Flashcards in Genitourinary Prolapse Deck (82)
What is a uterine prolapse?
When the female pelvic organs fall from their normal position into or through the vagina
What % of parous women are affected by pelvic organ prolapse?
Why is the exact incidence of pelvic organ prolapse difficult to determine?
Many do not receive medical advice
What is a woman's lifetime risk of surgery for pelvic organ prolapse?
What is the most common type of pelvic organ prolapse prolapse?
Prolapse of the anterior vaginal wall
What provides the main support for the pelvic organs?
- Levator ani muscle
- Endopelvic fascia
What is the endopelvic fascia?
A connective tissue network connecting the organs to the pelvic muscles and bones
What organs can be involved in a pelvic organ prolapse?
- Small or large bowel
- Vaginal vault
Where can the organs of a pelvic organ prolapse affect when they descend?
Anterior/posterior vaginal walls
What usually underlies most cases of pelvic organ prolapse?
What can be involved in the multifactorial causes of pelvic organ prolapse?
- Direct muscle trauma
- Neuropathic injury
- Disruption or stretching of support
What different compartments of the pelvis can be affected by pelvic organ prolapse?
What are the types of anterior compartment pelvic organ prolapse?
What are the types of middle compartment pelvic organ prolapse?
- Uterine prolapse
- Vaginal vault prolapse
What are the types of posterior compartment pelvic organ prolapse?
Why do crabs make good burglars?
They're great at pinching things
What is a urethrocele?
Prolapse of the urethra into the vagina
What is a cystocele?
Prolapse of the bladder into the vagina
What is a uterine prolapse?
Descent of the uterus into the vagina
What is a vaginal vault prolapse?
Descent of the vaginal vault post-hysterectomy
What is an enterocele?
Herniation of the pouch of Douglas (including small intestine/omentum) into the vagina
What is a rectocele?
Prolapse of the rectum into the vagina
What system is used to grade pelvic organ prolapse?
What is the POPQ system?
Pelvic Organ Prolapse Quantification System
What is a Stage 0 POPQ pelvic organ prolapse?
What is a Stage 1 pelvic organ prolapse?
More than 1 cm above the hymen level
What is a Stage 2 pelvic organ prolapse?
Within 1 cm proximal/distal to the plane of the hymen
What is a Stage 3 pelvic organ prolapse?
More than 1cm below the plane of the hymen but no further than 2cm less than total length of the vagina
What is a Stage 4 pelvic organ prolapse?
Complete eversion of the vagina
What are the risk factors for pelvic organ prolapse?
- Increasing age
- Vaginal delivery
- Increasing parity
- Previous hysterectomy
How do mild pelvic organ prolapses present?
Many are asymptomatic and are incidental findings
How severe can the symptoms of pelvic organ prolapse be?
Severe enough to affect quality of life
What are the symptoms of pelvic organ prolapse related to?
Site and type of prolapse
What are the vaginal/general symptoms of pelvic organ prolapse?
- Sensation of pressure/fullness/heaviness
- Sensation of bulge or 'something coming down'
- Seeing/feeling a bulge/protrusion
- Difficulty retaining tampons
What can cause spotting in a pelvic organ prolapse?
Ulceration of the prolapse
What are the potential urinary symptoms of pelvic organ prolapse?
- Feeling of incomplete bladder emptying
- Weak or prolonged urinary stream
- Need to reduce prolapse manually before voiding
- Need to change position to start voiding
What are the symptoms of coital difficulty that may present in pelvic organ prolapse?
- Loss of vaginal sensation
- Vaginal flatus
- Loss of arousal
What are the potential bowel symptoms in pelvic organ prolapse?
- Urgency of stool
- Incontinence of flatus or stool
- Incomplete evacuation
- Need to apply digital pressure to perineum or posterior vaginal wall to enable defecation
- Digital evacuation necessary
In what positions should patients presenting with pelvic organ prolapse be examined?
- Left lateral position
What should the patient be asked to do whilst examining for prolapse?
How should the vagina be examined when assessing pelvic organ prolapse?
With a speculum
What may be noticed on pelvic organ prolapse examination?
When are abnormalities of the mucosa likely to occur in pelvic organ prolapse?
When the prolapse protrudes beyond the hymen level
How is pelvic organ prolapse usually diagnosed?
Based on history and examination
What tests should be considered if urinary symptoms are present in pelvic organ prolapse?
