Uterovaginal Prolapse Flashcards
Definition of a uterogenital prolapse
When a defect in the pelvic floor allows one or more of the pelvic viscera to fall through it
20% of all gynae surgery
Not life threatening but has a severe impact on the quality of life
Structures of the pelvic floor (5)
Pelvic bones Levator Ani
Endopelvic fascia Viscera
Perineal Body
Anterior Compartment
Urethrocele - involves the lower part of the anterior vaginal wall
Cystocele - prolapse of the upper vaginal wall and bladder
Middle compartment
Uterovaginal prolapse - descent of the uterus and cervix through the vagina
Vault prolapse - after hysterectomies the vault can prolapse usually with small bowel and omentum
Posterior compartment prolapses
Enterocele - involves the upper part of the posterior vagina and can bowel loops and the POD - true herniation through the pelvic outlet
Rectocele - prolapse of the posterior vaginal wall containing the rectum
Urethrocele
Prolapse of the anterior vaginal wall including the urethra
Causes of Cystocele
Due to a defect in the pubovesical and pubocervial fascia - usually presents with a urethral prolapse
Causes of Uterovaginal prolapse
Usually related to damage of genital structures during childbirth
Vault prolapse
Mainly occur after hysterectomies
Similar symptoms to uterine prolapse but instead of uterus they have enterocele
Symptoms of Enterocele
Can cause lower abdominal pain and pelvic pressure which is relieved by lying down - worsening through the day
May only be palpable when supine if the patient bares down
Causes of Rectocele
Caused by a defect in the recto-vaginal fascia with separation of the levator ani musculature
Bladder dysfunction in Cystocele
Can compromise bladder emptying leading to higher residuals and recurrent UTIs - large cystoceles can kink the urethra causing retention, but incontinence if the posterior urethro-vesical angle is increased - makes pt vulnerable to acute increases in pressure
Complications of Uterovaginal prolapse (2)
Can impair bladder emptying
Cervical protrusion can predispose to mucosal dryness and infections
Procidentia
Total eversion of the vagina
Contents of the posterior compartment
Rectovaginal septum Puborectalis muscle
Uterosacral ligaments Perineal body
Perineal membrane Anal sphincters
Symptoms of Rectocele
Feelings of pressure in the perineum with defecation or difficulty defecating - pts can improve symptoms by pushing on the posterior vaginal wall to empty the rectum
POP classification of prolapses
Stage 0 - no descent of structures when straining
Stage 1 - descent up to 1cm above the hymenal ring
Stage 2 - from 1cm above or below the hymenal ring
Stage 3 -more than 1cm beyond the hymenal ring but no vaginal eversion
Stage 4 - Full vaginal eversion
Risk factors for pelvic prolapses
Age Oestrogen deficency or post-menopausal
Striated muscle weakness/neuromuscular disease
SVD, hysterectomy or collagen disorders (marfans or ehlers-danlos
Increased intra-abdominal pressure (chronic cough, heavy lifting, constipation, obesity
Long term steroid use
General symptoms of prolapse
At first can be asymptomatic - worsen over the day or activities which increase abdominal pressure
Backache or urinary symptoms
Dysparenuria
Examination for Prolapses
Lithotomy position using a speculum and bimanual or left lateral position using a simms speculum
Look for signs of decreased estrogens - vaginal atrophy etc
Physical Signs of reduced estrogens
Loss of rugae in the vaginal mucosa
Decreased secretions
Thin perineal skin
Easy perineal tearing
Prevention of pelvic floor damage
Minimizing trauma during labour - post natal pelvic floor exercises
Ensure adequate support of the vaginal vault at hysterectomy
Conservative Treatment
Small prolapses can be treated with reassurance and pelvic floor exercises
Avoid heavy lifting and straining
Ring (1st line) or shelf pessary as support - effective in 60% of women. Largest pessary which is comfortable. change every 6-12months.
Use of Pessaries vs surgery
Surgery is definitive treatment
Use pessaries if: during or after pregnancy if further pregnancies are planned.
to confirm benefit from surgery or while awaiting surgery - if unfit for surgery
