Urogynecology Flashcards
Define anterior compartment prolapse
Herniation of anterior vaginal wall
Cystocele: backward descent of the urinary bladder into vagina and beyond
Urethrocele: backward descent of urethra into vagina and beyond
Define posterior compartment prolapse
- Herniation of posterior vaginal wall
- Rectocele: forward descent of the rectum into vagina and beyond
Define apical compartment prolapse
Herniation of the apex of the vagina into the lower vagina, to the hymen or beyond the vaginal introitus
Apex can be either the uterus and cervix, cervix alone or vaginal vault
Enterocele: herniation of the pouch of Douglas which contains loops of intestines through the upper part of vagina
Uterine prolapse: downward displacement of uterus towards or through the introitus
* 1st degree: descent of cervix within vagina but not through introitus
* 2nd degree: descent of cervix but not the whole uterus through introitus
* 3rd degree: descent of cervix and the whole uterus thorugh introitus usually bringing with cystocele, rectocele and enterocele
Define uterine procidentia
Herniation of all 3 compartments through the vaginal introitus
What are the components comprising of pelvic support?
What are the 3 levels of anatomy of pelvic floor?
What are the RF for pelvic organ prolapse?
What is the ddx for pelvic organ prolapse?
- Cervical polyp
- Bartholins gland cysts
- Skenes duct cysts
- Vaginal cysts
What is the clinical manifestation of POP?
What PE done for POP?
Sims retractor (single blade speculum) or bivalve speculum
Visual inspection
Speculum and bimanual examination
Apical prolapse: bivalve speculum is inserted into vagina and then slowly withdrawn and any descent of apex is noted
Anterior vaginal wall: sims retractor or posterior blade of bivalve speculum is inserted into vagina with gentle pressure on posterior vaginal wall to isolate visualization of anterior vaginal wall.
Posterior vaginal wall: sims retractor or posterior balde of bivalve speculum is inserted into vagina with gentle pressure on anterior vaginal wall to isolate visualization of posterior vaginal wall.
Rectovaginal examination: for dx of enterocele. Assess integrity of perineal body.
Neuromuscular examination
S2-4 nerve roots: sensory of lumbosacral dermatomes for light touch and pin prick sensation
Pelvic floor muscle testing: inspection for presence of scarring and whether pelvic floor contraction pulls perineum inwards
What Ix to do in pelvic organ prolapse?
- RFT
- Urinalysis (UTI)
- Urine smear and culture (UTI)
- Bladder diary
- Urodynamic test (gold standard but not indicated for everyone): cystometry (for urinary incontinence), post void residual (PVR) measurement (for urinary retention)
What is the conservative treatment for POP?
Indications?
Complications?
Ring/cube pessary
Indications
* Patient physically unfit for surgery
* Patients refusal for surgery
* Temporary relief while awaiting surgery
* Pregnancy or want to preserve uterus for fertility
Complications
* Vaginal ulceration leading to PV bleeding
* Foul smelling discharge
* Urinary retention
* Slippage of vaginal pessary
Pelvic floor muscel training
What is surgical treatment for cystocele?
Complications?
Anterior colporrhaphy = pelvic floor repair
Plication of pubocervical fascia so that the descended bladder (cystocele) is elevated with the support of fascia
Often performed together with vaginal hysterectomy or with the repair of perineum
Complications: bladder perforation
What is surgical treatment for rectocele?
Complications?
- Posterior colporrhaphy (pelvic floor repair)
- Plication of part of levator ani muscles between posterior vaginal wall and anterior vaginal wall so that the herniated rectum (rectocele) is reduced by reinforced muscle
- Often performed together with vaginal hysteretomy or with repair of perineum (perinorrhaphy) for deficient perineal body
Complications
* Rectal perforation
* Dyspareunia secondary to tight vaginal opening afte repair
What is surgical treatment for enterocele?
- McCall culdoplasty
What is surgical treatment for uterine prolapse?
How is the procedure done?
Complications?
Vaginal hysterectomy +/-pelvic floor repair
* Uterus removed vaginally +/- removal of ovaries and fallopian tubes but not in case difficulty encountered. If uterus does not descend after anesthesia then will proceed to pelvic floor repair only.
* Pelvic floor supporting tissue or ligament strengthened with sutures before closure of vaginal incision.
* Cystoscopy performed to look for urinary tract injury
Frequent complications
* Vaginal bleeding
* UTI/urinary frequency
* Wound infection
* Postop pain with difficulty or dyspareunia
Serious complications
* New or continuing bladder dysfunction including difficulty in voiding which may results in long term catheterization or intermittent self catheterization
* Develop or unmask stress incontinence
* Injury to adjacent organs: bladder, ureters, bowel
* Pelvic abscess
* DVT or PE
What are the indications for sacrocolpopexy?
What does the procedure involve?
Indications: vault prolapse with bothersome symptoms or those who failed non surgical treatment
Abd procedure which mesh attaches the vault to sacrum. Top and back of vagina is attached to a ligament on the lower part of the sacral bone using a piece of synthetic mesh or tape. Mesh is covered by a layer of tissue called peritoneum that lines the abd cavity.
Different from sacrospinous fixation (which fixes the vaginal vault to sacrospinous ligament, not the sacral bone in this case)
What are the indications for sacrospinous fixation?
What does the procedure involve?
What are its complications?
Indication
* Vault prolapse with bothersome symptoms or those who failed non-surgical treatment
Vaginal procedure in which the vaginal vault is sutured to one or more sacrospinous ligament. Less effective than sacrocolpopexy. Less invasive and more easily performed.
Serious complications
* Dyspareunia
* Development of cystocele
* Development of overactive bladder
* Development of stress urinary incontinence due to change in anatomy
* Recurrence of vault prolapse (18% very common)
What are the indications for colpocleisis?
What does the procedure involve?
What are its complications?
Indication: genital prolapse of vault prolapse with bothersome dragging discomfort, AE on bowel or urinary function or failed non surgical treatment
Vaginal incision: vaginal epithelium removed from anterior and posterior vaginal walls. Vagina obliterated by sutures. Perineorrhaphy. Cystoscopy performed to look for urinary tract injury.
Complications
Common: fever, UTI, wound infection, wound haematoma, post op pain
Serious : new or continuing bladder dysfunction
Develop or unmask stress urinary incontinence
Post op cardiac, thromboembolic and pulmonary events
Pelvic abscess
Bleeding requiring blood transfusion
Type sof urinary incontinence
- Urge incontinence: involuntary leakage of urine accompanied by urgency. Inability to withhold passage of urien with a sudden strong desire to micturate due to hyperexcitability of bladder detrusor muscles
- Stress incontinence: involuntary leakage of urine with exertion, sneezing or coughing
- Overflow incontinene: involutnary leakage of urine when intravesical pressure exceeds maximum urethral pressure deu to bladder distension and in the absence of detrusor activity. Secondary to bladder outflow obstruction
- True incontinence: defect in anatomical integrity –> vesicovaginal fistula
- Functional incontinence: involuntary leakage of urine due to non physiological causes: inability of getting into toilet in a timely fashion.
What nerves controlling bladder?
Sympathetic nervous system: hypogastric nerve (T10-L2)
Parasympathetic nervous system: pelvic splanchnic nerves (S2-4)
Detrusor muscles of bladder
Internal sphincter muscle: involuntary smooth muscle
External sphincter muscle: voluntary striated muscle
What is the efferent innervation of the bladder?
Whata are the different phases of micturition?
Classification of different types of urinary incontinence and causes?
