Urogynaecology & vulval disorders Flashcards
What is a prolapse?
Protrusion of an organ or structure beyond its normal confines. In gynaecan occur in 3 compartments, classified by location & organ involved.
41-50% of women >40 years
Lifetime risk 7% of having an operation for prolapse
MDT: gynaecologists, urogynaecologists, nurse specialists (hospital & community), physiotherapists.
Risk factors for pelvic organ prolapse?
- Post-menopausal (loss of oestrogen – oestrogen increases strength of pelvic floor)
- Vaginal delivery (higher parity, larger babies, instrumental deliveries, poor tear / episiotomy repair, mechanical + nerve injury to pelvic floor)
- Post-operative (hysterectomy: importance of vaginal vault support)
- Congenital: collagen, congenital weakness (spina bifida / bladder extrophy)
- Raised intra-abdominal pressure: chronic cough, obesity, constipation, heavy lifting, pregnancy
How is pelvic organ prolapse classified?
- Anterior vaginal wall prolapse: cystocele, cystourethrocele or urethrocele (less common)
- Posterior vaginal wall prolapse: rectocele or enterocele (small bowel)
- Apical vaginal prolapse
• Uterus + inversion of upper vagina (uterovaginal prolapse)
• Vaginal apex (post-hysterectomy): (vault prolapse)
Cystocele: prolapse of the bladder against the anterior vaginal wall
Rectocele: prolapse of the rectum against the posterior vaginal wall
Enterocele: prolapse of the small bowel against the posterior vaginal wall (herniation of pouch of Douglas including small intestine into vagina, any laxity in peritoneum > small bowel comes into pouch of Douglas)
Examination findings possible in prolapse?
Digital examination of vagina:
o Rectocele: finger enters posterior fornix, can feel posterior fornix + rectocele below.
o Enterocele: enterocele covers whole of posterior fornix?
Uterine prolapse: prolapse of the uterus into the vagina, often with inversion of upper vagina (occasionally might see without anterior/posterior vaginal wall prolapse if only cervical lengthening is seen and uterus held in place by ligaments).
How is prolapse graded?
Several Grading Systems, simplest is 3 grades:
• 1st degree – descent within vagina
• 2nd degree – descent to the introitus
• 3rd degree (procidentia– descent outside the introitus – only applied when uterus still present)
Procidentia (i.e. grade 3): cervix and vaginal wall seen protruding from the introitus. The uterus is inside the vaginal wall that you can see – could also be bladder & bowel dropped down inside.
What are the symptoms of prolapse?
General prolapse: dragging sensation (discomfort, pain), feeling a lump in the vagina, dyspareunia
Cystocele: stress incontinence may coexist - not a causal relationship, voiding difficulties (urinary frequency, obstructive symptoms), recurrent urine infections, urgency / frequency
Rectocele: incomplete bowel emptying, difficulty wiping clean / soiling / incontinence, splinting / digitation
Severe prolapse anterior / apex: renal failure (ureteric kinking), urinary retention, bleeding / ulceration, infection
Treatment of prolapse? (non-surgical)
non-surgical
- No symptoms / mild prolapse (no treatment!)
- Correction of underlying risk factors: obesity, chronic cough, constipation
Physiotherapy: first line approach
Vaginal pessaries: various shapes / sizes, ring pessary common (diagram shows ring pessary in situ, restore anatomy, risks of ulceration / infection)
Women can get pregnant and use pessaries in the 1st trimester! As baby develops the prolapse will correct (but will return after delivery).
Useful treatment if: patient doesn’t want surgery, not fit for surgery, while awaiting surgery or to assess symptom relief by prolapse reduction
Surgical treatment of prolapse?
Aims to restore anatomy + function, choice depends on: sexual function needs, previous surgery, wish to preserve uterus.
- Cystocele/cystourethrocele: anterior colporrhaphy (anterior wall repair), colposuspension
- Uterine prolapse: hysterectomy, sacrohysteropexy
- Rectocele: posterior colporrhaphy (posterior vaginal wall repair)
What is urinary incontinence?
Urinary continence: ability to store urine and have conscious control over time and place of voiding
Urinary incontinence: involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem
Prevalence increases with age (15-44yrs 5%, 45-64yrs 10%, >65yrs 20%)
•Can significantly reduce QoL (physical health, psychological health, social well-being)
Outline nerve supply to bladder?
- Vesicle nerve plexus consists of sympathetic + parasympathetic component
- Parasympathetic (from nervi ergientes): S2, S3, S4 supplies motor fibres to detrusor muscle and inhibitory to the sphincter vessel
Risk factors for incontinence?
Damage during childbirth (pelvic floor muscles, nerve supply to urethral sphincter & pelvic floor)
- Menopause / tissue atrophy
- Connective tissue / collagen: nulliparous women can get it too, black women less likely to have it
- Chronic increased abdominal pressure: obesity, cough, straining
- Smoking: increases risk by 2-3x
- Radiotherapy: fibrotic bladder damage in up to 50%
- Medical co-morbidities: neurological conditions - MS 75% (frequency/urgency common), Parkinson’s (?age related).
What types of incontinence are there?
Urethral: • (urodynamic) stress incontinence • detrusor overactivity • retention with overflow (e.g. prostate enlargement) • congenital • acute infection • urethral diverticulae
Extra-urethral:
• Bladder extrophy
• Ectopic ulcers
• Vesicovaginal fistula (VVF)
What is stress incontinence?
Abnormal bladder neck / proximal urethra descent.
Intraurethral pressure < intravesical pressure (at rest): urethral scarring, lack of oestrogen. Lax suburethral support: pelvic floor injury.
Symptoms: involuntary leakage on cough/laugh/sneeze etc., leaking on intercourse, may have associated prolapse symptoms, can have urgency/frequency as well (mixed picture)
What is overactive bladder?
Symptoms: frequency, urgency (sudden compelling desire to void, difficult to defer), urge incontinence (leakage associated with urgency), nocturia, other (latchkey urgency, “toilet mapping”)
Overactive bladder syndrome (OAB): triad of frequency, urgency, nocturia (+/- leakage; wet / dry)
Detrusor overactivity is a urodynamic diagnosis (one of the causes of overactive bladder symptoms)
Other important symptoms: voiding dysfunction (incomplete emptying, poor flow, straining to void), recurrent infections, associated symptoms of prolapse, faecal incontinence (may not volunteer but may co-exist)
History and examination of incontinence?
Hx: check bowels, sexual and prolapse symptoms, obstetric history (number, mode, size of largest child), medical history (diabetes, neurological, depression), fluid intake, bladder irritants (caffeine, fruit juice, fizzy drinks), smoking, medications e.g. diuretics
Exam: BMI, abdominal masses (bladder compression), palpable bladder (retention), gynaecological (prolapse, leakage on coughing, ability to contract pelvic floor)
