Pelvic Support Issues ppt

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Questions and Answers

Which ligaments play a key role in suspending the upper and proximal vagina?

  • Perineal body ligaments
  • Arcus tendineus fascia pelvis
  • Cardinal and uterosacral ligaments (correct)
  • Levator ani and coccygeus muscles

What characterizes a rectocele?

  • Descent of the uterus into the vaginal cavity
  • Herniation of the bladder into the anterior vaginal wall
  • Herniation of intestines into the lateral vaginal wall
  • Prolapse of the rectum into the posterior vaginal wall (correct)

Which of the following describes a potential outcome if the vaginal angle becomes more vertical?

  • Increased risk of pelvic organ prolapse (correct)
  • Rejuvenation of pelvic floor muscles
  • Strengthened uterine positioning
  • Improved pelvic organ support

At what age range does the peak incidence of pelvic organ prolapse occur?

<p>70-79 years (A)</p> Signup and view all the answers

What structures comprise Level 2 support of the vagina?

<p>Arcus tendineus fascia pelvis along the mid-vagina (A)</p> Signup and view all the answers

What is a common symptom associated with pelvic organ prolapse?

<p>Sensation of vaginal bulging (B)</p> Signup and view all the answers

Which of the following factors is NOT associated with an increased risk of pelvic organ prolapse?

<p>High physical activity levels (A)</p> Signup and view all the answers

Which statement about the POP-Q staging system is correct?

<p>Stage I indicates that the most distal prolapse is more than 1 cm above the hymen. (A)</p> Signup and view all the answers

What is a potential complication of pessary use?

<p>Vaginal erosion (D)</p> Signup and view all the answers

How can pelvic floor physical therapy assist patients with pelvic organ prolapse?

<p>It strengthens pelvic floor muscles. (A)</p> Signup and view all the answers

In which scenario is surgical intervention for pelvic organ prolapse generally recommended?

<p>Patients desiring to improve quality of life (D)</p> Signup and view all the answers

What role do Kegel exercises play in the management of pelvic organ prolapse?

<p>They strengthen the pelvic floor muscles. (C)</p> Signup and view all the answers

What is one reason for performing a bimanual exam in the physical evaluation of pelvic organ prolapse?

<p>To evaluate pelvic organs and pelvic floor tone (C)</p> Signup and view all the answers

What influence does estrogen deficiency have on pelvic organ prolapse?

<p>It diminishes the quality and quantity of collagen. (A)</p> Signup and view all the answers

What is the significance of performing a speculum exam in a patient suspected of having POP?

<p>To visualize the anterior and posterior vaginal walls (B)</p> Signup and view all the answers

What factor should be considered when planning surgical management for pelvic organ prolapse?

<p>Patient's surgical preferences and goals (A)</p> Signup and view all the answers

What does a manual reduction of prolapse imply for urinary symptoms?

<p>It helps in starting or completing voiding. (D)</p> Signup and view all the answers

What is a characteristic of Stage IV pelvic organ prolapse according to the POP-Q system?

<p>The organ protrudes out of the body completely. (B)</p> Signup and view all the answers

What anatomical structure is primarily responsible for anchoring the upper and proximal vagina?

<p>Cardinal and uterosacral ligaments (B)</p> Signup and view all the answers

In which situation would pelvic organ prolapse most likely occur?

<p>When the vaginal angle becomes more vertical (C)</p> Signup and view all the answers

Which type of pelvic organ prolapse involves the bladder?

<p>Cystocele (B)</p> Signup and view all the answers

What is the estimated percentage of women in the US who report symptoms of vaginal bulging related to pelvic organ prolapse?

<p>3-6% (B)</p> Signup and view all the answers

Which layer comprises the primary support at Level 3 of vaginal support anatomy?

<p>Fibromuscular connective tissue (B)</p> Signup and view all the answers

What primarily contributes to the resistance of increased bladder pressure in an ideally supported urogenital tract?

<p>Support from levator ani and vaginal connective tissue (D)</p> Signup and view all the answers

Which type of urinary incontinence is characterized by leakage due to sudden urges to void?

<p>Urge Urinary Incontinence (B)</p> Signup and view all the answers

Which of the following factors is least likely to be a risk factor for urinary incontinence?

<p>High-impact aerobic exercise (B)</p> Signup and view all the answers

During what process does the bladder contract while the urethra relaxes to permit urine flow?

