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Obstetrics & Gynaecology > Prolapse > Flashcards

Flashcards in Prolapse Deck (9)
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1
Q

PRE-DISPOSING FACTORS:

A
  1. Childbirth
    - Multiple, operative, vaginal, macrosomia
  2. Surgery
    - suprapubic operation for urinary incontinence, hysterectomy
  3. Menopause
  4. Congenital
  5. Genetics
2
Q

AGGRAVATING FACTORS:

A

Conditions which raise intra-abdominal pressure:

  • Obesity
  • Chronic cough
  • Constipation
3
Q

TYPES:

A
  1. Urethrocele
    - Stress incontinence
  2. Cystocele
    - Cystourethrocele if together with urethra
  3. Uterus and Cervis
    a) First degree: Cervix does not reach introitus
    b) Second degree: Descent of cervix to level of introitus
    c) Third degree: Cervix and uterus protrude out of vagina
    d) Procidentia: Cervix, uterus and vaginal wall completely prolapse through introitus.
    - can lead to ulceration of cervix and thickening of vaginal mucosa
  4. Rectocele
  5. Enterocele
    - hernia
    - has sac, neck and contents
    - protrusion of peritoneum of pouch of Douglas, may contain small bowel/omentum
  6. Total Vault Prolapse
    - Complete eversion of vagina following hysterectomy
4
Q

SYMPTOMS:

  1. General
  2. Specific
A
    • asymptomatic
      - Dragging feeling
      - Backache that improves when lying down
  1. a) Anterior wall prolapse
    - Urinary symptoms: stress incontinence, frequency
    * large cystocele can cause incomplete emptying, urinary retention, recurrent UTI
    b) Uterine prolapse
    - Feeling of lump
    - Procidentia causes bleeding/discharge
    c) Rectocele
    - Incomplete evacuation
    - Have to press posterior wall backwards to pass stool
    d) Enterocele
    - Usually presents as lump
    - May be associated with non-specific lower abdominal discomfort
5
Q

SIGNS

A
  1. Obesity, signs of chronic chest condition
  2. On pelvic exam:
    - ask to strain
    - bimanual examination can help identify type and severity
    - Sims position
6
Q

MANAGEMENT:

  1. Conservative
  2. Surgical
A
    • treat underlying cause of raised abdominal pressure: weight loss, reduce cough, treat constipation
      - Pelvic floor exercises
      - Oestrogen cream(eg. vagifem) if atrophy present
      - Pessaries: Ring/shelf/gel horn. Change every 4-6 months.
  1. a) Anterior colporrhapy(anterior repair)
    - anterior vaginal wall prolapse.

b) Uterine descent
- Vaginal hysterectomy
- Manchester/Fothergill repair

c) Posterior colpo-perineorrhapy
- Rectocele
- Rectocele combined with enterocele

d) Total vault prolapse:
- Sacrocolpopexy
- Sacrospinous fixation
- Vaginal mesh repair

e) Complications:
- narrowed and shortened vagina which can cause dyspareunia- C-section likely indicated for deliveries

7
Q

TYPES OF PESSARIES:

A
  1. Ring
    - Most common
  2. Shelf
    - useful in procidentia
  3. Gelhorn
    - Softer so allows folding for insertion.
8
Q

COMPLICATIONS FROM PESSARIES:

A
  1. Urinary symptoms
    - frequency, infection
  2. Might not stay
  3. Vaginal discharge/bleeding
    - important to replace every 6/12
  4. Vaginal ulceration
    - if ring too large
  5. Fistula formation
  6. Granulation tissue
    - if not changed regularly
9
Q

VAGINAL MESH REPAIR COMPLICATIONS:

A
  1. Operative:
    - Bladder, rectal, vascular injuries.
  2. Long Term:
    - Dyspareunia, erosion/rejection of mesh
    - mesh-related infection
    - necrotising fasciitis