pelvic relaxation

Question 1

RF for prolapse

Answer 1

	Multiparity
	Operative vaginal delivery 
	Obesity 
	Advanced age 
	Prior pelvic surgery
	Estrogen deficiency 
	Neurogenic dysfunction of pelvic floor
	Connective tissue disorders
	Chronic increased intra-abdominal pressure

Question 2

prolapse is usually relieved in what position

Answer 2

v. Relieved by lying down

Question 3

when does prolapse worsen? (this is the KEY to dx)

Answer 3

throughout the day

Question 4

associated symptoms

Answer 4

i. Urinary stress incontinence–> UTI
ii. Urinary retention
iii. Defecatory dysfunction
iv. Sexual dysfunction
v. Vaginal discharge or bleeding

Question 5

grades of prolapse

Answer 5

1. 0: no prolapse
2. 1: halfway to the hymen/introitus
3. 2: at the hymen/introitus
4. 3: halfway out of the hymen
5. 4: total prolapse (procidentia)

Question 6

pessaries are most helpful for

Answer 6

mild to moderate prolapse

Question 7

what must a pessarie be used with

Answer 7

i. Must be used with topical estrogen to prevent vaginal ulceration in postmenopausal women

Question 8

a good pessarie fit

Answer 8

visible at the entroitis or easily able to take out

Question 9

after placement you should recheck pessarie in

once checked when would you instruct the pt to return to the office ?

Answer 9

ii. Check pessary 2-7 days after placement

Return every 3 months for exam

Question 10

If vaginal mucosal ulceration may occur

Answer 10

1. Stop using pessary 2-3 weeks
2. Continue topical estrogen therapy
3. Antibiotics may be needed if large ulceration or does not heal
4. Increase cleaning interval
5. Leave pessary out overnight
6. Can cause nasty infection if neglected

Question 11

Vaginal Vault Prolapse is the result of

Answer 11

Downward displacement of vaginal apex due to loss of apical support

Question 12

sxs associated with prolapse of the vaginal vault

Answer 12

c. Pelvic pressure, bearing down sensation, inguinal discomfort, dyspareunia, low back pain
d. Symptoms are progressively worse

Question 13

vaginal vault prolapse is usually due to

Answer 13

e. Due to repetitive increases in intra-abdominal pressure

usually always follow hysterectomy

Question 14

Hc and physical associated with vaginal vault prolapse

Answer 14

i. Urinary incontinence
ii. Causes of increased intra-abdominal pressure
iii. Speculum exam with straining
iv. Standing vaginal exam
v. Biospy to exclude vaginal neoplasm in severe chronic prolpase with ulceration

Question 15

vaginal vault tx for prolapse

Answer 15

h. Surgical repair
i. Temporary use of pessaries for symptomatic pts
j. Surgical techniques

Question 16

surgical techniques for vaginal vault

Answer 16

Colpectomy (removal of vagina)

Colpopexy (suspension of vaginal apex)

Question 17

III. Uterine Prolapse is usually due to

Answer 17

b. Usually due to injury to endopelvic fascia and relaxation of musculature of the pelvic floor

Question 18

Herniation of bowel and lining of peritoneal cavity through cul-de-sac/ pouch of Douglas

Answer 18

Enterocele

Question 19

enteroceles are usually seen with

Answer 19

rectocele

Question 20

Cystocele is due to

Answer 20

a. Downward displacement of bladder due to defect in anterior vaginal wall

Question 21

Q tip test is used to evaluate

Answer 21

c. Q-tip test to evaluate bladder neck mobility

determine an abnormal urethrovesical angle.

IV. Cystocele

Question 22

Procedure of choice is vaginal hysterectomy for this type of prolapse

Answer 22

uterine

Question 23

post operative care for surgical repair of prolapse involves

Answer 23

i. Ambulation
ii. Bladder drainage
iii. Bowel function
iv. Pelvic rest for 4-6 weeks

Question 24

which pessary

is used for severe prolapse

Answer 24

cube

Question 25

which pessari is used for rectocele

Answer 25

Gehrung

Question 26

which pessary is used for mild prolapse

Answer 26

ring

Question 27

which pessary is used for mod to severe prolapse

Answer 27

gellhorn (difficult to insert)

donut (used for urinary retention and perineal supprt)

inflatoball (easiest to insert)

Question 28

Cervix prolapses and brings along the anterior margin of the cul-de-sac

Answer 28

pulsion enterocele

Question 29

Cervix prolapses and brings along the anterior margin of the cul-de-sac

Answer 29

traction enterocele

Question 30

traction enteroceles are usually preceded by

Answer 30

cystocele or rectocele

Question 31

which enterocele is usually followed by rectocele or cystocele

Answer 31

pulsion