Structural Abnormalities

Question 1

What is cystocele?

Answer 1

bladder prolapse (cystocele) is a bulge of the bladder into the vagina

Question 2

What are the characteristics of cystocele?

Answer 2

anterior vaginal prolapse of the posterior bladder wall into the vagina, emerging from the introitus

Question 3

What can a cystocele result from?

Answer 3

childbirth, constipation, violent coughing, heavy lifting, or other pelvic muscle strain

Question 4

What are the symptoms of cystocele?

Answer 4

include feeling pressure in the pelvis and vagina, discomfort when straining, and feeling that the bladder hasn’t fully emptied after urinating

• feels like “sitting on a ball” or “something is falling out”
• worse with Valsalva and better with redundancy
• concurrent urinary incontinence

Question 5

How is a cystocele dx?

Answer 5

diagnose with POP-Q (pelvic organ prolapse quantification): quantifies the extend and location of defects, ultrasound, or MRI
-additional testing: Q-tip test, voiding cystourethrogram (VCUG), cystometrogram

Question 6

What is the tx of cystocele?

Answer 6

includes a flexible ring pessary to support the bladder or surgical repair with mesh augmentation

• prophylaxis with Kegel exercises: strengthen levator ani and perineal muscles
• estrogen therapy after menopause maintains tone and vitality of the tissue

Question 7

What is a rectocele?

Answer 7

herniation of the rectum into the posterior wall of the vagina

Question 8

What can lead to a rectocele?

Answer 8

childbirth and other processes that put pressure on the tissue wall can lead to a rectocele

Question 9

What does a rectocele result in?

Answer 9

pelvic pressure + bowel symptoms

Question 10

What are the symptoms of a rectocele?

Answer 10

include a soft bulge of tissue in the vagina that may or may not protrude through the vaginal opening

• defecatory dysfunction (constipation, straining, incomplete emptying)
• perceived or discovered bulge into the vagina, low back pain

Question 11

How is a rectocele dx?

Answer 11

POP-Q (pelvic organ prolapse quantification): quantifies the extent and location of defects
-get a colonoscopy to rule out cancer and rectal studies if indicated

Question 12

What is the tx of rectocele?

Answer 12

kegel exercises, pelvic floor retraining, behavioral changes, bowel regimen, pessary, surgical repair or repair with mesh augmentation

Question 13

What is ovarian torsion?

Answer 13

refers to the rotation of the ovary at its pedicle to such a degree as to occlude the ovarian artery and/or vein

Question 14

How do patients with ovarian torsion?

Answer 14

present with sudden onset of sharp and usually unilateral lower abdominal pain, in 70% of cases accompanied by nausea and vomiting

Question 15

How is ovarian torsion dx?

Answer 15

abdominal ultrasound with doppler flow is the diagnostic test of choice
-doppler flow is not always absent in torsion-the gold standard for the diagnosis of ovarian torsion is laparoscopy

Question 16

What is the tx of ovarian torsion?

Answer 16

the mainstay of treatment of ovarian torsion includes laparoscopic surgery to uncoil the ovary

Question 17

What is uterine prolapse?

Answer 17

when the uterus descends toward or into the vagina

• it happens when the pelvic floor muscles and ligaments become weak and there are no longer able to support the uterus
• in some cases, the uterus can protrude from the vaginal opening

Question 18

What are the signs and symptoms of uterine prolapse?

Answer 18

• caucasian women, after labor/delivery, chronic cough
• vaginal fullness, abdominal pain worse late in the day, after prolonged standing
• relieved by lying down

Question 19

How are uterine prolapse graded?

Answer 19

prolapse of the uterus into the vaginal canal - graded by uterine descent

Question 20

What is 0 degree uterine prolapse?

Answer 20

no descent

Question 21

What is 1st degree uterine prolapse?

Answer 21

to the upper vagina/between ischial spines and hymen

Question 22

What is 2nd degree uterine prolapse?

Answer 22

to the Introits/between ischial spines and hymen

Question 23

What is 3rd degree uterine prolapse?

Answer 23

cervix is outside the introitus/within hymen

Question 24

What is 4th degree uterine prolapse?

Answer 24

(sometimes referred to as providentia); uterus and cervix entirely outside the introitus/through the hymen

Question 25

How is uterine prolapse dx?

Answer 25

diagnosis is confirmed by a speculum or bimanual pelvic examination

• vaginal ulcers are biopsied to exclude cancer
• simultaneous urinary incontinence requires evaluation

Question 26

What is the tx of uterine prolapse?

Answer 26

asymptomatic 1st or 2nd degree prolapse can be treated with a pessary if the perineum can structurally support a pessary

• severe or persistent symptoms and 3rd or 4th degree prolapse require surgery
• usually hysterectomy with surgical repair of the pelvic support structures (colporrhaphy) and suspension of the top of the vagina (suturing of the upper vagina to a stable structure nearby)