Pelvic organ prolapse Flashcards
what is the endo-pelvic fascia?
network of fibro-muscular connective-type tissue that has a “hammock-like” configuration and surrounds the various visceral structures (Uteroscaral ligaments / Pubocervical Fascia / Rectovaginal Fascia).
what is the pelvic diaphragm?
layer of striated muscles with its fascial coverings (Levator ani & coccygeus).
what is the urogenital diaphragm?
the superficial & deep transverse perineal muscles with their fascial coverings.
why do women often describe a snap/pop before discovering a prolapse?
The fibro-muscular component can stretch, the connective tissue doesn’t stretch or attenuate, it breaks.
Utero-sacral ligaments/cardinal complex:
o Medially attached to uterus, cervix, lateral vaginal fornices
o Laterally attached to the sacrum & fascia overlying the piriformis
o Easily palpated, allows limited side-to-side movement of the cervix
Pubocervical fascia:
o Provides the main support for the anterior vaginal wall
o Has three attachments = three potential defects
o Tends to break at the lateral attachment to arcus tendineus or immediately in front of the cervix
Rectovaginal fascia:
o Fibro-musculo-elastic tissue
o Tends to break centrally o If upper defect = enterocele
o If lower defect = perineal descent and rectocele
risk factors for POP
Pregnancy and vaginal birth, Forceps delivery, Large baby, Prolonged second stage of pregnancy, Advancing age, Obesity, Previous pelvic surgery, Continence procedures, Hormonal factors, Quality of connective tissue, Constipation, Occupation with heavy lifting, Certain exercises
classifications of prolapse - use UCURE
Depends of the site of the defect and the involved pelvic viscera: • Urethrocele: lower anterior vaginal wall involving the urethra only • Cystocele: upper anterior vaginal wall involving the bladder • Uterovaginal prolapse: prolapse of uterus, cervix and upper vagina • Enterocele: upper posterior wall of the vagina usually containing loops of small bowel • Rectocele: lower posterior wall of the vagina involving the rectum bulging forwards into the vagina
sy/sx
Vaginal - Sensation of a bulge or protrusion, Seeing or feeling a bulge or protrusion, Pressure, Heaviness, Difficulty in inserting tampons Urinary - Urinary incontinence, Frequency/urgency, Hesitancy, Feeling of incomplete emptying Bowel - Incontinence of flatus, liquid or stool, Feeling of incomplete emptying, Urgency
what is the difference between stress and urge incontinence?
stress incontinence- involuntary loss of urine during increases intra abdo pressure i.e. coughing, sneezing. Urge incontinence - storng sudden need to urinate, followed by bladder contraction which results in involuntary leakage.
Risk factors of developing stress incontinence…
previous pregnancy (multigravida or difficult previous deliveries), Prolapse, menopause, collagen disorders, obesity.
assessment and ix
Examination to exclude pelvic mass/ Note position during examination: left lateral/lithotomy/standing POPQ score and Baden-Walker Grading Investigations No required for diagnosis – POP is a clinical diagnosis Investigations are done into symptoms/causes = US/MRI - allow identification of fascial defects. Urodynamics – if concurrent urinary incontinence. IVU/Renal US – if suspect ureteric obstruction.
Prevention
• Avoid constipation • Effective management chronic chest pathology • Smaller family size – less vaginal deliveries • Improvements in antenatal and intra-partum care also to avoid risk of uterine prolapse: GOOD SURGICAL TECHNIQUE AT HYSTERECTOMY, AVOID A PROLONGUED STAGE OF LABOUR, PELVIC FLOOR EXERCISES AFTER PREGNANCY, HRT AFTER MENOPAUSE.
Treatment
PHYSIOTHERAPY - Pelvic floor muscle training (PFMT): Increase pelvic floor strength and bulk – this relieves the tension on the ligaments, Works in cases of milder prolapse, Younger women who plan on further pregnancies, Not suitable treatment in advanced cases, Can’t treat fascial defects VAGINAL CONES - placed in the vaginal and a women is taught to support it. PESSARIES- Made from silicone, Lucite, rubber or plastic Advantages: Long shelf-life, Resistance to autoclaving and repeated cleaning, Non-absorbent, Inertness, Hypoallergenic, Patients can be taught how to remove and insert by themselves SURGERY - Aim: Relieve symptoms, Restore/maintain bladder and bowel function, Maintain vaginal capacity for sexual function, At 1 year follow-up: successful pessary treatment is as effective as surgery.
