Urogenital prolapse Flashcards
What is the aetiology of symptoms from pelvic organ prolapse?
- Direct due to the prolapsed organ
- Indirect due to organ dysfunction secondary to displacement from the anatomical position.
What are the signs and symptoms of prolapse?
- Sensation of vaginal bulge
- Heaviness
- Visible protrusion at or beyong the introitus
- Lower back pain or abdominal pai n
- Dragging discomfort relieved by lying or sitting
- Bleeding
- Ulceration/abrasion of the external prolapse
Indirect symptoms depend on which other organs are affected
What are the indirect symptoms of a prolapse?
Obstructive defecation - difficulty in voiding urine or emptying the bowel
Sensations of incomplete emptying of bladder or rectum
Digitation - need to support or reduce the prolapse with fingers to be able to void or evacuate stool completely (distinct from manual evacuation of the rectum). U
Urinary or faecal incontinence
Sexual intercourse difficulty - difficulty achieving penetration, dyspareunia and loss of sensation and difficulty achieving orgasm due to vaginal or introital laxity.
What are the risk factors for pelvic organ prolase?
Similar to those of stress incontinence:
- advancing age
- previous pregnancy and childbirth
- long labour
- perineal trauma
- forceps delivery
- multiparity (particularly vaginal births)
- high BMI/obesity
- FH e.g. connective tissue disease
- spina bifida
Pudental nerve damage during birth causing thinning of the puborectalis muscle from insertion on the pubic ramus
What is the pathophysiology of pelvic organ prolapse? What are the three levels of supporting ligaments and fascia providing support to the pelvic organs?
Pathophysiology = failure of interaction between levator ani muscles (puborectalis, pubococcygeus, iliococcygeus) and the ligaments and fascia that support the pelvic organs. Levator ani are meant to support the pelvic organs and relivee excessive pressure from ligaments and fascia.
Level 1 -
- Apical vaginal support given by uterosacral ligaments attaching cervix to sacrum.
- Defects –> descent of cervix into vagina.
Level 2 -
- Midvaginal support given by fascia lying between the vagina and bladder (pubocervical fascia) or vagina and rectum (rectovaginal fascia).
- Defects –> prolapse of vaginal wall (anterior or posterior) into vaginal lumen with the bladder or rectum prolapsing behind the vaginal wall due to fascial attachment.
Level 3 -
- Lower vaginal support given by the perineal body and posterior vaginal fascia. Can be damaged during episiotomy.
- Defects –> lower posterior vaginal wall prolapse but may also cause anterior vaginal wall prolapse since loss of perineal body increases size of vaginal opening.
What are the 3 stages of prolapse?
- Stage I where the prolapse does not reach the hymen.
- Stage II where the prolapse reaches the hymen.
- Stage III when the prolapse is mostly or wholly outside the hymen. When the uterus prolapses wholly outside this is termed procidentia.
What is the name for whole prolapse of the uterus?
procidentia
What is the name given to upper half anterior vaginal prolapse?
Cystocele
What is the name given to lower half anterior vaginal prolapse?
Urethrocele
What is the name given to posterior vaginal prolapse of the upper vs lower half?
Upper half = enterocele - herniation of the pouch of Douglas, including small intestine, into the vagina
Lower half = rectocele
What additional investigations should be arranged in vaginal prolapse causing indirect symptoms?
In view of the complex relationship between prolapse and bladder or bowel functions, if women have additional indirect symptoms, then it is prudent to arrange
- urodynamic assessment or functional tests of the lower bowel,
- endoanal ultrasound to check for anal a sphincter defects,
- rectal manometry,
- flexible sigmoidoscopy
- defaecating proctogram.
These investigations should be reviewed in an MDT with gynaecologists, colorectal surgeons, continence nurses and physiotherapists.
What general advice should you give to patients with urogenital prolapse? What conservative management can be used?
- Weight loss advice if BMI >30kg/m2
- Avoid heavy lifting
- Prevent/treat constipation
16-week course of pelvic floor exercises
What is the conservative/medical management of vaginal prolapse? What are the side effects of these treatments?
Pelvic floor muscle exercises - but unlikely to reduce anatomical extent of the prolapse and unhelpful for those with prolapse beyond the vaginal introitus
Vaginal suppport pessary changed every 6 months -
- Good for the medically unfit and elderly;
- Range of shapes available; changed every 6 months and examined for signs of ulceration + incarceration:
- Ring pessaries - tried first, require an intact perineal body, sex theoreticallly possible.
- Shelf pessaries, Gelhorn pessaries and others - useful in deficient perineal bodies but sex is not possible
- Complications include bleeding, discharge and incarceration (GA removal warranted), rectovagina;/vesicovaginal fistula formation
+/- conservative treatments for bladder/bowel problems
What surgical managements can be used for vaginal prolapse in patient with no preference for preservation of uterus?
Vaginal hysterectomy ± vaginal sacrospinous fixation (removal of the uterus ± stitching the top of the vagina to a right sacrospinous ligament with non-absorbable or slowly-absorbable sutures
Vaginal sacrospinous hysteropexy (cervix is stitched to a ligament in the pelvis)
Manchester repair (shortening of the cervix to support the uterus)
Sacro-hysteropexy with mesh (mesh used to attach the uterus to sacral vertebra)
What surgical management for vaginal prolapse can be used in a patient who wants to preserve their uterus?
Vaginal sacrospinous hysteropexy/fixation (shown) - most common as many women want to avoid hysterectomy
Sacrocolpopexy
What is Manchester repair?
Shortening of the cervix for vaginal prolapse