<p>Voiding Phase (C)</p> Signup and view all the answers

What mechanism do the deep folds of the urethral mucosa facilitate to help maintain continence?

<p>Urethral mucosal coaptation (A)</p> Signup and view all the answers

Which symptom is NOT typically associated with Overactive Bladder (OAB)?

<p>Leakage of urine after a sneeze (C)</p> Signup and view all the answers

What is a common physiological effect of compromised support from the levator ani during increases in intraabdominal pressure?

<p>Urinary leakage (B)</p> Signup and view all the answers

Which symptom would likely indicate Mixed Urinary Incontinence?

<p>A combination of stress and urge symptoms (D)</p> Signup and view all the answers

What is a common neurological condition associated with neurogenic detrusor overactivity?

<p>Spinal cord injury (D)</p> Signup and view all the answers

Which of the following is a treatment modality for urge incontinence?

<p>Pelvic floor muscle training (C)</p> Signup and view all the answers

What is the purpose of a Q-tip test in the evaluation of urinary incontinence?

<p>To evaluate urethral hypermobility (C)</p> Signup and view all the answers

Which medication is categorized as an anticholinergic/antimuscarinic used for urge incontinence?

<p>Oxybutynin (B), Tolterodine (D)</p> Signup and view all the answers

What is a key feature in taking a history for female urinary incontinence?

<p>Documenting the patient's surgical history (A)</p> Signup and view all the answers

What can cause changes in the vascular plexus leading to urinary incontinence?

<p>Hypoestrogenism (D)</p> Signup and view all the answers

Which condition is NOT typically associated with increased risk of stress urinary incontinence?

<p>Hyperthyroidism (D)</p> Signup and view all the answers

What urinary volume indicates a normal post void residual (PVR)?

<p>Less than 100mL (A), Less than 150mL (B)</p> Signup and view all the answers

What is a potential outcome of inadequate contraction of surrounding musculature in the urethral system?

<p>Stress urinary incontinence (B)</p> Signup and view all the answers

Which feature is crucial in the treatment of stress urinary incontinence with pelvic floor muscle training?

<p>Practice of Kegel exercises (C)</p> Signup and view all the answers

Flashcards

Pelvic Organ Support

The structural and functional support of the pelvic organs (bladder, uterus, vagina, rectum) provided by muscles, ligaments, and connective tissues.

Pelvic Floor Muscles

Muscles that form the base of the pelvis, creating a support system.

Uterosacral Ligaments

Ligaments that support the upper vagina and uterus.

Arcus Tendineus Fascia Pelvis

Strong connective tissue that provides a supporting arch within the pelvis.

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Pelvic Organ Prolapse

The downward displacement of pelvic organs into the vagina.

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Cystocele

Prolapse of the bladder into the vagina.

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Rectocele

Prolapse of the rectum into the vagina.

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Apical Prolapse

The prolapse of the uterus or cervix.

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Enterocele

Prolapse of the small intestine into the pouch of Douglas.

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Vaginal Support Levels

Three levels of support for the vagina based on attachment to supporting structures.

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Pelvic Organ Prolapse (POP)

The dropping or bulging of pelvic organs like the bladder, uterus, or rectum into or out of the vagina.

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Prevalence of POP

The frequency or proportion of women with pelvic organ prolapse; roughly 40-50% are affected.

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Pathophysiology of POP

The underlying mechanisms causing pelvic organ prolapse, such as weakened muscles and connective tissues.

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Levator Ani Muscle Tone

The strength of the pelvic floor muscles, crucial for supporting pelvic organs.

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Connective Tissue Support

The fibrous tissues that hold pelvic organs in place.

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Estrogen Decline (Menopause)

Reduced estrogen levels during menopause affect collagen and muscle support in pelvic floor.

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POP Symptoms (Bulge)

Physical symptoms of prolapse including sensation of bulging or protrusion.

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POP Symptoms (Urinary)

Urinary problems like incontinence, frequency, and straining during urination.

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POP Symptoms (Bowel)

Bowel problems like incontinence, straining during bowel movements, or feeling of blockage.

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POP Symptoms (Sexual)

Sexual problems like pain during intercourse or reduced lubrication.

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POP Risk Factors

Conditions and factors linked to an increased chance of developing prolapse.

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POP Physical Exam

Assessment of pelvic organ prolapse involving external and internal examinations.

