Postoperative Care and Complications Quiz

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Questions and Answers

What is a major disadvantage of the surgery mentioned?

Includes normal diagnostic access

Minimal surgical trauma

Loss of ability to engage in intercourse (correct)

Can be performed under general anesthesia

Which of the following is a requirement for postoperative care?

Avoid all medications for three days post-operation

Lift heavy weights after one week

Check residual urine should not exceed 30 ml before discharge (correct)

Allow coitus one week post-surgery

Which complication can occur immediately after surgery?

Hemorrhage (correct)

Vaginal stenosis

Fistula formation

Recurrence of prolapse

What should be avoided for two months following the surgery?

Coitus Signup and view all the answers

What is a potential delayed postoperative complication?

Dyspareunia due to vaginal stenosis Signup and view all the answers

Which of the following indicates the patient may need hospital delivery?

Soft tissue obstruction during labor Signup and view all the answers

What is the recommended action regarding heavy lifting after surgery?

Avoid for one month Signup and view all the answers

What percentage range indicates the likelihood of recurrence of prolapse after surgery?

5% - 10% Signup and view all the answers

What is likely to be demonstrated if the bladder is full during examination?

Stress incontinence Signup and view all the answers

Which examination method is used to assess the levator muscles tone?

Two-finger palpation Signup and view all the answers

What factors can lead to stress urinary incontinence?

Delivery and repeated operations causing scarring Signup and view all the answers

What symptom might occur if a large cystocele is present?

Retention followed by overflow incontinence Signup and view all the answers

What is the first step in evaluating for a prolapse during examination?

Inspection at rest Signup and view all the answers

Which type of prolapse occurs when the cervix protrudes outside the vagina?

Grade 3 uterine prolapse Signup and view all the answers

What is a common preoperative condition that may lead to surgical complications?

Persistent cough Signup and view all the answers

What could lead to inadequate closure of the urethra?

Scarring from childbirth Signup and view all the answers

What can lead to recurrent vaginal prolapse after surgery?

Early ambulation and lifting weights Signup and view all the answers

What differentiates a cystocele from a urethrocele during diagnosis?

Location of the bulge Signup and view all the answers

Which factor is particularly significant in the management of recurrent prolapse?

Type of re-operation Signup and view all the answers

What is a significant risk associated with total abdominal hysterectomy?

Prolapse of the vaginal vault Signup and view all the answers

What surgical error may contribute to failed pelvic floor repair during vaginal hysterectomy?

Inadequate suturing of vaginal ligaments Signup and view all the answers

What is the recommended timing for a second trial re-operation after a failed first attempt for prolapse?

At least 3-6 months post-operation Signup and view all the answers

Which condition can complicate the postoperative period after a prolapse operation?

Early intercourse or pregnancy Signup and view all the answers

What predisposing factor must be managed to prevent recurrence of prolapse?

Managing risks associated with lifestyle, such as smoking Signup and view all the answers

What is the procedure followed after addressing a rectocele with a deficient perineum?

Colpo-Perineorrhaphy Signup and view all the answers

What is considered a significant complication of the Abdominal Sling Operation?

Psoas spasm and left thigh pain Signup and view all the answers

What characterizes first degree uterine prolapse?

Cervix lies below the ischial spines but does not appear through the vulva. Signup and view all the answers

Fothergill’s Operation is the choice procedure for which condition?

Uncomplicated Utero-vaginal prolapse with no future childbearing Signup and view all the answers

Which statement about the Fothergill’s Operation is true?

It has a threat of both short and long-term complications. Signup and view all the answers

Which type of prolapse typically involves an inverted vagina with no cystocele?

Utero-vaginal prolapse. Signup and view all the answers

What is a common effect of uterine prolapse on the cervix?

Elongation of the supravaginal portion of the cervix. Signup and view all the answers

What potential risk is associated with high amputation of the cervix in Fothergill’s Operation?

Cervical incompetence leading to premature labor Signup and view all the answers

Which complication is specific to Manchester repair?

Vaginal narrowing or tender scar Signup and view all the answers

What is a characteristic symptom of chronic congestion in the uterus due to prolapse?

Dysmenorrhea. Signup and view all the answers

What type of factors are associated with vagino-uterine prolapse?

