Genitourinary Prolapse Flashcards by Elliot Jones

What is a uterine prolapse?

When the female pelvic organs fall from their normal position into or through the vagina

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What % of parous women are affected by pelvic organ prolapse?

40-60%

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Why is the exact incidence of pelvic organ prolapse difficult to determine?

Many do not receive medical advice

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What is a woman’s lifetime risk of surgery for pelvic organ prolapse?

12-19%

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What is the most common type of pelvic organ prolapse prolapse?

Prolapse of the anterior vaginal wall

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What provides the main support for the pelvic organs?

Levator ani muscle

- Endopelvic fascia

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What is the endopelvic fascia?

A connective tissue network connecting the organs to the pelvic muscles and bones

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What organs can be involved in a pelvic organ prolapse?

Uterus
Bladder
Rectum
Small or large bowel
Vaginal vault

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Where can the organs of a pelvic organ prolapse affect when they descend?

Anterior/posterior vaginal walls

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What usually underlies most cases of pelvic organ prolapse?

Multifactorial causes

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What can be involved in the multifactorial causes of pelvic organ prolapse?

Direct muscle trauma
Neuropathic injury
Disruption or stretching of support

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What different compartments of the pelvis can be affected by pelvic organ prolapse?

Anterior
Middle
Posterior

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What are the types of anterior compartment pelvic organ prolapse?

Urethrocele

- Cystocele

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What are the types of middle compartment pelvic organ prolapse?

Uterine prolapse
Vaginal vault prolapse
Enterocele

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What are the types of posterior compartment pelvic organ prolapse?

Rectocele

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Why do crabs make good burglars?

They’re great at pinching things

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What is a urethrocele?

Prolapse of the urethra into the vagina

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What is a cystocele?

Prolapse of the bladder into the vagina

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What is a uterine prolapse?

Descent of the uterus into the vagina

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What is a vaginal vault prolapse?

Descent of the vaginal vault post-hysterectomy

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What is an enterocele?

Herniation of the pouch of Douglas (including small intestine/omentum) into the vagina

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What is a rectocele?

Prolapse of the rectum into the vagina

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What system is used to grade pelvic organ prolapse?

POPQ system

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What is the POPQ system?

Pelvic Organ Prolapse Quantification System

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What is a Stage 0 POPQ pelvic organ prolapse?

No prolapse

What is a Stage 1 pelvic organ prolapse?

More than 1 cm above the hymen level

What is a Stage 2 pelvic organ prolapse?

Within 1 cm proximal/distal to the plane of the hymen

What is a Stage 3 pelvic organ prolapse?

More than 1cm below the plane of the hymen but no further than 2cm less than total length of the vagina

What is a Stage 4 pelvic organ prolapse?

Complete eversion of the vagina

What are the risk factors for pelvic organ prolapse?

- Increasing age - Vaginal delivery - Increasing parity - Obesity - Previous hysterectomy

How do mild pelvic organ prolapses present?

Many are asymptomatic and are incidental findings

How severe can the symptoms of pelvic organ prolapse be?

Severe enough to affect quality of life

What are the symptoms of pelvic organ prolapse related to?

Site and type of prolapse

What are the vaginal/general symptoms of pelvic organ prolapse?

- Sensation of pressure/fullness/heaviness - Sensation of bulge or 'something coming down' - Seeing/feeling a bulge/protrusion - Difficulty retaining tampons - Spotting

What can cause spotting in a pelvic organ prolapse?

Ulceration of the prolapse

What are the potential urinary symptoms of pelvic organ prolapse?

- Incontinence - Frequency - Urgency - Feeling of incomplete bladder emptying - Weak or prolonged urinary stream - Need to reduce prolapse manually before voiding - Need to change position to start voiding

What are the symptoms of coital difficulty that may present in pelvic organ prolapse?

- Dyspareunia - Loss of vaginal sensation - Vaginal flatus - Loss of arousal

What are the potential bowel symptoms in pelvic organ prolapse?

- Constipation/straining - Urgency of stool - Incontinence of flatus or stool - Incomplete evacuation - Need to apply digital pressure to perineum or posterior vaginal wall to enable defecation - Digital evacuation necessary

In what positions should patients presenting with pelvic organ prolapse be examined?

- Standing | - Left lateral position

What should the patient be asked to do whilst examining for prolapse?

Strain

How should the vagina be examined when assessing pelvic organ prolapse?

With a speculum

What may be noticed on pelvic organ prolapse examination?

- Ulceration - Hypertrophy - Bleeding

When are abnormalities of the mucosa likely to occur in pelvic organ prolapse?

When the prolapse protrudes beyond the hymen level

How is pelvic organ prolapse usually diagnosed?

Based on history and examination

What tests should be considered if urinary symptoms are present in pelvic organ prolapse?

- Urinalysis/MSU - Post-void residual urine volume testing using catheter or bladder USS - Urodynamic investigations - Urea and creatinine - Renal USS

What tests can be considered if bowel symptoms are present in pelvic organ prolapse?

