Gynecology: Pelvic Organ Prolapse PDF

GYNECOLOGY PELVIC ORGAN PROLAPSE Gynecology PELVIC ORGAN PROLAPSE DR. RCB LEGEND: Black – Powerpoint ; Blue – Book ; Green – Recording / Lecture Cardinal Ligament/Ligament of Mackenrodt ○ Strongest/Major sup...

GYNECOLOGY PELVIC ORGAN PROLAPSE Gynecology PELVIC ORGAN PROLAPSE DR. RCB LEGEND: Black – Powerpoint ; Blue – Book ; Green – Recording / Lecture Cardinal Ligament/Ligament of Mackenrodt ○ Strongest/Major supporting structure of the cervix and uterus (second strongest is the Uterosacral Ligament). ○ Extend from the lateral aspect of the upper part of the PELVIC FLOOR MUSCLES FEMALE cervix and the vagina to the pelvic wall. SUPERIOR VIEW Most important muscle of the pelvic floor is the Levator Ani PELVIC ORGAN PROLAPSE Failure of various anatomic structures to support the pelvic viscera; the descent of one or more of the vaginal walls or SUSPENSORY LIGAMENTS OF THE FEMALE cervix GENITAL ORGANS Types ○ Anterior vaginal wall prolapse (Cystocele, urethrocele, paravaginal defect) ○ Posterior vaginal wall prolapse (rectocele or enterocele) ○ Uterine / Cervical prolapse ○ Vaginal vault prolapse (After Hysterectomy where the apex of the vagina goes down) ○ Enterocele (when bowel also prolapsed) 1  GYNECOLOGY PELVIC ORGAN PROLAPSE ⤮ Vaginal bulging POSSIBLE ASSOCIATIONS WITH PELVIC ORGAN PROLAPSE ⤮ Pelvic pressure ⤮ Prior pelvic surgery ⤮ Need to replace the prolapse (splint) to ⤮ Hysterectomy void or defecate ⤮ Race and ethnicity SYMPTOMS ⤮ Sexual dysfunction ⤮ Irritable bowel syndrome ⤮ Vaginal bleeding or discharge ⤮ Episiotomy ⤮ Low backache ⤮ Higher weight of the largest infant delivered vaginally ⤮ Can be symptomatic ⤮ Chronic cough and respiratory disease ⤮ Symptoms are more common when the prolapse extends ⤮ Heavy lifting beyond the hymen ; usually involves more than one wall of the vagina Obstetric levator avulsion is strongly associated with pelvic organ prolapse POP NORMAL PELVIC ANATOMY Enterocele Anterior vaginal wall prolapse → Cystocele Posterior vaginal wall prolapse → Rectocele Vaginal vault prolapse → Enterocele ⤮ Vaginal apex and Cervix ↳ Uterosacral Level 1 ↳ Cardinal ligaments ↳ Connective tissues ⤮ Midvagina Level 2 ↳ Arcus tendineus fasciae ⤮ Distal vagina Level 3 ↳ Perineal membrane muscles BOOK: Fig. 20.5 Photographs in lithotomy position and sagittal magnetic resonance images showing vaginal wall prolapse. Prolapse might include (top to bottom): bladder (cystocele), small bowel (enterocele) or rectum (rectocele). Purple: bladder; orange: vagina; brown: colon, and rectum; green: peritoneum. BOX 20.1 Risk factors for development of Pelvic Organ Prolapse ⤮ Vaginal childbirth ⤮ Increasing parity ⤮ Aging ⤮ Obesity ⤮ Enlarged genital hiatus ⤮ Menopausal status ⤮ Chronic constipation / Straining ⤮ Genetic component and family history BOOK: ⤮ Connective tissue disorders (Ehlers-Danlos) Fig. 20.9 Level I (suspension) and level II (attachment) support of the ⤮ Neurologic injury vagina. In level I the paracolpium (uterosacral ligaments) suspends the 2  GYNECOLOGY PELVIC ORGAN PROLAPSE vagina from the lateral pelvic walls. Fibers of level I extend both vertically Baden-Walker system and posteriorly toward the sacrum. In level II support, the vagina is ○ Grade 0 → normal position attached to the arcus tendineus fasciae pelvis and superior fascia of the ○ Grade 1 → Descent halfway to the hymen levator ani by condensations of the levator fascia (e.g., endopelvic and ○ Grade 2 → Descent to the hymen pubocervical fascia). In level III support, the vaginal wall is attached directly to adjacent structures without intervening paracolpium (i.e., ○ Grade 3 → Descent halfway part the hymen urethra anteriorly, perineal body posteriorly, and levator ani muscles ○ Grade 4 → maximum possible descent laterally). PATHOPHYSIOLOGY OF PELVIC ORGAN PROLAPSE Multifactorial Loss of levator muscle bulk Aging effects More vertical vaginal axis and urogenital hiatus ⤮ Not specific to the area prolapsing ⤮ Many have no symptoms ⤮ Vaginal heaviness ⤮ Pressure PELVIC ORGAN ⤮ Vaginal bulging PROLAPSE ⤮ Vaginal bleeding SYMPTOMS ⤮ Back / pelvic pain not reliably associated ⤮ May affect quality of life, emotional health and social interaction, ability to do chores, exercise, participate in social events BOX 20.2 Pelvic Organ Prolapse