Content. Terminology Anatomy Aetiology Presentation Classification Management

Transcription

1 Prolapse

2 Content Terminology Anatomy Aetiology Presentation Classification Management

3 Terminology Prolapse Descent of pelvic organs into the vagina Cystocele ant. vaginal wall involving bladder Uterine uterus, cervix + upper vagina Enterocele upper posterior wall Rectocele lower posterior wall

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7 Aetiology Childbirth pelvic floor damage Menopause loss of collagen Gynaecological surgery Congenital weakness and neurological Chronic risk factors Race

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9 Symptoms General to all types Dragging sensation, discomfort, bulge Dyspareunia, difficulty inserting tampons Cystocele/Cysto-urethrocele Urinary symptoms (frequency, retention, reduced flow) Rectocele constipation, need for digital evacuation

10 Examination Examine the abdomen for masses/organomegaly Does the vagina look oestrogen deprived? Ask patient to cough when lying on back 2 nd /3 rd degree prolapse may appear Also examine with Sim s speculum

11 Classification... Baden-Walker half way system: Grade 0 no prolapse Grade 1 halfway to hymen Grade 2 to hymen Grade 3 halfway past hymen Grade 4 maximum descent OR 1 st degree lowest part descends ½ way down axis 2 nd degree extends to level of introitus or past on straining 3 rd degree lowest part extends past introitus and out of vagina

12 POP-quantitative scoring system Stage 0 no prolapse demonstrated Stage 1 distal portion more than 1cm above hymen Stage 2 within 1 cm proximal to hymen Stage 3 - more than 1 cm below but no farther than 2cm less than TVL Stage 4 vaginal eversion is essentially complete

13 POP-quantitative scoring system

14 POP-quantitative scoring system Six measurements given negative numbers (cm) if above hymen or positive if below Aa and Ap are reference points A anteriorly and posteriorly, respectively, usually -3cm Points Ba and Bp are lowest points of the prolapse between the vaginal apex (anteriorly point C, cervix and posteriorly point D, pouch of Douglas) and points Aa and Ap. Other measurements include TVL (total vaginal length, GH (genital hiatus, urethral meatus to posterior part of hymen) and Pb (perineal body, posterior genital hiatus to midanal opening) Allows for more objective assessment of prolapse without use of terms such as rectocele

15 Management Prevention Physiotherapy PFME for younger women Intravaginal devices

16 Management Prevention Physiotherapy PFME for younger women Intravaginal devices

17 Management Surgery Anterior repair cysto-urethrocele Posterior repair rectocele Vaginal hysterectomy apical Sacrospinous ligament fixation vaginal vault prolapse Risk to surrounding structures, 1/3 of prolapse surgery is for recurrent defects

18 Incontinence

19 Stress, urgency, mixed, OAB Stress UI occurs with effort or exertion, effort, sneezing or coughing. Urgency UI a sudden compelling desire to urinate that is difficult to delay. Mixed UI is associated with both urgency and stress Overactive bladder is urgency that occurs with or without incontinence. Associated with frequency and nocturia. Can be wet or dry Suggestive of detrusor overactivity

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21 Assessment History and exam Symptom scoring and QOL assessment Assessment of pelvic floor muscles Bladder diary Prolapse? Urine testing

22 Red flags Urgently refer if: visible haematuria microscopic haematuria in women aged > 50 recurrent or persisting UTI associated with haematuria in women aged > 40

23 Further consideration pain faecal incontinence neurological disease voiding difficulty urogenital fistulae previous pelvic surgery previous pelvic radiation therapy

24 Urodynamic testing Post-void residual volume Bladder pressure studies Multi-channel cystometry Ambulatory urodynamics Videourodynamics

25 Non-invasive therapies Lifestyle interventions Caffeine, fluid intake, weight Pelvic floor muscle training At least 8 contractions 3 times a day for 3 months. First pregnancy as a preventive strategy for UI. Therapeutic stimulation Electrical stimulation and/or biofeedback Absorbent products, urinals and toileting aids a coping strategy pending definitive treatment Bladder training First-line treatment to women with urgency or mixed UI.

26 Pharmacological treatment First line medication for UUI: Oxybutynin Avoid in frail, older women Tolterodine darifenacin

27 Pharmacological treatment Desmopressin Used to reduce nocturia avoid in those over 65 years with cardiovascular disease or hypertension. Duloxetine May be offered as second-line therapy if women prefer pharmacological to surgical treatment or are not suitable for surgical treatment. Oestrogens Offer intravaginal oestrogens for the treatment of OAB in postmenopausal women with vaginal atrophy.

28 Invasive procedures Botulinum toxin A Percutaneous sacral nerve stimulation Intramural bulking agents

29 Surgical approaches In SUI where conservative measures have failed: synthetic mid-urethral tape open colposuspension autologous rectus fascial sling

30 Bladder anatomy image from Wikipedia Internet source, available at: [Accessed 17/01/14] NICE guidelines on urinary incontinence in women Internet source, available at: [Accessed 17/01/14]

31 References Baden, W.F., Walker, T.A., Lindsey, J.H. (1968). The vaginal profile. Tex Med, 64 (5): Bladder anatomy image from Wikipedia Internet source, available at: [Accessed 17/01/14] Collins, S., Arulkumaran, S., Hayes, K., Jackson, S., Impey, L. (2013). Oxford Handbook of Obstetrics and Gynaecology 3 rd edition. Oxrord University Press. Drake, R.L., Vogl, A.W., Mitchell, A.W. (2010). Gray s Anatomy for Students 2 nd edition. Churchill Livingstone. Magowan, B., Owen, P., Frife, J. (2009). Clinical Obstetrics & Gynaecology 2 nd edition. Saunders Elsevier. McNeeley, G. (2008). Pelvic Floor Disorders. The Merck Manual Home Health Handbook. Internet source, available at: [Accessed 17/01/14]

32 Mypessary.com, (2014). Bowl Pessaries. Internet cource, available at: [Accessed 17/01/14] NICE guidelines on urinary incontinence in women Internet source, available at: [Accessed 17/01/14] Persu, C., Chapple, C.R., et al., Pelvic Organ Prolapse System (POP-Q) a new era in pelvic prolapse staging. J Med Life. 4 (1):