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Reproductive System > Pelvic Organ Prolapse > Flashcards

Pelvic Organ Prolapse Flashcards

1
Q

What does POP stand for?

A

Pelvic organ prolapse

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2
Q

What is prolapse?

A

Prolapse = protrusion of an organ or structure beyond its normal anatomical confines

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3
Q

What is female POP?

A

Female POP = refers to the descent of the pelvic organ towards or through the vagina

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4
Q

What are the 3 layers of the pelvic floor?

A
  • Endo-pelvic fascia
    • Network of fibro-muscular connective tissue, includes
    • Uteroscral ligaments
      • Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
      • Laterally – to sacrum and fascia overlying the piriforms muscle
      • Easily palpated by down traction of cervix
      • Tends to break medially
    • Pubocervical fascia
      • Provides the main support of anterior vaginal wall
      • Centrally – merge with the base of cardinal ligaments and cervix
      • Laterally – arcus tendinous fascia pelvis
      • Distally – urogenital diaphragm
      • Tends to break at lateral attachments or immediately in front of cervix
    • Rectovaginal fascia
      • Made from elastic tissue
      • Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
      • Laterally – fuses with fascia over levator ani
      • Distally – firmly to the perineal body
      • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele
  • Pelvic diaphragm
    • Layer of striated muscles with its fascial coverings, includes levator ani and occygeus
  • Urogenital diaphragm
    • Superficial and deep transverse perineal muscles with fascial coverings
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5
Q

What composes the endo-pelvic fascia?

A
  • Network of fibro-muscular connective tissue, includes
  • Uteroscral ligaments
    • Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
    • Laterally – to sacrum and fascia overlying the piriforms muscle
    • Easily palpated by down traction of cervix
    • Tends to break medially
  • Pubocervical fascia
    • Provides the main support of anterior vaginal wall
    • Centrally – merge with the base of cardinal ligaments and cervix
    • Laterally – arcus tendinous fascia pelvis
    • Distally – urogenital diaphragm
    • Tends to break at lateral attachments or immediately in front of cervix
  • Rectovaginal fascia
    • Made from elastic tissue
    • Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
    • Laterally – fuses with fascia over levator ani
    • Distally – firmly to the perineal body
    • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele
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6
Q

What are the attachments of the uterosacral ligaments?

A
  • Medially – to uterus, cervix, lateral vaginal fornices and pubocervical and rectovaginal fascia
  • Laterally – to sacrum and fascia overlying the piriforms muscle
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7
Q

Where does the uterosacral ligaments tend to break?

A

Medially

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8
Q

What is the function of the pubocervical fascia?

A
  • Provides the main support of anterior vaginal wall
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9
Q

What are the attachments of the pubocervical fascia?

A
  • Centrally – merge with the base of cardinal ligaments and cervix
  • Laterally – arcus tendinous fascia pelvis
  • Distally – urogenital diaphragm
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10
Q

Where does the pubocervical fascia tend to break?

A
  • Tends to break at lateral attachments or immediately in front of cervix
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11
Q

What are the attachments of the rectovaginal fascia?

A
  • Centrally – merge with the base of cardinal/uterosacral ligaments and peritoneum
  • Laterally – fuses with fascia over levator ani
  • Distally – firmly to the perineal body
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12
Q

Where does the rectovaginal fascia tend to break?

A
  • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele
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13
Q

What are the 2 kinds of defects of the rectovaginal fascia?

A
  • Tends to break centrally, if upper defect is called enterocele, if lower defect is called perineal body descent and rectocele
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14
Q

What is the pelvic diaphragm composed of?

A
  • Layer of striated muscles with its fascial coverings, includes levator ani and occygeus
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15
Q

What is the urogenital diaphragm composed of?

A
  • Superficial and deep transverse perineal muscles with fascial coverings
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16
Q

What are the 3 levels of endopelvic support?

A
  • Level 1
    • Uterosacral ligaments
    • Cardinal ligaments
  • Level 2
    • Para-vagina to arcus tendinous fascia
    • Pubocervical/rectovaginal fascia
  • Level 3
    • Urogenital diaphragm
    • Perineal body
17
Q

What are the different classifications of POP?