Acquired predisposing factors. Signup and view all the answers

Which statement is correct about the LeFort Operation?

It obliterates the central portion of the vaginal canal. Signup and view all the answers

What is generally recommended post-Operatively in Fothergill's Operation if rectocele is present?

Further perineorrhaphy Signup and view all the answers

Which effect on the vagina is related to chronic irritation from prolapse?

Keratinization and pigmentation. Signup and view all the answers

The most advanced stage of uterine prolapse is characterized by which condition?

The uterus lies outside the vulva. Signup and view all the answers

What anatomical structure is affected by the elongation caused by uterine prolapse?

Mackenrodt’s ligament. Signup and view all the answers

What is a common predisposing factor for vault prolapse?

Total abdominal hysterectomy instead of subtotal hysterectomy Signup and view all the answers

Which surgical method involves fixing the vaginal vault to the sacral promontory?

Abdominal sacrocolpopexy Signup and view all the answers

What does the second degree of retroversion describe?

The fundus is directed to the body of the sacrum Signup and view all the answers

Which of the following is NOT a cause of acquired retroversion?

Congenital factors Signup and view all the answers

Sacrospinous fixation has which of the following advantages?

Allows restoration of a normal vagina and preserves normal vaginal axis Signup and view all the answers

What is a symptom of congenital retroversion?

While usually mobile and asymptomatic Signup and view all the answers

What characterizes the first degree of uterus descent?

Fundus lies in line with the cervix and vagina Signup and view all the answers

Which of the following does NOT predispose to vault prolapse?

Full urinary bladder during labor Signup and view all the answers

Study Notes

Genital Organs Displacement

Displacement of a genital organ refers to its presence outside its normal anatomical position.
Displacement can be categorized as vertical, antero-posterior, or sideward.
Vertical displacement includes downward (prolapse) and upward displacement.

Types of Displacement

Vertical Displacement: A downward shift of the uterus and/or other pelvic organs is called genital prolapse. An upward displacement can be caused by adhesions or tumors pushing on the uterus.
Antero-Posterior Displacement: The anterior displacement involves the uterus shifting, often from acute AVF uterus, hypoplastic uterus, or uterovesical adhesions. Posterior displacement involves the uterus moving back, often in RVF uteri.
Sideward Displacement: Displacement of the uterus to the right or left can result from the pressure of tumors or adhesions.

Genital Organ Prolapse

Definition: Genital prolapse is the downward displacement of one or more genital organs beyond their normal anatomical position.
Incidence: 5-10% and varies depending on antenatal care levels; prolapse is less common in Black and Asian women than white women.
Cystourethrocele is the most common type of prolapse, followed by uterine descent and rectocele.

Etiological Factors

Acquired Predisposing Factors (Childbirth): Childbirth is the most significant factor related to labor and delivery. Factors involve trauma, denervation issues, high parity, rapid deliveries, precipitate labor, and macrosomia. Factors during labor and delivery include pushing before full cervical dilation, prolonged second stage, neglecting perineal tears, and improper forceps use. The puerperium includes early ambulation and proper postnatal care.
Menopausal Predisposing Factors (Estrogen Deficiency): Menopause leads to a decrease in vascularity and degeneration (atrophy) of ligaments, potentially contributing to prolapse.

Anatomy of Female Pelvis

Pubocervical fascia: This fascia supports the organs like a hammock.
Illustration of the female pelvis showing the relationship between the various anatomical structures.

Bladder Neck Prolapse/ Uterine or Vault Prolapse

Illustration of bladder neck prolapse, showing the damaged anterior hammock support, and uterine prolapse showing damage to the posterior hammock support.

Prolapse (Descent) of the Bladder Neck and Uterus

Illustration showing the prolapse of the bladder neck and uterus, including the prolapse of the anterior vaginal wall and pubocervical fascia. The diagram emphasizes the poor support of the uterus.

Bladder and Uterine Prolapse

Illustration of a well-supported bladder neck versus one that is prolapsed. The illustration also displays a prolapsed uterus.