- Anal manometry - Defecography - Endo-anal USS

When is treatment of a prolapse not necessary?

In mild and/or asymptomatic prolapse

What are the broad management options for pelvic organ prolapse?

- Conservative - Vaginal pessary - Surgery

Who is conservative management of pelvic organ prolapse particularly helpful for?

- Mild prolapse - Want further pregnancies - Frail or elderly - High anaesthetic risk - Don't want surgery

What are the approaches to conservative management of pelvic organ prolapse?

- Watchful waiting - Lifestyle modification - Pelvic floor muscle exercises - Vaginal oestrogen creams

When may further treatment be required for pelvic organ prolapse following watchful waiting?

If symptoms become troublesome or complications develop

What lifestyle modifications can conservatively treat pelvic organ prolapse?

- Weight loss - Minimising heavy lifting - Preventing or treating constipation

Who can vaginal oestrogen creams be useful for treating pelvic organ prolapse in?

Women with signs of vaginal atrophy

What is the function of a vaginal pessary in pelvic organ prolapse?

It is inserted in the vagina to reduce the prolapse and provide support and relieve pressure on the bladder and bowel

What can vaginal pessaries be used in combination with to treat pelvic organ prolapse?

Pelvic floor muscle exercises

How long can vaginal pessaries for prolapse be used for?

- Short-term prior to surgery | - Long-term if surgery is not an option

What should patients wanting vaginal pessary for prolapse be made aware of?

- More than one fitting may be necessary - May affect sexual intercourse - Should be changed every 6 months - Complications

What are the potential complications of a vaginal pessary for pelvic organ prolapse?

- Bleeding - Discharge - Difficulty removing pessary - Expulsion - Vesicovaginal and rectovaginal fistulas - Faecal impaction - Hydronephrosis - Urosepsis

What are the indications for surgical intervention for pelvic organ prolapse?

- Failure of conservative management - Presence of voiding problems or obstructed defecation - Recurrence of prolapse - Ulceration - Irreducible prolapse - Woman prefers surgery

What are the goals of surgical intervention for pelvic organ prolapse?

- Restore anatomy - Improve symptoms - Return bladder, bowel and sexual function

What does the choice of surgical procedure for pelvic organ prolapse depend upon?

- If woman is sexually active - If family is complete - General fitness - Whether has had a hysterectomy - Nature of prolapse

What is a controversial surgery for pelvic organ prolapse?

Mesh repair

Why is mesh repair for pelvic organ prolapse a topic of controversy?

Concerns of long-term health problems

What are the long-term complications of mesh repair for pelvic organ prolapse?

- Extrusion - Erosion - Bleeding - Pain - Dyspareunia - Bladder/bowel dysfunction

What are the surgical options for bladder/urethral prolapse?

- Anterior colporrhaphy | - Colposuspension

What happens in an anterior colporrhaphy?

Folds the fibromuscular layer of the anterior vaginal wall

What are the intraoperative complications of anterior colporrhaphy?

- Haemorrhage - Haematoma - Cystotomy

When can a colposuspension be considered for treatment of pelvic organ prolapse?

For urethral sphincter incontinence associated with cystourethrocele

How is a colposuspension performed?

Paravaginal fascia on either side of the bladder neck and base of the bladder are approximated to pelvic side wall by sutures through ipsilateral iliopectineal ligament

What are the surgical options for a uterine prolapse?

- Hysterectomy - Sacrocolpoplexy - Sacrospinus fixation

What is a sacrocolpoplexy?

The uterus is attached to the longitudinal ligament over the sacrum

What are the ways a sacrocolpoplexy can be performed?

- Laparoscopic | - Open

What is an advantage of a sacrocolpoplexy for uterine prolapse?

Woman can retain her uterus

What is a sacrospinus fixation of uterine prolapse?

Unilateral or bilateral fixation of the uterus to the sacrospinus ligamnet

What are the risks of sacrospinus fixation for uterine prolapse?

Injury to the pudendal nerve and vessels and the sciatic nerve

What are the surgical options for a vault prolapse?

- Sacrospinus fixation | - Sacrocolpoplexy

What is the surgical option for a recto/enterocele?

Posterior colporrhaphy

What is obliterative surgery for pelvic organ prolapse?

The prolapse is corrected by moving the pelvic viscera back into the pelvis and closing off the vaginal canal

What are the advantages of obliterative surgery for pelvic organ prolapse?

- Almost 100% effective - Reduced peri-operative morbidity - Safe for those who are frail

What is the main disadvantage of obliterative surgery for pelvic organ prolapse?

Vaginal intercourse is no longer possible

What are the potential complications of pelvic organ prolapse?

- Ulceration and infection of prolapsed organs outside introitus - Urinary tract complications - Bowel dysfunction

What are the urinary complications that can occur with pelvic organ prolapse?

- Stress incontinence - Chronic retention and overflow incontinence - Recurrent UTIs

Genitourinary Prolapse Flashcards

(82 cards)