Urogynecology (Tests, Surgeries, Etc) Flashcards
POP-Q
gold standard for measuring prolapse;
Stage 0: no prolapse
Stage 1: distal point is greater than 1cm above distal to hymen
Stage 2: distal point is equal or less than 1 cm above or below hymen
Stage 3: distal point is greater than 1 cm below hymen protruding 3/4 of vaginal length
Stage 4: complete eversion of the tvl (greater than 2cm)
Surgery for anterior prolapse or cystocele
anterior repair with or without mesh (vaginal), paravaginal repair; colposuspension, paravaginal (suprapubic)
Surgery for Apical or Uterine Prolapse
Vaginal hysterectomy, vault repair, sacrospinous fixation, bilateral iliococcygeal hitch (Vaginal)
Sacrohysteropexy, sacrocolpopexy (suprapubic)
Surgery for posterior wall prolapse or rectocele
levator plication, fascial repair with or without mesh, transanal repair (vaginal), mesh interposition, sacrocolpopexy with mesh interposition (suprapubic)
Indication for ring pessary
useful in treatment of uterine prolapse (stage 1 or 2)–cystocele, SUI
platform pessary
folded then placed in vagina; aids in reduction of prolapse equally in vagina; able to have intercourse with in place
Gellhorn pessary
For patients with severe uterine or vaginal prolapse; useful for large prolapse of anterior wall. difficult to self insert
inflatable pessary
doughnut shaped device with stem; requires manual dexterity (all prolapse)
cube pessary
six concave surfaces create suction effect and hold pessary in place; useful in patients with vaginal eversion and complete vaginal prolapse (all prolapse)
smith-hodge pessary
elevates the bladder neck into a retropubic position; help predicts likelihood of incontinence after surgery for correction of prolapse (small cystocele, enterocele, sui)
Colplexin
sphere shaped device that is easily inserted; use with PF exercises
DeLancey I Classification & Symptoms
Classification: Superior vaginal & uterine supor, cardinal and uterosacral ligaments; uterus and upper vaginal region
Sxs: Cervix first prolapse, pelvic heaviness, back pain; “drooping” cystocele which causes voiding dysfunction
DeLancey II Classification & Symptoms
Mid vaginal suspensory mechanism–main support for urethra, bladder, rectum (pubocervical fascia and rectovaginal fascia) Muscle connections; ATFP/ATLA
Sxs: Cystocele (SUI, voiding dysfunction), rectocele (FI, incomplete evacuation) ** Not typically back pain
DeLancey III Classification & Symptoms
lowest portion of vagina; no paracolpium to support; fuses with LA mm, urethra and perineum; ant ligaments to maintain continence
Sxs: Severe leakage from pubo-urethral ligament and laxity of “hammock”, gaping at introitus, perineal body is broad and inferior
Pfanenstiel Incision
RA mm separated from fascia using blunt or sharp dissection or electrocautery; leads to pain inthe abdominal skin superior to incision;
** Also, may have direct nerve injury of ilioinguinal nerve at superficial inguinal ring
Maylard incision
used in hysterectomy 2/2 cervical CA; direct trauma to RA mm at incision line that is 3-5 cm above insertion into pubis
Lateral Femoral Cutaneous Nerve Entrapment
travels posterior psoas, QL, ant iliacus, under inguinal ligament; innervates ant and lat thigh
Cherny Incision
same place as pfannenstiel, but cuts at pubic symphysis then reattaches
Midline Incision
used for more extensive abdominal explorations, vertical through linea alba (diverts around umbilicus)
paramedian incision
verticle to the L or R of the umbilicus
McBurney incision
Appendix
Ilioinguinal Nerve Entrapment
*ilioinguinal nerve: superficial inguinal ring–> pain in inguinal distribution radiating to perineum and medial thigh; pain increases with hip ext; pain with palpation medial to ASIS.
Etiolog: Lower abdominal incision, cherny incision, pregnancy, iliac bone harvesting, UI sx 18 mo post-op, femoral catheter, orchiectomy, tearing of lower EO aponeurosis
Also common in vulvar pain, instability of Tsp & Lsp, constipation
Iliohypogastric Nerve Entrapment
*iliohypogastric n: will affect motor function of IO and TrA; sensation at posterolateral gluteal skin and pubic skin; Tracks trhough psoas, QL, Transversus, IO and EO; Entrapment when surgical incision extends laterally to less than 3cm from AS iliac incision
Genitofemoral Nerve Entrapment
*genitofemoral n: will affect function of genital branch (cremaster), skin of scrotum, mons pubis, labia majora and upper ant thigh; Travels through psoas, under ilioinguinal ligament
Trapped by lateral retractors, pfannensteil, cherny OR biopsies, C/s, intrapelvic trauma, retroperitoneal hematoma, pregnancy, trauma to inguinal lig
S/s: groin pain, worse with IR/ER of hip, prolonged walking light touch
Obturator Nerve Entrapment
L2, L3, L4 anteriorly fuse to form;
Etiology: pelvic trauma and fx between head of fetus and bony structures; between tumor and bony pelvis, obturator canal during sx or with total hip malposition of LE for long periods, abnormal positioning of LE of newborn with delivery;
S/s: difficulty with ambulation, unstable LE in anterior branch entrapment, medial aspect of thigh; weakness worse with Exercises; Severe loss of ADD and IR occur;
** Recognize early; treat with ES, stretching, Massage; Surgical intervention
Femoral Nerve Entrapment.
femoral n: injured 2/2 retractors (stretch and compression); wknss in iliacus, pectinus and ant compartment mm; skin on and thigh and med leg; Travels under psoas ant iliacus and under inguinal lig; Common with hyper hip flexion during delivery;
Problems after Hysterectomy
Pain in the vaginal scar, disruption of nerves (orgasm!); with radical hysterectomy (2/2 cancer–pt may have bladder nerves disrupted)
Retropubic colposupsensions
For SUI (Burch, Marshall-Marchetti-Krantz)
- suspension of the periurethral vaginal wall to structures in or on the bony pelvis
- access space of retzius
- can damage femoral, obturator, pudendal and perineal nn.
Voiding dysfunction
*Open burch is used for young women desiring fertility, complications from mesh in past, combined with otheropen repairs
Needle Procedures
Pereyra, Raz, Gittes, Stamey
Sutures placed periurethrally to anchor tissue and improve suspension
Pubovaginal Slings
Fascial slings; for women who don’t want foreign substance; more women had UTIs, voiding dysfunction and UUI after sx compared to Burch
TVT & TOT
TOT may have less overcorrection/urgency/dysuria; Less risk for bladder damage but impacts OI mm
Urethral bulking
cure/improvement in 70-80% of pts (total in 40%), repeat may be required
Anterior Colporrhaphy & repair with graft
incision anteriorly, defect is folded over or removed then stitched back together; improved with use of mesh or graft
Posterior vaginal repair: graft, colporhaphy
midline fascial plication; dyspareunia and defecatory dysfunction common after
Rectocele specific repair had same oucomes; graft does not improve outcomes
Transvaginal approach preferred to rectal
Obliterative Procedures
Colpocleisis;
Risks: Bowel dysfunction, Regret
Uterus is only removed if pathological
Sacrocolpopexy
Vaginal vault is tacked to sacral prominence; performed abdominally
sacrospinous ligament fixation for vaginal vault prolapse
