Repro Exam 2: Aliff: Pelvic Floor Prolapse

Front 1

What are risk factors for pelvic floow prolapse?

Back 1

Multiparity
Advanced age
Estrogen deficiency
Obesity
Neurogenic dysfunction of the pelvic floor
Connective tissue disorders
Chronically increased intra-abdominal pressure

Front 2

Again know definitions for the exam!

Back 2

go

Front 3

What is a Cystocele?

Back 3

downward displacement of the bladder

Front 4

What is a cystourethrocele?

Back 4

cystocele that includes the urethra

Front 5

What is a Uterine Prolapse?

Back 5

Descent of the uterus and cervix into the vaginal canal toward the vaginal introitus

Front 6

What is a rectocele?

Back 6

protrusion of the rectum into the posterior vaginal lumen

Front 7

What is a Enterocele?

Back 7

Herniation of the small bowel into the vaginal lumen

Front 8

What are the 4 major structures that offer pelvic support for the pelvic floor?

Back 8

1. UTEROSACRAL
2. CARDINAL LIGAMENT
3. LEVATOR ANI MUSCLES
4. ENDOPELVIC FASCIA

Front 9

What anatomical structure connects the levator muscle and the obturator muscle?

Back 9

The bowl-shaped levator muscle is joined to the obturator muscle at the arcus tendineus.

Front 10

What are the 3 parts of the LEVATOR MUSCLE?

Back 10

iliococcygeus,
pubococcygeus,
puborectalis

Front 11

What anatomical structures sit within the levator muscle?

Back 11

urethra,
bladder base,
vaginal tube,
anorectum

Front 12

What is referred to as the PELVIC FLOOR?

Back 12

levator complex of muscles and the surrounding connective tissue, vessels, and nerves are often referred to as the PELVIC FLOOR

Front 13

There are 3 main levels of support for the pelvic floor. What are they?

Level 1
Level 2
Level 3

Back 13

Level 1: Level I shows connective-tissue fibers extending both cephalad and dorsally toward the sacrum

Level 2: Level II shows the lateral attachment to the arcus tendineus fascia of the pelvis

Level 3: Level III shows the lateral attachment and anterior attachment of connective tissue to the lateral arcus tendineus fascia and posterior pubic symphysis.

Front 14

What is the endopelvic fascia

Back 14

pelvic connective tissue network
demonstrates the continuity of the pelvic connective tissue as it surrounds the pelvic organs

it attaches to the pelvic sidewalls

Pelvic floor support Level 1

Front 15

What structure is the proximal urethra and bladder base above if the pelvis is intact?

Back 15

When the anatomy of the pelvis is intact, the proximal urethra and bladder base are held above the perineal membrane

Front 16

What is important about keeping the strutures above the perineal membrane?

Back 16

This intra-abdominal position (at or above the perineal membrane) keeps the urethra within the continence zone.

Front 17

How will a women present if she has a pelvic floor problem?

Back 17

usually asymptomatic

No clear relationship with location of prolapse and dysfunction

Front 18

If a women does feel something with pelvic floor issues how will she often present?

Back 18

Feeling of pressure (most common) similar to sitting on an egg or low backache heaviness that worsens as the day progresses

Front 19

What type of prolapse has:
hypermobile bladder neck with urinary stress incontinence

Back 19

Anterior

Front 20

What type of prolapse has:
vaginal vault eversion with urinary retention

Back 20

Large anterior

Front 21

What type of prolapse has:
rectocele can cause obstipation

Back 21

Posterior

Front 22

What type of prolapse can have sexual impairment?

Back 22

Sexual impairment with any compartment

Front 23

What are urinary complaints prolapse uterus?

Back 23

- Stress incontinence
- Frequency
- Urgency/ urge incontinence
- Hesitancy / weak or prolonged stream
- Incomplete voiding
- Need to reduce prolapse or change position to initiate voiding (SPLINTING)******EXAM

Front 24

What are bowel symptoms of prolapse uterus?

Back 24

- Difficulty/ discomfort
- Incontinence of flatus/ stool
- Urgency
- Incomplete emptying
- Rectal protrusion during or after defecation
- Need to reduce prolapse to defecate

Front 25

What are sexual symptoms of uterus prolapse?

Back 25

- Pain
- Change in orgasmic response
- Incontinence

Front 26

What are pelvis and perineum symptoms for prolapse uterus?

Back 26

- Vaginal pressure/ heaviness
- Pain
- Awareness of protrusion
- Low back pain
- Abdominal Pressure
- Observation/ palpation of a mass

Front 27

What are the different tests you can do to examine for a prolapse uterus?

Back 27

- Recumbent and Standing pelvic exams

- Pelvic Organ Prolapse Quantification or PQP-Q system

- Pelvic Exam: stand on floor with one foot elevated perform rectovaginal exam with vasalva. Supine use Sims speculum.

- Q-tip test - stick a q-tip in the urethra and if >30degress hypermobile.

Also look for stress incontinence and mobility of urethra

Front 28

Is imaging helpful is examining for pelvic floor prolapses?

Back 28

No

Front 29

What may you order to look at the nerve tissues for the pelvic floor?

Back 29

electromyography / pressure recording
from the urethra, vagina, and anus

Front 30

What is an Enterocele?

********EXAM

Back 30

herniation of bowel and the lining of the peritoneal cavity through the cul-de-sac of Douglas.

Front 31

What are some embryological factors that can increase the chance of enterocele?

Back 31

Embryologic factors: congenitally deep cul-de-sac serves as a wedge for small bowel to dissect down.

Front 32

What could a enterocele cause?

Back 32

May cause vaginal vault eversion

Front 33

You also need to know the different types of enteroceles.....

