Pelvic floor disorders Flashcards
Define prolapse
- Descent of pelvic organs due to weakness of the structures that normally hold in place
Endopelvic fascial ligaments
- Pubocervical
- Cardinal ligaments
- Uterosacral ligaments
Etiology
- Congenital weakness in endopelvic fascia
- Acquired
a. Childbirth->Forceps, vacuum, ++birth weight, prolonged second stage b. Lifestyle->Obesity, chronic cough, constipation, heavy loads, ageing
Classification of genital prolapse
- Dislocation of the urethra
Displaced downwards and backwards off the pubic
- Cystocele
Herniation of bladder trigoe->weak vaginal/pubocervical fascia
Bladder pouch forms, residual urine, UTI
- Uterine prolapse
Uterus and cervix
- Enterocele
Pouch of douglas herniation
- Rectocele
Prolapse of lower vaginal wall->rectum bulges into vagina
- Perineal body
May be deficien/part of anal canal buldging into vagina
Degress of cystocele
- First degree: Cervix remains in upper vagina, >1 cm from hymen 2. Second degree: Cervix reaches down to vulva on straining, doesn’t pass through it w/i 1cm hymen 3. Third degree: cervix/some of uterus prolapsing outside vaginal orifice
History in pelvic organ prolapse
- Symptoms
a) Vaginal b) Urinay c) Bowel d) sexual
Lump in vagina
Dragging feeling
Bachache
Difficult intercourse
Bleeding/discharge/ulceration
UTI Incomplete bladder emptying
Manual defecation/urination
- Risk factors
Vaginal birth
Operative
Pelvic surgery
Obesity
Constipation
Cough
Smoking
CT->history of hernias
Eamination
- Empty bladder/bowel 2. Speculum 3. Strong valsalva 4. Anterior Urethra + bladder 5. Central w/ uterus, small bowel Uterine prolapse Vault prolapse 6. Posterior compartment Small bowel Rectum
Differential
Vaginal and periurethral cysts
Tumors
Diverticulum of urethra
Urethral caruncle
Mucosal prolapse
Prevention
- In childbirth
Careful Mx of labour
Discourage from pushing until fully dilated= ++strain on uterine supports’
Do not prolong second stage unduly
Carefully suture episiotomies in layers
Postnatal exercises
- Lose weight
- Treat underlying cause of cough
- Smoking cessation
- Treat constipation
Management
- Pelvic floor exercises, watchful waiting
- Treat UTI
- Antispasmodics for urge incontinence and detrusor instability
- Pessaries
Exchanged every 3-4 months
B/t posterior fornix and anterior vaginal wall
May cause ulceration, embed in wall, carcinoma
- Vaginal surgery
Anterior and posterior colporrhaphy
Sling repair, transvaginal mesh repair
Need urodynamics prior to treatment
- Uterine prolapse
Hysterectomy
Apex or paravaginal repair
Delancey classification
- Level 1 (paramilleurian): The cardinal-uterosacral ligament complex provides apical attachment of the uterus and vaginal vault to the bony sacrum. Uterine prolapse occurs when the cardinal-uterosacral ligament complex breaks or is attenuated.
Organ: Uterus, vault
Symptoms: Back pain, urinary obstruction, fullness/mass, UTI
Pathology: Uterine prolapse
Treatment: Transvaginal sacrospinous fixation/hysteropexy->attach to sacrospinous ligament
Laparoscopic sacrocolpopexy->Mesh fixed to ant and posterior vault stapled to sacral promontory
- Level 2: The arcus tendineous fascia pelvis and the fascia overlying the levator ani muscles provide support to the middle part of the vagina
Damage results in rectocele or cystocele (pubo-vesical-cervical fascia)
a) Anterior
Organ: Bladder: paravaginal fascia
Symptoms: obstruction
Pathology: cystocele
Treatment: Native tissue repair, Mesh repair (low recurrence, extrusion, protrusion)
Colporrhaphy
b) Posterior: Rectum
3. Level 3 (urogenital sinus, cloaca): The urogenital diaphragm and the perineal body provide support to the lower part of the vagina.
Damage results in deficient perineal body or urethrocele
a) Anterior: Urethra, periurethral fascia
Symptoms: Stress urinary incontinence
Pathology: Urethrohypomobility
Treatment: Transvaginal tape
b) Posterior: Perineum, peritoneum
Symptoms: Vaginal wind
Pathology: Deficient perineum
Treatment: Perinealplasty
Staging uterine prolapse
Stage 0: No prolapse
Stage I: The most distal portion of the prolapse is >1 cm above the level of the hymen
Stage II: The most distal portion of the prolapse is ≤1 cm proximal or distal to the hymen
Stage III: The most distal portion of the prolapse is >1 cm below the hymen but protrudes no further than 2 cm less than the total length of the vagina
Stage IV: Complete eversion of the vagina
Degree of perineal tear
Episiotomy
- Incision in perineum
- the perineum is incised with scissors or a scalpel as the infant’s head is crowning.
- An incision is begun at the posterior fourchette and continued downward at an angle of at least 45° relative to the perineal body. The angle of the incision may approach 90° (perpendicular to the posterior fourchette) if the perineum is significantly stretched by the fetal head, so that upon relaxation of the perineum the angle will approach 45°. The incision can be performed on either side and is generally 3-4 cm in length.
- anatomic structures involved in a mediolateral episiotomy include the vaginal epithelium, transverse perineal muscle, bulbocavernosus muscle, and perineal skin.