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POP-Q System

System that measures the severity of pelvic organ prolapse using specific measurements relative to the hymen.

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POP-Q Scoring

Using the POP-Q system, different stages or degrees of severity are assessed using specific measurements.

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Expectant Management

A watchful waiting approach for mild or asymptomatic patients with no immediate need for treatment.

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Kegel Exercises

Pelvic floor muscle exercises to strengthen the muscles and improve support.

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Pelvic Floor Physical Therapy

Therapy focused on strengthening or releasing pelvic floor muscles for prolapse support and related issues.

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Pessary

Medical device inserted into the vagina to provide support for prolapsed organs.

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Surgical Management

Procedures to repair pelvic organ prolapse, often involving reconstructive techniques.

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Stress Urinary Incontinence

Involuntary leakage of urine during activities that increase abdominal pressure.

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Pelvic Organ Support

Structural & functional support provided by muscles, ligaments, and connective tissue to support pelvic organs.

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Vaginal Support Levels

Three levels of support for the vagina based on attachment to different areas/structures.

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Pelvic Organ Prolapse (POP)

Downward displacement of pelvic organs into the vagina.

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Cystocele

Prolapse of the bladder into the vagina.

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Rectocele

Prolapse of the rectum into the vagina.

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Apical Prolapse

Prolapse of the cervix/uterus.

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Enterocele

Prolapse of small intestine into pouch of Douglas.

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Uterosacral Ligaments

Ligaments supporting the upper vagina and uterus.

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Levator ani muscles

Pelvic floor muscles that form part of pelvic diaphragm, and are crucial for supporting pelvic organs.

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Pelvic Diaphragm

Muscles that make up the pelvic floor.

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Pelvic Floor Problems

Issues with the muscles, ligaments, and connective tissues that support pelvic organs.

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Female Urinary Incontinence

Involuntary leakage of urine.

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Bladder Wall Layers

Mucosal, Submucosal, Muscular, Adventitial layers.

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Detrusor

Muscle in the bladder wall.

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Internal Urethral Sphincter

Muscle that helps control urinary flow.

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Urogenital Sphincter

3 muscles closing the urethra.

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Continence

Ability to control urination.

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Stress Urinary Incontinence (SUI)

Leakage with increased abdominal pressure (coughing, sneezing).

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Urge Urinary Incontinence

Leakage after sudden urge to urinate.

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Mixed Urinary Incontinence

Combination of stress and urge incontinence.

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Overactive Bladder (OAB)

Urinary urgency with or without incontinence.

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Risk Factors for Urinary Incontinence

Conditions that increase chances of incontinence.

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Pathophysiology of Anatomic Stress Incontinence

Weakened support leads to urine leakage under pressure.

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Urethral Mucosal Coaptation

Mucosal folds close off urethra.

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Urethral vascular plexus

Network of blood vessels around the urethra, important for function and support.

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Viscous and elastic mucosa

Properties of the lining of the urethra that enable flexibility to the flow.

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Detrusor overactivity

Involuntary bladder contractions, causing urgency/urge incontinence.

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Neurogenic detrusor overactivity

Detrusor overactivity with a neurological cause.

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Idiopathic detrusor overactivity

Detrusor overactivity without apparent neurological causes.

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Stress incontinence

Involuntary leakage of urine upon actions that increase abdominal pressure like exercise, sneezing, or laughing.

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Urge incontinence

Incontinence of urine due to sudden and powerful urge to urinate.

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Post-void residual (PVR)

Urine left in the bladder after urination; used to assess bladder emptying.

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Urodynamic studies

Tests measuring bladder pressure and flow rates during urination; to diagnose incontinence in mixed/complex cases.

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Pelvic floor muscle training

Exercises to strengthen pelvic floor muscles, critical to urinary control and support.

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Kegel exercises

Exercises to practice and maintain pelvic muscle contraction, as a strengthening aid.

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Estrogen therapy

Hormonal treatment for urinary incontinence with vaginal estrogen; improving functioning and support.

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Study Notes

Female Pelvic Anatomy

  • Pelvic organ support relies on interactions between pelvic floor muscles, connective tissue, and vaginal walls.
  • Key structures include uterosacral ligaments, arcus tendineus fascia pelvis, levator ani muscles, pelvic diaphragm, levator ani and coccygeus muscles, perineal body, and levator hiatus.
  • The levator hiatus is a U-shaped opening in the pelvic floor allowing passage of urethra, vagina, and rectum.