Cystocele (Anterior Vaginal Wall Prolapse)

Diagram showing the pubic bone, arcuate tendon, lateral tear in pubocervical fascia, and uterus.
Illustration detailing the anatomy of the female pelvis with a lateral defect in the pubocervical fascia presenting a cystocele.

Normal Position of the Uterus

The uterus is centrally located in the pelvis, with the bladder anteriorly and the rectum posteriorly.
In the erect posture, the uterus lies almost horizontally over the empty bladder.
The cervix of the uterus is situated approximately at the level of the ischial spine.
Different diagrams illustrate and label the various ligaments and anatomical structures that support the uterus, such as round, uterosacral, and cardinal ligaments.

Version, Anteverted, and Anteflexed Positions of the Uterus

Version: The relationship of the whole uterus to the vertical axis, not the vagina.
Anteverted: The uterus tilts forward (~90 degrees) with the cervical canal forward and upward. PV exam shows the cervical os pointing downward and backward (in its normal position)
Anteflexed: The uterus inclines forward forming an obtuse angle (~170 degrees)

Slightly Dextroflexed and Dextrorotated Positions of the Uterus

Slightly dextroflexed: The uterus is tilted to the right.
Slightly dextrorotated: The uterus rotates clockwise (right) around its longitudinal axis bringing the cornu closer to the front.

RVF Uterus

RVF uterus (retroverted and flexed) is angulated backward, and roughly 20% of uteri are found in this position. Illustration showing this position.

Uterine Supports

Ligaments (true and false): Support the uterus.
Peritoneal Reflections: Provide very weak support via uterovesical and Douglas pouches.
Pelvic Floor: Provides indirect support.

Cervical (True) Ligaments

Fan-shaped support.
Runs from the base of the broad ligament to the lateral pelvic wall.
Includes Ureter and Uretine art. (related structures)

Recto-uterine peritoneal fold

Refers to the posterior aspect of the uterus.

Pubocervical Ligament

Extends forward beneath the base of the bladder, the urethra, to the posterior surface of the spinal column.
It is not a well-formed ligament; rather, it allows for bladder distension.

Other (False) Ligaments

Broad, Round, and Ovarian ligaments.

Etiological Factors (Developmental Factors)

Congenital bony defects (e.g., split pelvis).
Congenital conditions affecting pelvic innervation (e.g., spina bifida, cauda equina).
Collagen disease (altered collagen metabolism).
Anatomical abnormalities in the vagina and utero-vesical/uterorectal pouches.
Weakness of connective tissues
Race (black women less prone to this)
Chronic obstructive airway disease, smoking, straining, heavy physical work.

Precipitating Factors

Factors that cause prolapse when supports are weakened: raised intraabdominal pressure (e.g., chronic obstructive airway disease), smoking, straining, heavy physical work. and masses/traction on the uterus (e.g., polyps, fibroids).

Vaginal Wall Prolapse

Anterior: Cystocele (bladder prolapse), Urethrocele (urethra prolapse), and Cysto-urethrocele (combined).
Posterior: Enterocele (prolapse of upper part of the posterior vaginal wall), Rectocele (prolapse of lower part of the posterior vaginal wall).

Uterine Prolapse (degrees)

First Degree: Cervix is below the ischial spines (not protruding).
Second Degree: Cervix and part of the uterus protrudes in the vaginal opening
Third Degree: Entire uterus (cervix and body) lies outside the vulva.

Combined Prolapse (Utero-Vaginal) and Vagino-Uterine

Utero-Vaginal: Uterine prolapse precedes vaginal prolapse, usually in young women, with a typical pattern
Vagino-Uterine: Vaginal prolapse precedes uterine prolapse, typically in older women, with a pattern of extensive cystocele.

Effects on the Genital Tract

Vaginal effects: Chronic irritation, thickening and pigmentation, congestion.
Cervical and uterine effects: Elongation, congestion, hypertrophy/thickening, and trophic ulcers. -Urinary effects: Urethrocele changes can result in stress incontinence, and huge prolapse may result in dysuria and retention. Bladder involvement may lead to incomplete emptying, residual urine buildup, infection, and possibly chronic irritation leading to hypertrophy.
Rectal effects: Incomplete bowel emptying, increased defecation desire (frequency), and potential constipation complications.