Symptom Categories for Clinical Evaluation ⤮ Lower urinary tract symptoms ⤮ Urinary incontinence ⤮ Frequency, urgency, nocturia BOX 20.3 Staging of Pelvic Floor Prolapse using International ⤮ Voiding difficulty; slow stream, incomplete emptying, Continence Society terminology obstruction STAGE 0 ⤮ No prolapse is demonstrated. Points Aa, Ap, Ba, ⤮ Urinary splinting and Bp are all at -3cm, and either point C or D is BOWEL SYMPTOMS between total vaginal length -2cm. ⤮ Constipation STAGE I ⤮ Criteria for stage 0 are not met, but the most distal ⤮ Straining portion of the prolapse is more than 1 cm above the ⤮ Incomplete evacuation level of the hymen ⤮ Bowel splinting STAGE II ⤮ The most distal portion of the prolapse is 1 cm or ⤮ Anal incontinence less proximal or distal to the plane of the hymen SEXUAL SYMPTOMS STAGE III ⤮ The most distal portion of the prolapse is more ⤮ Interference with sexual activity than 1 cm below the plane of the hymen but ⤮ Dyspareunia PROTRUDES no farther than 2 cm less then the ⤮ Decreased sexual desire total vaginal length in centimeters ⤮ Urinary incontinence with intercourse, orgasm STAGE IV ⤮ Essentially complete eversion of the total length of OTHER SYMPTOMS the lower genital tract. ⤮ Pelvic pressure, heaviness, pain ⤮ Presence of vaginal bulge / mass ⤮ Low back pain POP Q ⤮ Tampon not retained ⤮ Quality of life effects MEASURING PELVIC ORGAN PROLAPSE Best measured with a patient straining in the lithotomy position Maximum prolapse → more likely to be observed with a full bladder in the standing position at the end of the day All three compartments (anterior, posterior, and apical) should be individually assessed in all patients with prolapse. It is important to measure or at least qualitatively assess all of the vaginal walls because often more than one compartment is affected There are several systems for objectively measuring POP. In one system, ○ First degree → prolapse into the upper barrel ○ Second degree → prolapse is to the introitus ○ Third degree → prolapse past the introitus ○ Fourth degree/Procidentia → complete eversion of the vagina 3  GYNECOLOGY PELVIC ORGAN PROLAPSE CONSERVATIVE MANAGEMENT OF POP ANTERIOR VAGINAL WALL PROLAPSE EXPECTANT MANAGEMENT CYSTOCELE, URETHROCELE, ENTEROCELE Can be left alone unless with urinary retention or The anterior vaginal wall is the most common site of POP hydronephrosis no matter what degree or stage Most commonly involves cystocele and less commonly enterocele and urethrocele Can be associated with stress, incontinence, urgency, and retention ⤮ Sensation of fullness ⤮ Pelvic pressure ⤮ Vaginal bulge ⤮ Feeling that organs are falling out SYMPTOMS ⤮ Incomplete bladder emptying ⤮ Slow urinary stream ⤮ Urinary urgency ⤮ Splinting ⤮ Stress incontinence DIAGNOSIS Urethroceles should be differentiated from enlarged skene’s gland and urethral PELVIC FLOOR STRENGTHENING diverticula For mild to moderate POP ○ Urethroceles: Soft, nontender Pelvic floor PT and Kegel exercise ○ Enlarged Skene’s gland: there Decrease the risk of progression and improve sensation of is discharge, redness, pain pressure Cystoceles vs bladder tumors and PT can also treat urinary, bowel and sexual dysfunction bladder diverticula TOPICAL VAGINAL ESTROGEN Improves vaginal atrophy SURGICAL TREATMENT Makes POP less uncomfortable ANTERIOR COLPORRHAPHY Can reduce pain of intercourse, decrease risk of irritation and Pelvic floor strengthening and pessary are first-line for all erosions from pessaries, decrease irritative bladder symptoms types of prolapse Use not associated with cancer or blood clot development due Vaginal estrogen to decrease discomfort and improve tissue to very low dosage only before surgery Done in conjunction with repair of all pelvic support defects PESSARIES Silicon vaginal support device All women should be offered pessary management for symptomatic prolapse regardless of age or stage of prolapse Alternative to surgery in patients with medical conditions and those who have not completed child bearing. COMPLICATIONS Rare with proper use: regular removal, cleaning and replacement, use of vaginal estrogen cream Include: ○ Bleeding ○ Discomfort ○ Vaginal erosions ○ Difficulty Removal ○ Erosion into the bladder or rectum ○ Increased Vaginal Discharge SURGERY Avoided until a woman has completed her family Options: ○ Vaginal Fig. 20.19 Classic anterior colporrhaphy. A, The initial midline anterior vaginal wall incision is demonstrated. B, The midline incision is extended ○ Laparoscopic using scissors. C, Dissection of the vaginal epithelium off the underlying ○ Robotic connective tissue and fibromuscular layer. D, The dissection is complete. ○ Open without mesh E, The initial plication layer is placed. F, The second plication layer is Hysterectomy alone is NOT a surgical treatment for prolapse placed, if needed. G, Trimming of excess vaginal epithelium. H, Closure of vaginal epithelium. 