Pelvic organ prolapse Flashcards
Yellow (31 cards)
What is meant by pelvic organ prolapse?
Weakness of supporting structures causing descent of vaginal walls and/or uterus beyond normal anatomical confines. Structures from beyond the vaginal boundary may then herniate.
What is the prevalence of prolapse?
Affects up to 50% of women (typically parous)
By age 80, 10% will have had surgery for prolapse
What percentage of patients need further surgery for recurrent prolapse?
30%
In the normal pelvis, how are the vagina and uterus suspended?
Pelvic floor, split into 3 levels
Level 1 - cervix/upper third vagina supported by cardinal and uterosacral ligaments
Level 2 - middle third vagina attached to pelvic side walls by endopelvic fascia
Level 3 - lower third vagina supported by levator ani muscles and perineal body (pelvic diaphragm)
What types of prolapse can occur?
Anterior wall prolapse
Posterior wall prolapse
Uterine/vaginal vault prolapse
What terms are given when surrounding structures herniate in a prolapse?
Cystocele/urethrocele
Rectocele
Enterocele
What can be responsible for the weakness behind prolapse?
Prolonged labour
Traumatic delivery (use of instruments etc)
Lack of pelvic floor exercises
Obesity
Prolonged straining (chronic cough, constipation)
Congenital (e.g. Ehlers-Danlos)
Previous pelvic surgery
Post-menopausal (oestrogen withdrawal causes breakdown in collagen)
What may accompany an anterior wall prolapse, and how may it present?
Cystocele (urethrocele) Frequency Incomplete emptying, hesitancy, difficulty urinating, dysuria Recurrent UTI Leakage on straining Dragging sensation, feel a bulge, visible bulge Back ache Sexual dysfunction
What may accompany a posterior wall prolapse, and how may it present?
Rectocele, enterocele Constipation Incomplete emptying (may require digitation) Dragging sensation, feel a bulge Back ache Sexual dysfunction May be asymptomatic
What is uterine prolapse?
Cervix and uterus descend into vagina
Complete procidentia (displacement) when excludes past introitus (hymenal ring)
-Can become swollen/difficult to replace
-Can cause acute urinary retention
What is vaginal vault prolapse?
Top of vagina descends further down into vagina (post hysterectomy)
How would a pt present with uterine/vaginal vault prolapse?
Bladder and bowel dysfunction Dragging sensation, feel a bulge Sexual dysfunction Pain/bleeding (ulceration of extruding portion) Backache
How can prolapse be prevented?
Lower parity
Better obstetric practice
Maintain pelvic floor exercises
How should patients with suspected prolapse be examined?
Bimanual to rule out pelvic masses
Speculum (Simms) - check for atrophy/descent
Prolapse may not be obvious - ask patient to strain/stand (‘John Wayne’)
If urinary incontinence - refer to urodynamics
POP-Q scoring (grid score, tells where prolapse is)
How can prolapse be graded?
Baden-Walker classification
0 - No descend of pelvic organs during straining
First degree - lowest part of prolapse moves towards, but does not reach, introitus
Second degree - lowest part extends to introitus, and extends beyond introitus on straining
Third degree - lowest part extends beyond introitus and outside the vagina
Procidentia - uterus lying outside of vagina (fourth degree uterine prolapse)
What conservative management options can be used for prolapse?
Do nothing Pelvic floor exercises (ref to physio) Weight loss Stop smoking Avoid straining (reduce intra-abdo pressure)
What medical options are available for prolapse?
Vaginal oestrogen
Pessaries
How can prolapse be managed?
Reassure
Ring (pessaries)
Repair (surgery)
What kind of pessaries are available?
Ring (placed posterior aspect of symphysis pubis and posterior fornix)
Shelf
Gelhorn (mushroom shape)
What is it important to consider when offering a pessary?
Type of prolapse
Degree of prolapse
Sexual activity
Patient choice
How are pessaries fitted?
Trial and error
Use oestrogen cream (most pts post-meno so have atrophic vagina; oestrogen stimulates secretion, more comfortable for pt)
Ensure comfort and able to urinate after first fitting
Change every 6m and perform speculum to ensure no ulceration/bleeding
When would surgery be considered for prolapse?
Severe symptoms
Sexually active pt
Failure of pessary
What surgical options are available in prolapse?
Pelvic floor repair (colporrhaphy, perineorrhaphy)
Sacrospinous fixation (vaginal vault/cervix attached to sacrospinous ligament)
Sacrocolpopexy (vaginal vault attached to sacral promontory with mesh)
Hysteropexy (uterus attached to sacral promontory with mesh)
Hysterectomy (although risk of vaginal vault prolapse)
Colpocleisis/vaginal closure
How successful is anterior vaginal wall repair and what complications are associated with it?
70-90% success
Assoc with cystitis, constipation, dyspareunia and recurrence