- Post-void residual urine volume testing using catheter or bladder USS
- Urodynamic investigations
- Urea and creatinine
- Renal USS
What tests can be considered if bowel symptoms are present in pelvic organ prolapse?
- Anal manometry
- Endo-anal USS
When is treatment of a prolapse not necessary?
In mild and/or asymptomatic prolapse
What are the broad management options for pelvic organ prolapse?
- Vaginal pessary
Who is conservative management of pelvic organ prolapse particularly helpful for?
- Mild prolapse
- Want further pregnancies
- Frail or elderly
- High anaesthetic risk
- Don't want surgery
What are the approaches to conservative management of pelvic organ prolapse?
- Watchful waiting
- Lifestyle modification
- Pelvic floor muscle exercises
- Vaginal oestrogen creams
When may further treatment be required for pelvic organ prolapse following watchful waiting?
If symptoms become troublesome or complications develop
What lifestyle modifications can conservatively treat pelvic organ prolapse?
- Weight loss
- Minimising heavy lifting
- Preventing or treating constipation
Who can vaginal oestrogen creams be useful for treating pelvic organ prolapse in?
Women with signs of vaginal atrophy
What is the function of a vaginal pessary in pelvic organ prolapse?
It is inserted in the vagina to reduce the prolapse and provide support and relieve pressure on the bladder and bowel
What can vaginal pessaries be used in combination with to treat pelvic organ prolapse?
Pelvic floor muscle exercises
How long can vaginal pessaries for prolapse be used for?
- Short-term prior to surgery
- Long-term if surgery is not an option
What should patients wanting vaginal pessary for prolapse be made aware of?
- More than one fitting may be necessary
- May affect sexual intercourse
- Should be changed every 6 months
What are the potential complications of a vaginal pessary for pelvic organ prolapse?
- Difficulty removing pessary
- Vesicovaginal and rectovaginal fistulas
- Faecal impaction
What are the indications for surgical intervention for pelvic organ prolapse?
- Failure of conservative management
- Presence of voiding problems or obstructed defecation
- Recurrence of prolapse
- Irreducible prolapse
- Woman prefers surgery
What are the goals of surgical intervention for pelvic organ prolapse?
- Restore anatomy
- Improve symptoms
- Return bladder, bowel and sexual function
What does the choice of surgical procedure for pelvic organ prolapse depend upon?
- If woman is sexually active
- If family is complete
- General fitness
- Whether has had a hysterectomy
- Nature of prolapse
What is a controversial surgery for pelvic organ prolapse?
Why is mesh repair for pelvic organ prolapse a topic of controversy?
Concerns of long-term health problems
What are the long-term complications of mesh repair for pelvic organ prolapse?
- Bladder/bowel dysfunction
What are the surgical options for bladder/urethral prolapse?
- Anterior colporrhaphy
What happens in an anterior colporrhaphy?
Folds the fibromuscular layer of the anterior vaginal wall
What are the intraoperative complications of anterior colporrhaphy?
When can a colposuspension be considered for treatment of pelvic organ prolapse?
For urethral sphincter incontinence associated with cystourethrocele
How is a colposuspension performed?
Paravaginal fascia on either side of the bladder neck and base of the bladder are approximated to pelvic side wall by sutures through ipsilateral iliopectineal ligament
What are the surgical options for a uterine prolapse?
- Sacrospinus fixation
What is a sacrocolpoplexy?
The uterus is attached to the longitudinal ligament over the sacrum
What are the ways a sacrocolpoplexy can be performed?
What is an advantage of a sacrocolpoplexy for uterine prolapse?
Woman can retain her uterus
What is a sacrospinus fixation of uterine prolapse?
Unilateral or bilateral fixation of the uterus to the sacrospinus ligamnet
What are the risks of sacrospinus fixation for uterine prolapse?
Injury to the pudendal nerve and vessels and the sciatic nerve
What are the surgical options for a vault prolapse?
- Sacrospinus fixation
What is the surgical option for a recto/enterocele?
What is obliterative surgery for pelvic organ prolapse?
The prolapse is corrected by moving the pelvic viscera back into the pelvis and closing off the vaginal canal
What are the advantages of obliterative surgery for pelvic organ prolapse?
- Almost 100% effective
- Reduced peri-operative morbidity
- Safe for those who are frail
What is the main disadvantage of obliterative surgery for pelvic organ prolapse?
Vaginal intercourse is no longer possible
What are the potential complications of pelvic organ prolapse?
- Ulceration and infection of prolapsed organs outside introitus
- Urinary tract complications
- Bowel dysfunction