A

Classification, depends on the site of the defect and presumed pelvic viscera involved:

  • Urethrocele
    • Prolapse of lower anterior vaginal wall involving urethra only
  • Cystocele
    • Prolapse of upper anterior vaginal wall involving the bladder
  • Uterovaginal prolapse
    • Prolapse of uterus, cervix and upper vagina
  • Enterocele
    • Prolapse of the upper posterior wall of the vagina usually containing small loops of bowel
  • Rectocele
    • Prolapse of the lower posterior wall of vagina involving rectum bulging into vagina
18
Q

What is urethrocele?

A

Prolapse of lower anterior vaginal wall involving urethra only

19
Q

What is cystocele?

A
  • Prolapse of upper anterior vaginal wall involving the bladder
20
Q

What is uterovaginal prolapse?

A
  • Prolapse of uterus, cervix and upper vagina
21
Q

What is enterocele?

A
  • Prolapse of the upper posterior wall of the vagina usually containing small loops of bowel
22
Q

What is rectocele?

A
  • Prolapse of the lower posterior wall of vagina involving rectum bulging into vagina
23
Q

What is the prevalence of POP?

A
  • Prevalence 12-30% multiparous woman, 2% nulliparous woman
24
Q

What are risk factors for POP?

A
  • Greater parity (parity is the amount of times a woman has been pregnant)
  • Forceps delivery
  • Large baby (>4.5kg)
  • Prolonged second stage of labour
  • Advanced age
  • Obesity
  • Previous pelvic surgery
    • Such as continence procedures or hysterectomy
  • Hormonal factors
  • Constipation
  • Occupation with heavy lifting
  • Exercise
    • Such as weight lifting, high impact aerobics and long distance running
25
Q

What is the presentation of POP?

A
  • Vaginal symptoms
    • Sensation of bulge or protrusion
    • Seeing or feeling a bulge or protrusion
    • Pressure
    • Heaviness
    • Difficulty in inserting tampons
  • Urinary symptoms
    • Urinary incontinence
    • Frequency/urgency
    • Weak or prolonged urine stream/hesitancy/feeling of incomplete emptying
    • Manual reduction of prolapse to start or complete voiding
  • Bowel symptoms
    • Incontinence of flatus, or liquid or solid stool
    • Feeling of incomplete emptying/straining
    • Urgency
    • Digital evacuation to complete defecation
    • Splinting (pushing on or around vagina or perineum) to start or complete defecation)
26
Q

What are different methods of measuring the severity of POP?

A
  • Baden-Walker-Halfaway grading
  • POPQ score – gold standard (image below)
  • Others
27
Q

What are the different stages of POPQ score?

A
28
Q

What investigations are done for POP?

A
  • USS/MRI
    • Identification of fascial defects/measurement of levator ani thickness
  • Urodynamics
    • Concurrent UI or to exclude occult SI
  • IVU or renal USS
    • If suspicious of ureteric obstruction
29
Q

Describe the management of POP?

A
  • Prophylaxis
    • Avoid constipation
    • Effective management of chronic chest pathology (COAD and asthma)
    • Smaller family size
    • Improvements in antenatal and intra-partum care
  • Physiotherapy
    • Pelvic floor muscle training (PFMT)
      • Increase pelvic floor strength and bulk to relieve tension of ligaments
      • Can be supplemented with perineometer and biofeedback, vaginal cones and electrical stimulation
      • Indication – mild cases of prolapse, younger woman who have not yet completed family
      • Contraindication – no role in advanced cases, cannot treat fascial defects
  • Pessaries
    • Prosthetic device inserted into vagina
    • Made from different materials, silicone is best due to long shelf life, resistance to autoclaving and repeated cleaning, non-absorbent towards secretions and odors
  • Surgery
    • Aim is to relieve symptoms, restore/maintain bladder and bowel function, maintain vaginal capacity for sexual function
    • Done with prophylactic antibiotics and thrombo-embolism prophylaxis
30
Q

What can be done for prophylaxis of POP?

A
  • Avoid constipation
  • Effective management of chronic chest pathology (COAD and asthma)
  • Smaller family size
  • Improvements in antenatal and intra-partum care
31
Q

What does PFMT stand for?

A

Pelvic floor muscle training

32
Q

What are pessaries?

A
  • Prosthetic device inserted into vagina
  • Made from different materials, silicone is best due to long shelf life, resistance to autoclaving and repeated cleaning, non-absorbent towards secretions and odors
33
Q

What is surgery for POP done with?

A
  • Done with prophylactic antibiotics and thrombo-embolism prophylaxis

Reproductive System (88 decks)

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