Professional Documents
Culture Documents
Enterocele
o Hernia of the intestines to or through the vaginal wall
Procidentia
o Hernia of all three compartments through the vaginal introitus.
The terms anterior vaginal wall prolapse and posterior
vaginal wall prolapse are preferred to cystocele and
rectocele because vaginal topography does not reliably
predict the location of the associated viscera in POP
Hysterectomy
o Hysterectomy is associated with increased apical prolapse
o ? Vaginal > Abdominal ?
Advanced anterior or apical prolapse may “kink” the urethra and result in
symptoms of obstructed voiding such as
o slow urine stream
o need to change position
o manually reduce (splint) the prolapse to urinate
o sensation of incomplete emptying
o complete urinary retention
13% to 65% of continent women develop symptoms of SUI after surgical
correction of prolapse
Women with POP have a two- to five-fold risk of overactive bladder symptoms
(urgency, urge urinary incontinence, frequency) compared with the general
population
To POP-Q or not to POP-Q
0 – No prolapse
1 – Leading edge of prolapsed structure descends halfway to
vaginal introitus (hymen)
2 – Leading edge of prolapsed structure descends to the vaginal
introitus
3 – Leading edge of prolapsed structure(s) protrudes up to
halfway outside the vagina
4 – Leading edge of prolapsed structure(s) protrudes more than
halfway outside the vagina
Examination components
o Visual inspection
o Speculum examination
o Bimanual pelvic examination
o Rectovaginal examination
o Pelvic Floor Muscle evaluation
Instruments
o Sims retractor (single blade speculum) or a bivalve
speculum that can be easily taken apart so that the
anterior and posterior blades can be used separately to
observe individual compartments of the vagina (anterior,
posterior, apical).
o To make the measurements for the POPQ system, a ruler
or a large cotton swab or sponge forceps marked in 1 cm
increments is used
o Ring Forceps occasionally used for evaluation of occult
incontinence to reduce prolapse
The examination is performed with resting and maximal straining
position
In patients with prolapse to or beyond the hymen, the vaginal tissue is examined
for ulceration.
Any other findings (eg, skin or mucosal lesions) should be noted and evaluated
appropriately
The speculum and bimanual examinations are the principal components
• Apical prolapse (prolapse of the cervix or vaginal vault) – A bivalve speculum is inserted
into the vagina and then slowly withdrawn; any descent of the apex is noted
• Anterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum is
inserted into the vagina with gentle pressure on the posterior vaginal wall to isolate
visualization of the anterior vaginal wall
• Posterior vaginal wall – A Sims retractor or the posterior blade of a bivalve speculum into
the vagina with gentle pressure on the anterior vaginal wall to isolate visualization of the
posterior vaginal wall
To complete the exam, a bimanual examination is performed in order to evaluate for any
coexisting pelvic abnormalities
Diagnose an enterocele
Differentiate between a high rectocele and an enterocele
Assess the integrity of the perineal body
Detect rectal prolapse
The best method for detecting an enterocele is to perform
the rectovaginal exam with the patient standing (?); the
small bowel can be palpated in the cul-de-sac between
thumb and forefinger
Pelvic floor muscle testing
o The pelvic floor musculature is inspected to evaluate integrity and
symmetry
o The examiner should also note the presence of scarring and
whether pelvic floor contraction pulls the perineum inward
o Palpation through the vagina or rectum helps in assessing pelvic
floor squeeze strength and levator muscle thickness.
o The tone and strength of the pelvic floor muscles can be assessed
by asking the patient to contract the pelvic floor muscles around the
examining fingers.
o Women with poor pelvic floor muscle function may benefit from
pelvic physical therapy
Establishing patient goals
o Treatment is individualized according to each patient’s symptoms
and their impact on her quality of life
o Patient satisfaction after POP surgery correlates highly with
achievement of self-described, preoperative surgical goals, but
poorly with objective outcome measures
Management options
o Women with symptomatic prolapse can be managed expectantly, or
treated with conservative or surgical therapy
o This systematic review included six trials, however, none of these evaluated the role of estrogen in
treating POP
Vaginal pessary
o The mainstay of non-surgical treatment for POP is the vaginal pessary
o Pessaries are silicone devices in a variety of shapes and sizes, which support the pelvic organs
o Approximately half of the women who use a pessary continue to do so in the intermediate term of
one to two years
o Pessaries must be removed and cleaned on a regular basis
CONTRAINDICATIONS
o Local infection — Active infections of the vagina or pelvis, such as vaginitis or pelvic inflammatory
disease, preclude the use of a pessary until the infection has been resolved
o Latex sensitivity — The Inflatoball pessary is made of latex; therefore, it is contraindicated in
women with latex allergies. The other pessaries discussed below are nonallergenic.
o Noncompliance — Noncompliance with follow-up could be harmful since an undetected and
untreated erosion could put the patient at risk of developing a fistula
o Sexually active women who are unable to remove and reinsert the pessary — Inability to manage
the pessary around coital activity could be discouraging
Fitting the pessary
o Women to be fitted for a pessary are first examined with an empty bladder in the
dorsal lithotomy position
Pessaries are inserted into the vagina with the dominant hand, while the
nondominant hand separates the introitus and depresses the perineal
body.
After the pessary is inserted into the vagina, the woman is asked to strain
and cough repeatedly on the examination table, ambulate in the office, and
void and strain while sitting on a toilet
This "office trial" helps determine if she will be able to retain the pessary
and void when she returns home, and if bothersome urinary incontinence
will develop.
She should have a negative cough stress test following pessary placement,
as she is unlikely to be satisfied if there are significant SUI symptoms
Women should be reassured that it is not an emergency if the pessary is
expelled; they should just bring the pessary back to the office and a
different type or size of pessary will likely be effective
Follow-up
o A follow-up visit is scheduled one to two weeks later.
o The pessary is removed and cleaned with soap and water, and the
vagina is examined for erosions
o If the pessary fits well and there were no side effects, motivated and
able patients are taught how to remove, clean, and reinsert their
pessary at least once per week, with follow-up in one to two months,
and every 6 to 12 months thereafter
o If the patient cannot, or chooses not, to remove and reinsert her
pessary, then she returns for follow-up in one to two months, and
every three to four months thereafter for pessary cleaning and
assessment by the provider.
Offer most women low-dose estrogen vaginal cream (0.25 to 0.5 g
applicator, two to three nights per week) to treat co-existing vaginal
atrophy and dryness from estrogen deficiency
o KY or other non-hormonal lubrication may be used for those patients where estrogen
is contraindicated (breast ca, etc)
In some women, the width of the introitus may decrease in size after
several weeks of pessary use. In such women, a new smaller size
pessary is prescribed to allow for easier removal and insertion
Candidates
o Symptomatic POP
o Failed or declined conservative management
o Women finished with childbearing
• Reports of uterine sparing procedures
o Young or Elderly-
• Risk of recurrence in young (sacral colpopexy) and comorbidities in
elderly (colpocliesis)
• Reconstructive or obliterative
• Most women with symptomatic POP are treated with a
reconstructive procedure
• Obliterative procedures (eg, colpocleisis) are reserved for women
who cannot tolerate more extensive surgery or who are not planning
future vaginal intercourse
• Concomitant hysterectomy
• When apical prolapse is repaired, the decision must be made
whether to perform a hysterectomy as a part of the procedure.
• Surgical route for repair of multiple sites of prolapse
• Reconstructive surgery for POP often involves repair of multiple anatomic sites of
prolapse (apical, anterior, posterior)
• The choice of surgical route depends upon the optimal approach for the combination
of prolapse sites.