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Prolapse and Incontinence

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1 Prolapse and Incontinence
Craig Dyson Sioned Griffiths October 2013

2 Contents Normal Anatomy Causes of prolapse Types of Prolapse
Investigation Management Treatment of prolapse described since beginning of written history.

3 Anatomy

4 Anatomy When the body is in a standing position, the levator plate is horizontal and supports the rectum and upper two thirds of vagina above it. Weakness of the levator ani may loosen the sling behind the anorectum and cause the levator plate to sag. This opens the urogenital hiatus and predisposes to pelvic organ prolapse. Women with prolapse have been shown to have an enlarged urogenital hiatus on clinical examination.

5 Anatomy The perineal body is a pyramidal fibromuscular structure in the midline between the anus and vagina with the rectovaginal septum at its cephalad apex. Attached to the perineal body are the rectum, vaginal slips from the pubococcygeus, perineal muscles, and the anal sphincter; it also contains smooth muscle, elastic fibers, and nerve endings. During childbirth, the perineal body distends and then recoils. It is an important part of the pelvic floor; just above it are the vagina and the uterus. Acquired weakness of the perineal body gives rise to elongation and predisposes to defects such as rectocele and enterocele.

6 Prolapse “To fall out” Protrusion of an organ or structure beyond its normal confines and with an epithelial surface Genitourinary prolapse – Descent of one or more of pelvic organs. 41% of year old’s but uncertain Uterocoele, Cystocoele, Rectocoele, Enterocoele

7 Pathophysiology Levator Ani/Endopelvic Fascia important
Damage to these structures can occur through: Trauma Neuropathic Injury Disruption/Stretching Multifactorial – Orientation of bones may be a factor. The pelvic organs are mainly supported by the levator ani muscles and the endopelvic fascia (a connective tissue network connecting the organs to the pelvic muscles and bones). Genitourinary prolapse occurs when this support structure is weakened through direct muscle trauma, neuropathic injury, disruption or stretching. A multifactorial cause for this damage is likely. The orientation and shape of the bones of the pelvis have also been implicated in the pathogenesis of genitourinary prolapse.

8 Risk Factors Increasing Age (Double risk with every decade)
Vaginal Delivery Increasing parity Obesity Spina Bifida Pregnancy Variables Macrosomia Prolonged 2nd stage Episiotomy Use of forceps/oxytocin FH of prolapse Constipation Connective Tissue Disorder Occupation

9 Types Anterior Urethrocoele Cystocoele Both
Urinary Stress Incontinence Rare Cystocoele Increased frequency UTI Sensation of mass No Symptoms Both Most Common

10 Types Middle Uterine Prolapse Vaginal Vault Prolapse Enterocoele
Post Hysterectomy Assoc with cystocoele, rectocoele and enterocoele. Retention Enterocoele Pouch of Douglas Cough Impulse

11 Types Posterior Rectocoele

12 POPQ System Pelvic Organ Prolapse Quantification System
Valsalva - ? Left Lateral Stage 0 Stage 1 – 1cm above hymen Stage 2 - Within 1 cm of hymen Stage 3 - >1cm below plane of hymen but <2cm of total length of vagina Stage 4 – Complete eversion of vagina Introitus – Above – Level 1, At – Level 2, Below – Level 3

13 Symptoms General Urinary Coital Bowel Fullness Sensation of bulge
Backache Urinary Incontinence Frequency Coital Dypareunia Flatus Bowel Constipation/Incontinence Need to apply digital pressure

14 Investigations History and Examination Urinalysis
Post-Voidal Urine volume testing Urodynamics US Urea/Creatinine

15 Management Conservative Watchful Waiting Lifestyle Modification
Pelvic Floor Exercises Evidence? Vaginal Oestrogen Creams Pessary

16 Pessary Inserted into vagina to reduce prolapse
Made of silicon or plastic or Soaked in wine… Good short term option

17 Management Surgical Effective Re-operation required in 29% of cases
Fitness of patient Sexually Active Surgeons Advice

18 Surgery Anterior Colporrhaphy Hysterectomy Sacrospinous Fixation
Involves plication of anterior vaginal wall to reinforce. Hysterectomy Sacrospinous Fixation Unilateral or bilateral fixation of uterus to sacrospinous ligament Sacocolpoplexy Mesh used to attach top of vagina to sacrum.

19 Summary Prolapse is increasingly common with age.
Can be classified according to compartment or level of prolapse Can be clear on examination Good conservative and surgical options available Good prognosis

20 References Pessary treatment for pelvic organ prolapse and health-related quality of life: a review. Lamers BH, Broekman BM, Milani AL - Int Urogynecol J (2011) Rev Urol. 2004; 6(Suppl 5): S2–S10. PMCID: PMC Female Pelvic Floor Anatomy: The Pelvic Floor, Supporting Structures, and Pelvic Organs. Sender Herschorn Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092–1139. Rectocele | Vaginal Surgery & Urogynecology Institute Int J Med Sci 2012; 9(10): doi: /ijms Three-dimensional Ultrasound Appearance of Pelvic Floor in Nulliparous Women and Pelvic Organ Prolapse Women. Tao Ying Corresponding address, Qin Li, Lian Xu, Feifei Liu, Bing Hu

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