Pelvic organ prolapse: Difference between revisions
ClaireLewis (talk | contribs) No edit summary |
Moomoodoctor (talk | contribs) |
||
(12 intermediate revisions by 3 users not shown) | |||
Line 2: | Line 2: | ||
[[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]] | [[File:Blausen 0732 PID-Sites.png|thumb|Pelvic anatomy.]] | ||
*Definition: herniation of pelvic organs to or beyond vaginal walls | *Definition: herniation of pelvic organs to or beyond vaginal walls | ||
*First Degree: Lowering of cervix into lower 1/3 of vagina | |||
*Second Degree: Protrusion of cervix through the vaginal introitus | |||
*Third Degree: Complete externalization of the uterus and inversion of the vagina (also called descensus or procidentia) | |||
===Risk Factors=== | ===Risk Factors=== | ||
Line 11: | Line 14: | ||
* [[Connective tissue disorder]]s | * [[Connective tissue disorder]]s | ||
* Chronic [[Cough]] | * Chronic [[Cough]] | ||
* Heavy lifting | |||
===Types=== | ===Types=== | ||
Line 24: | Line 28: | ||
**Apex= uterus and cervix, cervix, or vaginal vault | **Apex= uterus and cervix, cervix, or vaginal vault | ||
**Apical prolapse often associated with enterocele | **Apical prolapse often associated with enterocele | ||
*Urethral Prolapse | |||
**Postmenopausal and prepubescent females | |||
==Clinical Features== | ==Clinical Features== | ||
[[File:PMC3180421 1752-1947-5-459-2.png|thumb|Total uterine prolapse.]] | |||
[[File:PMC5350386 CRIOG2017-1640614.001.png|thumb|Uterine prolapse.]] | |||
*Severity may be related to position | *Severity may be related to position | ||
**Less noticeable in AM and supine | **Less noticeable in AM and supine | ||
Line 34: | Line 42: | ||
**Urgency | **Urgency | ||
**[[Urinary incontinence]] | **[[Urinary incontinence]] | ||
**Enuresis | **Enuresis | ||
*Defecatory dysfunction | *Defecatory dysfunction | ||
**[[Constipation]] | **[[Constipation]] | ||
Line 45: | Line 53: | ||
**Dyspareunia | **Dyspareunia | ||
**Avoidance of sexual activity due to fear of discomfort or embarrassment | **Avoidance of sexual activity due to fear of discomfort or embarrassment | ||
*Urethral prolapse | |||
**pain with unination | |||
**blood in diaper or underwear | |||
**tenderness while wiping | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Postmenopausal Pelvic Pain DDX}} | {{Postmenopausal Pelvic Pain DDX}} | ||
{{Prepubescent Urethral Prolapse}} | |||
==Evaluation== | ==Evaluation== | ||
Line 60: | Line 73: | ||
**Wait 15 minutes for edema to subside and re-attempt reduction | **Wait 15 minutes for edema to subside and re-attempt reduction | ||
**If reduction fails, consult gynecology | **If reduction fails, consult gynecology | ||
**Saline-soaked gauze applied to prolapsed organs could provide both comfort and protection of exposed mucosa | |||
*For urethral prolapse: | |||
**Topical estrogen twice daily (0.01%) | |||
**Sitz baths | |||
**Consult urology if concern for necrosis of tissue | |||
===Outpatient=== | ===Outpatient=== | ||
Line 65: | Line 83: | ||
*Expectant management | *Expectant management | ||
*Conservative (vaginal pessary, pelvic floor muscle exercises) | *Conservative (vaginal pessary, pelvic floor muscle exercises) | ||
*Estrogen creams and Sitz baths (Urethral Prolapse) | |||
*Surgical | *Surgical | ||
==Disposition== | ==Disposition== | ||
*Discharge with outpatient Gynecology referral | *Discharge with outpatient Gynecology or Urology referral | ||
==See Also== | ==See Also== |
Latest revision as of 17:43, 28 April 2024
Background
- Definition: herniation of pelvic organs to or beyond vaginal walls
- First Degree: Lowering of cervix into lower 1/3 of vagina
- Second Degree: Protrusion of cervix through the vaginal introitus
- Third Degree: Complete externalization of the uterus and inversion of the vagina (also called descensus or procidentia)
Risk Factors
- Advancing Age
- Multiparity
- Obesity
- Race (Latina/white women at higher risk than black women)
- Constipation
- Connective tissue disorders
- Chronic Cough
- Heavy lifting
Types
- Cystocele
- Most common form of pelvic organ prolapse
- Hernia of anterior vaginal wall + descent of bladder
- Rectocele
- Hernia of posterior vaginal segment + descent of rectum
- Enterocele
- Hernia of intestines to or through vaginal wall
- Uterine/vaginal vault prolapse
- Descent of apex of vagina to lower vagina, hymen, or beyond introitus
- Apex= uterus and cervix, cervix, or vaginal vault
- Apical prolapse often associated with enterocele
- Urethral Prolapse
- Postmenopausal and prepubescent females
Clinical Features
- Severity may be related to position
- Less noticeable in AM and supine
- Worse as day progresses, upright, and active
- Vaginal bulge/fullness, pressure
- Urinary dysfunction
- Overactive bladder symptoms
- Urgency
- Urinary incontinence
- Enuresis
- Defecatory dysfunction
- Constipation
- Incomplete emptying
- Fecal urgency
- Fecal incontinence
- Obstructive symptoms- straining or need for digital pressure to vagina in order to completely evacuate
- Sexual dysfunction
- Reports of adverse effects or orgasm and sexual satisfaction
- Dyspareunia
- Avoidance of sexual activity due to fear of discomfort or embarrassment
- Urethral prolapse
- pain with unination
- blood in diaper or underwear
- tenderness while wiping
Differential Diagnosis
Postmenopausal Pelvic Pain
Gynecologic
- Vulvovaginitis
- Atrophic vaginitis
- Infectious (STI)
- Allergic
- Uterine prolapse
- Cystocele
- Rectocele
- Enterocele
- Uterine/Vaginal Vault Prolapse
- Cervical polyps
- Uterine fibroids
- Endometrial hyperplasia
- Neoplasm
- Uterine
- Ovarian
Gastrointestinal
- Rectocele
- Diverticulitis
- Neoplasm
- Appendicitis
- Ischemic Bowel (Mesenteric Ischemia)
Urologic
- Infection
- Cystourethrocele
Prepubescent-Urethral prolapse
Urologic
- Sarcoma botryoides
- sarcoma botryoides
Evaluation
- Clinical diagnosis
Management
Emergency Department
- Look for signs of infection or skin breakdown if prolonged prolapse
- Reduction may be as simple as pushing organ back inside
- If difficult reduction due to edema:
- Provide analgesia, and place copious granulated sugar
- Wait 15 minutes for edema to subside and re-attempt reduction
- If reduction fails, consult gynecology
- Saline-soaked gauze applied to prolapsed organs could provide both comfort and protection of exposed mucosa
- For urethral prolapse:
- Topical estrogen twice daily (0.01%)
- Sitz baths
- Consult urology if concern for necrosis of tissue
Outpatient
Treatment includes:
- Expectant management
- Conservative (vaginal pessary, pelvic floor muscle exercises)
- Estrogen creams and Sitz baths (Urethral Prolapse)
- Surgical
Disposition
- Discharge with outpatient Gynecology or Urology referral
See Also
References
- Rogers, RG, Fashokun, TB. Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations, and management. In: Post T, ed. UpToDate; Waltham, MA.: UpToDate; 2020. www.uptodate.com. Accessed June 16, 2020