urogynecology

Question 1

DDX of mass protruding from vagina

Answer 1

1. prolapse
2. uterine fibroid
3. inverted uterus
4. sarcoma botyroides( children younger than 5)

Question 2

levels of vaginal support

Answer 2

level 1- cervix and upper third of vagina= transverse cervical ligament and uterosacral and pubocervical ligament
level 2- middle third- endofascia to the pelvic sidewall
level 3- levator ani and diaphragm and perineal body
axis of vagina horizontal on levator ani muscles

Question 3

causes of prolapse

Answer 3

1. vaginal delivery (large babies, prolonged second stage of labor, instrumental forceps delivery)
2. congenital (collagen problems)
3. menopause
4. surgeries (hysterectomy/ incontinence)
5. chronic predisposing factos (increase intraabdominal pressure)

Question 4

uterine prolapse grades

Answer 4

first degree- descent of cervix into vagina 
second degree- cervix protrudes through introitus 
third degree(providentia)- Complete eversion of vagina

Question 5

muscle injured by perineal tear during birth

Answer 5

pubococcygeus(levator ani) innervated by pudendal nerve

Question 6

symptoms of prolapse

Answer 6

heaviness, dyspareunia, discomfort and backache
cystourethrocele- urgency and frequency, incomplete emptying, urinary retention and UTI due to kinking of ureters
rectocele- constipation and may digitally reduce it to defecate
deficient perineum= widened introitus, sexual symptoms
exposed cervix may ulcerate= vaginal bleeding

Question 7

modified Oxford system for grading pelvic floor strength

Answer 7

using vaginal palpation 
0= no contraction 
1=flicker
2=weak
3=moderate
4=good with lift 
5= strong

Question 8

conservative management of prolapse

Answer 8

prevention:1 reduction of prolonged labor, instrumental delivery, Kegel exercises, treatment of chronic constipation, cough
pessaries
estrogen

Question 9

surgical treatment of prolapse vaginal route

Answer 9

anterior vaginal wall= anterior colporrhaphy/ transverse mesh repair/
posterior= posterior colpoperineorrhaphy/ TMP/
uterovaginal(apical) prolapse= vaginal hysterectomy
Manchester (preserve uterus)
vaginal vault= sacrospinous ligament fixation

Question 10

prolapse surgeries laparoscopy

Answer 10

anterior= paravaginal repair/ sacrocolpopexy
posterior= sacrocolpopexy
uterine= hysteropexy
vaginal vault- sacropoplexy

Question 11

complication of surgeries

Answer 11

Manchester= cervical incompetence
sacrospinous ligament fixation= changes vaginal axis= dyspareunia
sacrocolpopexy= mesh erosion into vagina/ bladder/ rectum