Vaginal Support Levels

  • Level 1: Supports the upper proximal vagina via cardinal and uterosacral ligaments attached to cervix and upper vagina.
  • Level 2: Attaches mid-vagina to arcus tendineus fascia pelvis.
  • Level 3: Involves perineal body, superficial/deep perineal muscles, and fibromuscular connective tissue.

Functional Pelvic Support

  • Vertical vaginal angle, versus horizontal, can lead to pelvic organ prolapse (POP).
  • Levator ani muscle tone changes can be observed.

Pelvic Organ Prolapse (POP)

  • Definition: Descent of vaginal and uterine components, potentially causing nearby organs to herniate.
  • Types:
    • Anterior vaginal wall: Cystocele (bladder)
    • Posterior vaginal wall: Rectocele (rectum)
    • Uterus/cervix: Apical prolapse
    • Lateral/superior posterior vaginal wall: Enterocele (intestines)

POP Epidemiology

  • Highest incidence in 70-79 year old women.
  • ~3-6% US women report vaginal bulging symptoms.
  • Exam prevalence of POP: 40-50%.
  • Limited research on natural progression of POP.

POP Pathophysiology

  • Loss of levator ani muscle tone.
  • Connective tissue support damage/change in the pelvis.
  • Uterosacral ligament smooth muscle loss.
  • Arcus tendineus fascia pelvis stretching/tearing.
  • Estrogen decline (menopause) negatively impacts collagen and muscle quality.
  • Vaginal wall fibromuscular layer damage/loss.

POP Symptoms

  • Bulge symptoms: Sensation/feeling of vaginal bulging, pressure, heaviness.
  • Urinary symptoms: Incontinence, frequency, urgency, hesitancy, incomplete emptying, need for postural changes to urinate.
  • Bowel symptoms: Incontinence (flatus, liquid/solid stool), urgency, straining, incomplete emptying, digital evacuation, splinting.
  • Sexual symptoms: Dyspareunia, decreased lubrication.
  • Pain: Vaginal, bladder, rectal, pelvic, and low back pain.

POP Risk Factors

  • Parity (pregnancy, vaginal delivery), aging, obesity, connective tissue disorders, menopause, chronic increased intra-abdominal pressure (e.g., constipation, COPD), pelvic floor trauma.

POP Physical Exam

  • Patient in dorsal lithotomy position.
  • Vulva/perineum exam for signs of atrophy.
  • Valsalva maneuver to observe prolapse degree.
  • Speculum exam.
  • Split speculum exam (viewing anterior and posterior vaginal walls with and without Valsalva).
  • Bimanual exam for pelvic organ/floor tone evaluation.

POP Quantification (POP-Q)

  • System for staging POP severity.
  • Stages 0-IV (0: no prolapse; I-IV: increasing prolapse severity, with Stage IV representing complete eversion).
  • Measures site-specific pelvic support relative to hymen.

POP Treatment

  • Expectant management: May be appropriate for asymptomatic/mildly symptomatic patients .
  • Treatment decisions based on symptoms, severity, age, comorbidities, recurrence factors, and desire for sexual/fertility function.
  • Treat modifiable risk factors (constipation, cough).

Nonsurgical Options

  • Kegel exercises.
  • Pelvic floor physical therapy.
  • Pessary.

Pessary

  • Silicone/plastic device to reduce prolapse, often used long-term.
  • Aids in diagnosis/treatment prognosis.
  • Trial use to assess symptom improvement or resolution.
  • May be used prior to surgery to assess incontinence risk.
  • Separate fitting appointment to determine best size/shape.
  • Often used with vaginal estrogen cream.
  • Self-managed or managed by provider with appointments (every 2-3 months).
  • Potential complications: vaginal erosion, bleeding.

Surgical Management

  • Individualized approach based on anatomy, goals, and health characteristics.
  • Reconstructive repair addressing different vaginal compartments.
  • Primarily vaginal approach, with some laparoscopic/robotic procedures available.

POP Surgery and Incontinence

  • Pre-surgical evaluation for stress urinary incontinence.
  • Concurrent stress incontinence procedures recommended if symptoms present.
  • Latent incontinence may appear post-repair.
  • Individualized decisions about anti-incontinence surgeries.

Healthcare Team

  • Patient, support persons, primary care provider, gynecologist/urogynecologist, physical therapist, operating room team.

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