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Prolapse (Clinical presentation (Asymptomatic, Bowel symptoms
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Prolapse
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Pathophysiology
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Types
Cystocele
Anterior wall of vagina and attached bladder
May get frequency and dysuria if residual urine inside
Can get a urethral prolapse (urethrocystocele)
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Uterocele
Uterus, cervix and upper vagina
If total hysterectomy, vaginal vault may prolapse alone
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Grading
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Second degree
Lowest part extends to introitus, and through on straining
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Diagnosis
Examination
Bimanual (pelvic)
Cough - see level of prolapse
Check for masses
Pelvic muscle strength - nil (0), flicker (1), weak (2),
moderate (3), good (4), strong (5)
Speculum
Best on L lateral with Sim's speculum
Descent, atrophy
QoL assessment
Questionnaire e.g. Vaginal Symptoms Module
of International Consultation on
Incontinence Questionnaire (ICIQ-VS)
Investigations
Bedside
Obs: HR, BP, RR, sats, temp
Bloods
FBC, U+E, LFTs, hormones
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History
PC/HPC
Dragging/coming down,
urinary/bowel symptoms
PGH
Known conditions, menses/menopause,
bleeding, contraception, STIs, smears
POH
Gravidy/parity, delivery (instrumentals),
gestation, complications
PMH
Known conditions, surgeries
DH
Current meds, allergies
FH
Prolapse, gynae, cancers
SH
Occupation, smoking,
alcohol, support, exercise, ADLs
Management
Medical
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Pessaries
Indication: surgery CI/unsuitable/not wanted
MOA: intrauterine device (ring, shelf, hodge)
to hold the prolapsed part in place; change 6m
Surgical
Anterior defect
Anterior repair
Indication: cystourethrocele
MOA: vaginal route; excision of
vaginal skin, buttress sutures
Paravaginal repair
Indication: cystocoele
MOA: abdo route (laparotomy/laparoscopy);
elevate vagina and reattach to pelvic sidewall
Sacrocolplexy
Indication: cystocoele
MOA: abdo route, mesh over
anterior vaginal wall to sacrum
Transvaginal mesh repair
Indication: cystocoele
MOA: vaginal route, mesh support
Posterior defect
Posterior repair
Indcation: rectocele
MOA: repair of rectovaginal fascia
and removal excess vaginal skin
Transvaginal mesh repair
Indication: rectocoele
MOA: vaginal route, mesh support
Sacrocolpoplexy
Indication: rectocoele
MOA: abdo route, mesh over
posterior vaginal wall to sacrum
Apical defect
Hysterectomy
Indication: uterovaginal prolapse
MOA: vaginal route, removal of uterus
Hysteropexy
Indication: uterovaginal prolapse
MOA: abdo route (laproscopic/open);
uterus and cervix attached to sacrum with mesh
Sacrospinous fixation
Indication: uterovaginal prolapse
MOA: vaginal route, fixation to sacrospinous ligament
Sacrocolpoplexy
Indication: uterovaginal prolapse
OA: abdo route, mesh over
apical vaginal wall to sacrum
Conservative
Physiotherapy
Indication: young, parous women with mild prolapse
MOA: pelvic floor exercises, biofeedback
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Prevention
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Perinatal/postnatal
Avoid prolonged labour
Minimal trauma during instrumental delivery
Postnatal pelvic floor exercises
Definition
Protrusion of uterus +/or vagina beyond
normal anatomical confines; often also
involves bladder, urethra, rectum and bowel
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