Flashcards in 18: Pelvic organ prolapse Deck (24)
Pelvic organ prolapse
herniation of the anterior, apical, or posterior vaginal walls into the vaginal lumen. Traditionally, these were named by the organ presumed to be behind the prolapse including bladder (cystocele), urethra (urethrocele), rectum (rectocele), small bowel (enterocele), and/or uterus (uterine prolapse).
Vaginal vault prolapse occurs most commonly in patients who have undergone
hysterectomy but may occur in conjunction with weakness or laxity of the cardinal/uterosacral ligaments as seen with uterine prolapse. The vagina can then invert into the vaginal canal and potentially prolapse outside the body in its most severe form.
risk factors for prolapse
obstetric trauma (vaginal deliveries), advancing age, menopause, and parity, chronic elevations in intra-abdominal pressure, obesity, chronic cough (COPD), heavy lifting, hypoestrogenic state, and inherent poor tissue quality, such as associated with musculoskeletal syndromes/CT disorders, hysterectomy (apical)
Pelvic organ prolapse primarily manifests as ?
pelvic pressure and vaginal bulging although urinary, defecatory, and sexual dysfunction can be present
Pelvic organ prolapse is diagnosed primarily by ?
H+P, may also require urine cultures, cystoscopy, urethroscopy, urinary dynamic studies, anoscopy, sigmoidoscopy, and defecography as indicated.
Both the ? and the ? are used for the quantification of pelvic organ prolapse.
POP-Q and the Baden-Walker systems
POP-Q is used more in research, whereas Baden-Walker halfway system is used more clinically to quantify the degree of pelvic organ prolapse.
Pelvic organ prolapse can be treated nonsurgically with ?
Kegel exercises, pelvic floor physical therapy, and biofeedback. Vaginal pessary use is the mainstay of nonsurgical management of POP
-low-dose vaginal estrogen to improve tone and reverse atrophy
Surgical treatment options for POP
anterior and posterior colporrhaphy for cystoceles and rectoceles, respectively. These procedures repair the fascial defect and strengthen the existing vaginal wall support.
Uterine prolapse is most commonly treated with ?
abdominal or vaginal hysterectomy with apical suspension of the vault.
Vaginal vault prolapse is repaired by ?
resuspending the vaginal vault to a fixed structure in the pelvis.
women who are poor surgical candidates and no longer plan vaginal intercourse may be offered a ?
colpocleisis. This vaginal obliterative procedure is less invasive with a shorter operative time, fewer complications and recurrences and a high patient satisfaction rate.
technique to best visualize prolapse
split-speculum examination: using a Sims speculum or the lower half of a Grave speculum to retract the posterior vaginal wall (to visualize cystocele) and split speculum placed upside down retracting the anterior vaginal wall (to visualize rectoceles and enteroceles)
complete eversion of the vagina with the entire uterus prolapsing outside the vagina
Baden-Walker Halfway Scoring System
0 represents normal anatomic position (i.e., no descensus)
1 represents descensus halfway to the hymen
2 represents descensus to the hymen
3 represents descensus halfway past the hymen
4 represents maximum descent.
Pelvic Organ Prolapse Quantitative scale (POP-Q)
focuses on the physical extent of the vaginal wall prolapse
-uses six points within the vagina that are measured relative to a fixed point of reference: the hymen.
ddx for cystocele and urethrocele
urethral diverticula, Gartner cysts, Skene gland cysts, and tumors of the urethra and bladder
ddx for rectocele
obstructive lesions of the colon and rectum (lipomas, fibromas, sarcomas)
ddx for uterine prolapse
Cervical elongation, prolapsed cervical polyp, prolapsed uterine fibroid, and prolapsed cervical and endometrial tumors, lower uterine segment fibroids.
Pessaries act as ?
mechanical support devices to replace the lost structural integrity of the pelvis and to diffuse the forces of descent over a wider area
-fitted in the vagina, positioned like a diaphragm, and serve to hold the pelvic organs in their normal position
Anterior colporrhaphy: Plication (reinforcement) of the endopelvic fascia and reattachment to the apex or uterine cervix (if present) to resuspend the anterior vaginal wall and bladder
Posterior colporrhaphy: Similar to anterior colporrhaphy, except the posterior endopelvic fascia is identified and reattached to the apical support or uterine cervix (if present) and distally to the perineal body
Vaginal enterocele repair: The enterocele is repaired along with the reattachment of the rectovaginal fascia to the apex or uterine cervix (if present)
Uterine prolapse repair
Hysterectomy (abdominal or vaginal) and McCall culdoplasty: Hysterectomy followed by attachment of the resulting vaginal cuff to the uterosacral ligaments to decrease the risk of future vault prolapse