Complications of Delivery - POP, FUI Flashcards
(40 cards)
epidemiology of POP?
- 50% of parous, 12-30% multiparous, 2% nulliparous - 10% of the 50% asymtptomatic
- 20% of the waiting list fr major gynaecological surgery
what are the main structures in the pelvis that will increase the abdominal pressure?
- bladder
- rectum
- uterus
the 3 pelvic floor layers and their function.
- endopelvic fascia - forms a hammock and holds the visceral structures together.
- pelvic diaphragm - levator ani and coccygeus muscle + fascial coverings
- urogenital diaphragm - superficial/deep transverse perineal muscles and fascial coverings.
what are the 4 fascial structures that make up the endopelvic fascia? Just the name
- cardinal/uterosacral complex
- pubocervicalis fasica
- rectovaginalis fascia
- endopelvic coverings
what are the 3 levels of prolapse that can happen in endopelvic covering, and what damage to which structures will cause which prolapse?
level 1: apical prolapse - uterosacral/cardinal ligaments complex
level 2: post/ant vaginal wall prolapse - pubocervicalis fascia, rectovagianlis fascia, arcus tendineus fascia
level 3: perineal plasty - perineal body, urogenital diaphragm
what are the attachments and most likely damage of the cardinal ligament?
fibromuscular connective tissue btw cervix and sacrum, allows restricted side to side movement of cervix
attachments:
- medially: uterus, cervix, vaginal fornices, puborectalis/vaginalis fascia
- laterally: sacrum, fascia over the piriformis
damage:
- medially –> uterine prolapse when the ligament is flaccid (during sleep)
what are the attachments and most likely damage of the pubocervicalis fascia?
trapezoid fibromuscular tissue that provides the main support between the bladder and ant vaginal wall.
attachements:
- medially: base of cervix and cardinal ligament
- laterally: arcus tendineus fascia pelvis
- distally: urogential diaphragm
damage:
- lateral vaginal damage: worsens with central suture
- central damage: needs central suture
what are the attachments and most likely damage of the rectovaginalis fascia?
fibromuscular ELASTIC tissue
attachments:
- medially: cardinal/uterosacral ligament, peritoneum
- laterally: levator ani fascia
- distally: perineal body
defects:
- upper defect: enterocele
- lower defect: rectocele
etiology/risk factors for POP (10) - which is the strongest risk factor?
- higher parity - MAIN
- large baby
- forceps delivery
- obesity
- increasing maternal age
- hormonal issues (decreased E with age)
- quality of connective tissue
- previous pelvic surgery
- prolonged second stage labor
- increased intra-abdominal pressure: constipation, heavy lifting, exercise, lung conditions that cause coughing.
what are the types of pelvis surgery that puts people at risk of POP (3)
- continence procedures
- 25% burch colposuspension (fixing lateral vaginal fornices to the iliopectineal ligaments, resulting in posterior vaginal wall damage)
- hysterectomy (11.9%, esp for previous prolapse)
types of prolapse (5) - describe the location of prolapse and the organ it involves
- urethrocele - lower anterior wall, involving the urethra
- cystocele - upper anterior wall, involving the bladder
- uterovaginal prolapse - apical, involving the uterus/cervix/upper vagina
- enterocele - upper posterior wall, involving the small bowels
- rectocele - lower posterior wall, involving the rectum
presentation of POP, divide into vaginal (3), urinary (3), and bowel (4) symptoms.
vaginal:
- sensing/seeing the bulge/protrusion
- feeling of pressure and heaviness
- difficulty inserting tampons
urinary:
- frequency/urgency - MAIN
- incontinence
- retention (prolapse resulting in kink in the urethra) - hesitancy, weak/prolonged stream, incomplete emptying –> manual reduction of the prolapse is needed
bowel:
- incontinence of flatus/liquid/solid
- incomplete emptying
- constant feeling of urgency
- digital evacuation through the vagina instead of rectum is needed
how is POP diagnosed?
clinical diagnosis + examination
POP investigations are not for diagnosis but for its symptoms. List some (5)
- examination (to exclude pelvic mass)
- POPQ score (GOLD standard)
- USS/MRI (identify fascial/muscle defects)
- urodynamics (exclude SUI)
- IVU/renal USS (ureteric obstruction)
management of POP? (5) Which are the main conservative managements?
- *pelvic floor muscle training (PFMT)
- *vaginal pessaries
- avoid increased intra-abdominal pressure (treat constipation, lung conditions)
- constant perineal message
- surgery
the roles of surgery in POP (3)
- relieve symptoms
- restore/maintain bladder and bowel function
- maintain vaginal sexual function
what are some of the prophylactic/post surgical management you need to consider after POP surgery?
- prophylaxis abx
- thrombo-embolic prophylaxis
- post-op catheter/SPC
is PFMT useful all the time?
no, it is only useful in mild (stage I/II) POP, and in those who still wish to get pregnant
what are the surgery needed for each type of POP?
- ant/post wall prolapse: wall repair
- apical prolapse: (can combine)
- vaginal hysterectomy/hysteropexy
- sacrospinous fixation
- abdominal sacrocolpopexy/hysteropexy
- colpocelsis (only in those who are no longer sexually active)
what is the clinical significance of the vesicoureteric mechanism?
allows urine to pass from 1 direction only and protects the nephrons from back pressure and infection from the bladder
the 4 parts of the nervous system and its control over micturition.
- sympathetic (hypogastric n. T10-12) –> storage
- contraction of urethral sphincters
- relaxation of bladder
- parasympathetic (pelvic n. S2-4) –> voiding
- relaxation of urethral sphincters
- contraction of bladder
- autonomic (pudendal n. S2-4) –> voluntary
- contraction of pelvic floor muscles
- contraction of urethral sphincter
- cortical activity and higher centers (pontine micturition center)
- storage: (+SNS, -PNS) contraction of rhabdosphincter and bladder base
- voiding: (-SNS, +PNS) detrusor contraction, urethral sphincter relaxation, sphincter coordination
- voluntary: hypothalamus override
3 different types of incontinence and their definition.
- stress UI (SUI): involuntary leakage on effort or exertion, like sneezing/coughing
- urgency UI (UUI): involuntary leakage with immediate or preceded by urgency
- mixed UI (MUI): involuntary leakage immediately followed or preceded by urgency upon exertion.
epidemiology of FUI
- 10-25% 15-60 yrs (> 45 yrs)
- 15-40% > 60 yrs
- 50% women in care homes
risk factors of FUI
(same as POP with addition of smoking)
- parity
- instrumental delivery
- age
- medical conditions
- poor connective tissue quality
- smoking
- menopause (hormones)
- trauma to pelvic floor
- pervious surgery (if previous conservative treatment failed, they would need continence surgery)
- denervation
- increased intra-abdominal pressure