Clinical Picture/Symptoms

Mass: A mass, often palpable, in the vagina, particularly during straining.
Pain: Pain in the back, lower abdomen from stretching of the ligaments, relieved by lying down in some cases
**Vaginal/Sexual: ** Blood-stained vaginal discharge, vaginal pain, lack of sexual satisfaction, and vaginal ulcer/infection in some cases.

Examination

General physical exam (abdominal, predisposition, precipitating causes).
Examination under non-straining and maximal straining (Valsalva) conditions.
Pelvic exam to assess tissue type and degree of prolapse.

Investigations

Preoperative preparation (x-ray, imaging, blood work, etc.)
Evaluation for medical conditions (e.g., chronic cough, urinary infections).

Differentiation of conditions

Anterior Vaginal Wall Prolapses: Differentiate from other conditions such as Gartner's cysts and Uretral diverticulum.
Posterior Vaginal Problems: Differentiate Rectocele, Enterocele, and Implantation Dermoid/Vaginal Cysts.

Uterine Prolapse:

Distinguish between Congenital Elongation (Young, Nulligravida) and normal aging related elongation situations (Older high parity).

Differentiation between uterine prolapse and masses protruding from the vulva

Fibroid polyp: Absence of the external os, the cervix is normally positioned, sound can go deep inside uterine cavity.
Inversion of uterus:Absence of the external os, the mass is covered by smooth endometrium, sound can't go deep inside uterine cavity
Cauliflower carcinoma: The mass is friable, necrotic, indurated at the base and bleeds on touch.

Prophylactic Measures

Proper obstetric care during all stages of labor and delivery.
Postnatal pelvic floor exercises.
Limit use of forceps.
Cesarean section when indicated.
Avoid smoking, straining, constipation, heavy physical work.

Management of Prolapse

Conservative techniques (pessaries, Kegel exercises, estrogen hormones, behavioral alterations).
Corrective surgery is indicated when conservative treatment isn't sufficient: Only when symptoms warrant it.

Reconstructive Surgery

Support weak, prolapsed tissue by suturing to bone or using mesh. Surgical techniques include strengthening of the fascia and application of mesh/synthetic materials.

Choice of Operation

Type and extent of descent/prolapse.
Patient's requirements (e.g., sexual activity, desire for fertility).
Vaginal suturing with interrupted sutures.
Synthetic absorbable sutures are preferred.

Anterior Repair

Aims at reducing cystocele, repairing fascial defects, suturing the bladder/endopelvic fascia, and removing redundant vaginal wall.
Postoperative urinary retention. Complications including urinary retention.

Posterior Repair

Aims at reducing rectocele, closing the levator ani, repairing the perineal body, and preventing potential enterocele. Repairing Defects.
Associated complications include constipation and bowel emptying; issues in the pelvic floor

Repair of Douglas Pouch Hernia

Vaginal methods: Wedge-shaped incision allows for reduction reduction of sac, contents excision, and Douglas pouch closure with purse string sutures. Support with uterosacral ligaments.
Abdominal methods: (for enterocele): Excision of herniated peritoneum and approximation of uterosacral ligaments.

Vaginal Hysterectomy and Pelvic Floor Repair

Support vaginal vault structures with transverse cervical and uterosacral ligaments when these are insufficient. Following by colpo-perineorrhaphy if necessary.

Abdominal Sling Operation

Uterus support using nylon tape or mesh (Sacral Cervicopexy).
Post-operative complications are possible and include, bowel obstruction, blood vessel injury or issues related to the psoas muscle.

Fothergill's Operation (Manchester Repair)

Preferred if uterus is to be preserved, but future fertility isn't required
Includes amputation of cervix, fixation of Mackenrodt's ligaments, anterior and posterior colporrhaphy, and D&C (if necessary).
Important to consider complications including excessive operating time, blood loss, risk of cervix injury, potential infertility, dysmenorrhea and recurrence.
Alternatives include sling operations for better results.

Lefort Operation

Obliterates the central portion of the vaginal canal, while preserving lateral channels for drainage. Advantages of this procedure include minimal trauma, and suitability for local anesthesia.
Disadvantages of this procedure include the loss of intercourse ability, and difficulty with D&C in certain cases.
May lead to issues with urinary incontinence