4  GYNECOLOGY PELVIC ORGAN PROLAPSE POSTOPERATIVE RESTRICTIONS UTERINE PROLAPSE Avoid straining from constipation, heavy lifting, strenuous Prolapse of the uterus and cervix into the vagina activity for 6-12 weeks Associated with injuries of the endopelvic connective tissue and Nothing should be placed in the vagina until it heals except level 1 support structures including the cardinal and vagunal estrogen (resumed 2-4 weeks post-op or when no uterosacral ligaments more spotting /bleeding) Often associated with anterior and posterior vaginal wall prolapse and enterocele POSTERIOR VAGINAL WALL PROLAPSE ⤮ Feeling of pelvic pressure and heaviness RECTOCELE ⤮ Fullness ⤮ Pelvic pressure ⤮ Bulge or “falling out” in perineal area ⤮ “Falling Out” feeling in the vagina SIGNS AND ⤮ S/Sx of cystocele / rectocele ⤮ Vaginal bulge SYMPTOMS ⤮ Introital mass ⤮ Disruption in sexual activity ⤮ Pain and bleeding from ulcerations SYMPTOMS ⤮ Constipation ⤮ Discharge and secondary infection, edema ⤮ Incomplete emptying of the rectum ⤮ Evisceration of abdominal contents ⤮ Splinting that have bowel movement ⤮ *** Aggravated by prolonged standing exertion MANAGEMENT ⤮ *** Often but not always improve after repair No treatment for mild/asymptomatic or pelvic floor muscle strengthening, pessary, surgery DIAGNOSIS If asymptomatic: Transabdominal or transvaginal surgery Physical exam with the patient in dorsal lithotomy position with suspension procedure Posterior vaginal wall prolapse-descent of the posterior vaginal Approach depend on patient comorbidities, patient preference, wall and may include an enterocele (small bowel), a rectocele surgeon expertise (rectum), or both SURGERIES: ○ Vaginal hysterectomy with vault suspension to uterosacral MANAGEMENT or sacrospinous ligaments POSTERIOR REPAIR ○ Abdominal supracervical hysterectomy with Nonoperative similar for sacrocolpopexy cystocele ○ Colpocleisis Screen for colorectal cancer if ○ Abdominal uterosacral ligament suspension with or appropriate without hysterectomy Dietary fiber, fluid intake, ○ Transvaginal hysteropexy regular exercise, regulate ○ Sacrohysteropexy bowel habits if with ○ Manchester constipation and straining issues FERTILITY SPARING SURGERY FOR UTERINE PROLAPSE Anatomic position may be HYSTEROPEXY corrected but defecatory If a young woman wishes to preserve problems remain fertility and has symptomatic uterine Posterior colporrhaphy + prolapse Perineorrhaphy Not for women with cervical/uterine cancer risk, elongated cervix, ENTEROCELE enlarged uterus or AUB Herniation of the pouch of Limited data on recommended route Douglas (cul-de-sac) between the of delivery uterosacral ligaments into the rectovaginal septum containing VAGINAL VAULT PROLAPSE small bowel APICAL PROLAPSE AFTER HYSTEROSCOPY Often occurs after an Signs and symptom similar to other types of vaginal prolapse abdominal or vaginal Expectant or with pelvic floor muscle strengthening if not hysterectomy bothersome; pessaries, estrogen Result of a weakened support for the pouch of Douglas and Surgeries: loss of vaginal apical support by the uterosacral ligaments ○ Abdominal sacral colpopexy ○ Transvaginal: DIAGNOSIS AND MANAGEMENT ⟡ Sacrospinous ligament fixation Transillumination ⟡ Uterosacral ligament suspension Rectovaginal exam ○ Le Fort Colpocleisis Expectant if asymptomatic ⟡ Total closure of the vaginal canal Pessaries or surgery ⟡ Anterior and posterior vaginal wall is abated McCall Culdoplasty for prevention (suspension procedure) 5  GYNECOLOGY PELVIC ORGAN PROLAPSE COLPOCLEISIS SOURCE Comprehensive Gynecology 8th edition ○ Chapter 20: Pelvic organ Prolapse, Abdominal hernias, and Inguinal hernias – Diagnosis and Management Dr. RCB Powerpoint and lecture 6