Back 33

go

Front 34

What type of enterocele has:
Posterior to vaginal vault. Mostly without vault eversion

Back 34

Congenital

Front 35

What type of enterocele has:
Due to cervical prolapse which brings the anterior margin of the cul-de-sac down

Back 35

Pulsion

Front 36

What type of enterocele has:
Prolapsed organs exert tension on vaginal vault.
Preceded by cystocele and rectocele

Back 36

Traction

Front 37

What type of enterocele is:
Surgically induced

Back 37

Iatrogenic

Front 38

How may a enterocele present clinically?

Back 38

1) Pelvic heaviness and bearing down feeling especially when standing (due to the pull of gravity which stretches the mesentery)

2) Backache (involvement of the cardinal and uterosacral ligaments)

3) Dyspareunia

4) Vaginal dryness

5) Ulceration, bleeding

6) Bowel difficulty

7) Post-evacuation discomfort

Front 39

What are different ways to Diagnose an enterocele?

Back 39

1. Physical Exam:

2. Best performed when standing or straining

3. Recto-vaginal exam (thumb in rectum)

4. Defacography

Front 40

What is the Treatment options for an enterocele?

1st Prophylaxis?

Back 40

decrease intra abdominal pressure!!

do this by decreasing obesity, girdles, and stop smoking

Front 41

What are enterocele treatments after they have occured?

Back 41

Medical: Pessaries

Rings
Doughnuts
Gellhorn

You can also give estrogen creams
and prescribe Kegel's if the prolapse is NOT advanced

Front 42

I appologize

Back 42

everything up to NOW was PELVIC FLOOR PROLAPSE

I wrote uterine for a couple of them

Front 43

Now uterine prolapse

Back 43

go

Front 44

What is a uterine prolapse?

Back 44

Descent of the uterus and cervix down the vaginal canal toward the introitus

Front 45

What are the most common causes of uterine prolapses?

Back 45

Usually due to injury to the endopelvic fascia (cardinal/ utersacral ligaments) and relaxation of the musculature of the pelvic floor (levator ani)

Front 46

What are risk factors for uterine prolapses?

Back 46

Post menopause, multipara, loss of estrogen, repetitive increase in intra-abdominal pressure (smoker)

Front 47

If a women says it feels like she is sitting on a lump but when she lies down it goes away....what is this???

Uterine prolapse?
Pelvic Prolapse?
Enterocele?

Back 47

Uterine Prolapse******

Clinical Manifestations of Uterine Prolapse:
Same as enterocele plus….
Sitting on a lump
More urinary symptoms
Symptom relief from lying down

Front 48

How are Uterine prolapses dx and graded?

Back 48

Clinical (graded on a scale 0-4)

0: none,
4: procidentia (inaccurate)

POP-Q (more specific)

Front 49

Why is surgery indicated for uterine prolapses?

Back 49

Treatment indicated primarily to relieve pain

Front 50

What if a women is asymptomatic why would you treat a uterine prolapse?

Back 50

Asymptomatic: hydronephrosis, other surgery required

Front 51

When would you use a pessary for uterine prolapse tx?

Back 51

PESSARY: for poor surgical candidates

Front 52

Are Kegels helpful with uterine prolapses?

Back 52

KEGEL’S: little value

Front 53

Is vaginal estrogen a good thing in uterus prolapse?

Back 53

VAGINAL ESTROGEN: improves tissue quality

Will help the prolapse not reverse it

Front 54

What kind of surgery options are there for uterine prolapse?

Back 54

SURGERY: Suspension procedures.

Front 55

What are your surgical options for uterine prolapse?

Back 55

- Colporrhaphy: Traditionally high failure rates >50%

Mesh augmentation: No long term trials. Worry about mesh complications.


Suspension: Sacrospinous ligament fixation vs. Abdominal Sacrocolpopexy (gold standard now being done with robotics!!)

Front 56

What is the Gold Std of surgical options for uterin prolapse?

Back 56

Suspension: Sacrospinous ligament fixation vs.

******Abdominal Sacrocolpopexy (gold standard now being done with robotics!!)

Front 57

If you use the mesh augmentation surgery what ligaments are you using?

Back 57

self-fixating tips to place mesh into the sacrospinous ligament through a single vaginal incision.

Front 58

What is a COLPOCLEISIS?

Back 58

The vagina is sutured together

Front 59

What is Stress Urinary Incontinence?

EXAM***********

Back 59

Loss of urine during activities resulting in increased intra-abdominal pressure

Abdominal pressure overcomes urethral closure pressure

Front 60

What is the most common cause of urinary incontinence?

Back 60

Most commonly associated with urethral hypermobility due to prior birth injury.

Front 61

What are tests you can do to Diagnose Urininary Incontence?

Back 61

Intake and voiding diary.
Pelvic exam with Q-tip test.
Urine analysis and culture.
Simple office cystometrics.
Video Urodynamics

Front 62

What are NON-surgical options for urinary incontinence?

Back 62

- Intake restriction and timed voiding.
- Kegel’s exercises if mild.
- Pessary with incontinence ring.

Front 63

Surgical option for urinary incontence:
Gold standard. Invasive via abdominal approach

Back 63

Burch
**********EXAM

Front 64

Surgical option for urinary incontenence:
Less invasive suprapubic approach.

Back 64

Tension free vaginal tape

Front 65

This is another less invasive surgical treatment for urinary incontenence

Back 65

Transobturator midurethral sling. Less invasive.

Front 66

This is the newest and least invasive technique for surgical treatment of urinary incontenience

Back 66

Single incision slings

Front 67

WE learned that MESH is bad for the uterus but what about the bladder?

Back 67

Mesh for urethra and bladder is ok