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Pelvic Organ Prolapse

武功密笈

小黃藏書

OBS
GYN
Gyn Oncology
Infertility
Urogynecology

首頁 向上 Urinary Incontinence Urogynecologic Sono Pelvic Organ Prolapse Bladder Disorder UTI 婦女泌尿學 GSI acute urethral syndrome UTI in pregnancy

~ Pelvic Organ Prolapse ~

 

Ä Definition:

Cystocele: a downward displacement of the bladder

Cystourethrocele: a cystocele including the urethra as part of the prolapse organ complex

Uterine Prolapse: descent of uterus and cervix down the vaginal canal toward the vaginal

introitus

Rectocele: a protrusion of the rectum into the posterior vaginal lumen

Enterocele: a herniation of the small bowel into the vaginal lumen

 

Ä Classification:

  Half way system (0-4):

 

Grade

Description

0

Normal position for each side

1

Descent halfway to hymen

2

Descent to hymen

3

Descent halfway past hymen

4

Maximum possible descent for each side

  (1-3):

 

Grade

Description

1

Descent beyond hymen

2

Descent reaching hymen

3

Protruding below vaginal introitus

  ICS classification

Statge 0: No prolapse is demonstrated. Ponts Aa, Ap, Ba, and Bp are all at –3 cm and either point C or D is between –TVL cm and –(TVL-2) cm (i.e., the quantitation value for point C or D is -[TVL-2] cm

Stage 1: The criteria for stage 0 are not met, but the most distal portion of the prolapse is > 1cm above the level of hymen (i.e., its quantitaion value is < -1 cm)

Stage II: The most distal portin of the prolapse is 1 cm proximal to or distal to the plane of the hymen (i.e., its quantitation value is -1 cm but +1 cm)

Stage III: The most distal portion of the prolapse is > 1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in cm (i.e., its quantitaion value is > +1cm but < +[TVL-2] cm

Sgage IV: Essentially, complete eversion of the total length of the lower-genital tract is demonstrated. The distal portion of the prolapse protrudes to at least (TVL-2) cm (i.e., its quantitation value is [TVL-2] cm). In most instance, the leading edge of stage IV prolapse is the cervix or vaginal cuff scar.

Ä Symptoms:

  • A feeling of pressure or that something is protruding from the vagina
  • A dragging discomfort, which is described as a low backache or feeling of heaviness and

generally is relieved by lying down, is less noticeable in the morning, and worsens as the

day progresses, particularly if patients are on their feet for long periods of time

  • Stress incontinence, when urethal hypermobility resulted from loss of ant. vaginal support
  • Voiding difficulty on the condition of large ant. vaginal prolapse
  • Inefficient rectal emptying often described as constipation, if rectocele developing

 

Ä Examination for Pelvic Organ Prolapse:

  • In the standing position as well as in the standard dorsal lithotomy position
  • PV as well as rectovaginal examination
  • Evaluation of pelvic organ prolapse:

j The nature of prolapse: uterine prolapse? cystocele? rectocele? Enterocele?

k Maximal extent

l Each aspect of vaginal support: ant.? post.? lat.?

 

 

Ä Treatment:

  • Asymptomatic prolapse does not need treatment.
  • Management for symptomatic prolapse:

j Conservative Management:

ò Pessary:

1). Individually fitted for each patient

2). Requiring well-estrogenized vagina

For women who are past menopause, it is preferable to use intravaginal

estrogen cream 4-6 weeks before the pessary is inserted, because this

makes the pessary more comfortable to wear and dramatically increases

compliance and promotes long-term use.

3). Regular follow-up to prevent complications (eg. chronic irritation, erosion,

vesicovaginal fistula

first visit: within 1 week

thereafter: 4-6 months

k Surgical Management:

­ Operations for vaginal prolapse:

- Vaginal hysterectomy

- Manchester/Fothergill operation

- Uteropexy

- Paravaginal defect repair operation

- P-repair

­ Operations for complete eversion of the vagina:

- Colpectomy and colpocleisis

- Colpopexy

The standardization of terminology of female pelvic organ prolpase and pelvic floor dysfuncion. Am J Obstet Gynecol 1996;175:10

Point Aa: A point located in the midline of the anterior vaginal wall 3 cm proximal to the external urethral meatus, corresponding to the approximate location of the "urethrovesical crease," a visible landmark of variable prominence that is obliterated in many patients.

Point Ba: a point that represents the most distal (i.e., most dependent) position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa.

Point C: A point that represents either the most distal (i.e., most dependent) edge of the cervix or the leading edge of the vaginal cuff (hysterectomy scar) after total hysterectomy.

Point D: A point that represents the location of the posterior fornix (or pouch of Douglas) in a woman who still has a cervix. It represents the level of uterosacral ligament attachment to the proximal posterior cervix. It is included as a point of measurement to differentiate suspensory failure of the uterosacral-cardinal ligament complex from cervical elongation. Point D is omitted in the absence of the cervix.

Point Bp: A point that represents the most distal (i.e., most dependent) position of any part of the upper posterior vaginal wall from the vaginal cuff or posterior vaginal fornix to point Ap.

Point Ap: A point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen.

OTHER LANDMARKS AND MEASUREMENTS. The genital hiatus is measured from the middle of the external urethral meatus to the posterior midline hymen. If the location of the hymen is distorted by a loose band of skin without underlying muscle or connective tissue, the firm palpable tissue of the perineal body should be substituted as the posterior margin for this measurement. The perineal body is measured from the posterior margin of the genital hiatus to the midanal opening. Measurements of the genital hiatus and perineal body are expressed in centimeters. The total vaginal length is the greatest depth of the vagina in centimeters when point C or D is reduced to its full normal position.

 

Filename: Pelvic Organ Prolapse