vaginal tissue to create vesicouterine space. Cardinal ligament pedicles. Uterine artery pedicles. Deliver uterus downwards to identify utero-ovarian ligaments, round ligaments and fallopian tubes. Perform ligation as indicated (i.e. ovarian conservation vs. BSO). Deliver pelvic organs. Check haemostasis. Closure.
Describe your management options for anterior vaginal prolapse:
What % of anterior compartment prolapse will have recurrent prolapse following surgery?
What complications are associated with these procedures?
- Anterior colporrhaphy.
- Paravaginal repair
- (Mesh repair).
Recurrence rate up to 40%.
Complications:
- Injury to bladder, ureters, urethra, genitofemoral or ilioinguinal nerves (0.5-2%)
- Urinary: retention, recurrent UTIs, de novo SUI or UUI
- Enterocoele
- Erosion of mesh or suture material
- Dyspareunia (less common c.f. posterior repairs)
Describe your management options for posterior vaginal prolapse:
What are the complications associated with these procedures?
- Posterior colporrhaphy
- Site specific fascial defect repair
- Vaginal enterocoele repair
Complications:
- Rectal injury
- Dyspareunia
- Vaginal shortening
- Pundendal neuralgia
- Worsening bowel symptoms
Describe your management options for vault prolapse:
- Abdominal sacrocolpopexy
- SSF
- Colpoclesis
Describe the indication for abdominal sacrocolpopexy, success rate and complications:
Indication: vaginal vault prolapse.
Success rate: 90-98%
Complications: bleeding, rectal trauma, ileus, mesh erosion, occult SUI, sacral osteomyelitis.
Describe the indication(s) for sacrospinous fixation, success rate and complications:
Indications: vaginal vault prolapse; uterine prolapse.
Success rate: >90%
Complications: pudendal neurovascular injury; buttock pain; anterior vaginal wall prolapse development; sexual dysfunction.
Justify the reasons (as per RANZCOG statement) on why mesh should not be a first line treatment for anterior vaginal prolapse treatment:
- Risk of mesh erosion 8-15%
- Increased risk of re-operation for prolapse, urinary incontinence and mesh exposure.
- High rates of bladder injury, SUI and prolapse in other vaginal sites.
When might you, if any, consider vagina mesh implants for treatment of anterior vaginal prolapse?
If woman is at high risk of recurrence i.e. obesity, young age, increased intra-abdominal pressure (asthma, chronic cough), stage 3-4 prolapse.
Outline how you would counsel a woman with anterior vaginal prolapse regarding mesh repair:
- Very little robust data on efficacy and safety of TV mesh products
- Mesh is not indicated for asymptomatic POP; there is limited long term data on outcomes for untreated asymptomatic POP
- Explain that it is considered a permanent procedure and that it may not be possible to completely remove mesh.
- Potential complications: mesh erosion / exposure; reoperation; dyspareunia; vaginal scarring/stricture; fistul aformation; unprovoked pelvic pain at rest.
- Alternatives to surgery: PFMT, vaginal pessaries.
- Alternative surgeries: anterior colporraphy, abdominal sacrocolpopexy.
- If mesh issues arise, issues may not complete resolve with removal of mesh.
List symptoms a patient may present with that may indicate a mesh complication:
- Pain in back, abdo, vagina, pelvis, leg, groin or perineum.
- Fistula
- Abnormal vaginal discharge or bleeding
- Dyspareunia; pain or injury in partner.
- Bowels: difficulty or pain on defaecation, faecal incontinence, rectal bleeding or passage of mucus
- Infection