structural abnormalities

What is the surgical repair of a cystocele called?

Anterior vaginal colporrhaphy.

uterine prolapse treatment

Complications of uterine prolapse include urinary retention, which can lead to hydronephrosis and obstructive nephropathy. Treatment plans depend on the symptomaticity of the patient. Those with mild prolapse usually do not require treatment because they are typically asymptomatic. Symptomatic patients can be managed conservatively with pelvic floor exercises (Kegel exercises) and vaginal support devices (e.g., pessaries). Although these methods are helpful to improve pelvic floor strength, there is no evidence that it will cause regression of a prolapsed uterus. Pessaries may also increase the risk of vaginitis, bleeding, ulcerations, urinary obstruction, fistula formation, and erosion of the tissues into the bladder or rectum. They are contraindicated in cases of acute pelvic inflammatory disease. Surgery is indicated in women with symptomatic uterine prolapse who have failed or declined conseravtive therapy. A sacrocolpopexy is a procedure in which either a mesh or graft can be applied to provide mechanical support to the uterus and apical vagina. This procedure can be done by an open abdominal surgery, by laparoscopy, or by robotic laparoscopy. Reparative surgery can also be done via the vagina to suspend the vaginal apex with sutures. Various factors such as the patient's medical condition, age, comorbidities, severity of symptoms, and history of previous pelvic surgery must be taken into account. A hysterectomy is usually done at the same time as uterine prolapse surgery, but the uterus can be preserved if the patient desires.

There are conservative and surgical treatments for pelvic organ prolapse.

Conservative therapy includes weight loss in patients who are obese, reduction in straining (e.g., heavy weightlifting, chronic coughing, constipation), and Kegel exercises, which strengthen the pelvic floor muscles that provide support to the pelvic organs. Pessaries are another nonsurgical treatment option. They are removable devices that can be inserted into the vagina to provide support to the pelvic organs. Surgical treatment can be considered in symptomatic patients who have not improved with conservative treatment or have declined conservative treatment. There are reconstructive and obliterative approaches to surgery. Reconstructive surgery aims to restore normal anatomy, while obliterative surgery involves removing or closing off at least a portion of the vaginal canal. Patients who wish to have sexual intercourse should not have obliterative pelvic organ prolapse surgery. Obliterative surgeries have a low risk of recurrence or perioperative complications but eliminate the possibility of vaginal intercourse or evaluation of the cervix and uterus, such as during a Pap smear. Reconstructive surgery is performed more often. There are vaginal and abdominal approaches to pelvic organ prolapse surgery. Two common vaginal-approach repair techniques include uterosacral ligament suspension and sacrospinous ligament suspension. Women undergoing transvaginal apical suspension who require repair of anterior or posterior vaginal wall prolapse should have colporrhaphy performed. Cystoceles require anterior colporrhaphy. Hysterectomy is often performed at the time of apical prolapse repair because it reduces the risk of recurrence.

Ovarian Torsion

Patient will be a woman, 15-30 years old or postmenopausal Sudden onset of unilateral (right > left) abdominal and pelvic pain Labs will show leukocytosis Imaging will show enlarged ovary or ovarian mass Definitive diagnosis and management: laparoscopy

uterine prolapse presentation

Patients may be asymptomatic, especially in mild cases. In more moderate to severe cases, especially those in which the uterus has descended through the introitus, patients may experience vaginal fullness or pressure, low back pain, vaginal spotting (due to ulceration of the exposed sensitive genital tissue), lower abdominal pain, difficulty voiding or defecating, and dyspareunia. Patients also may report feeling a bulge protruding through the introitus. On physical examination, there may or may not be grossly prolapsed tissue present. If there is some prolapsed tissue present, there may be some ulcerations due to chronic rubbing of the tissue against clothing. The patient should be asked to perform a Valsalva maneuver to determine the degree of prolapse. A lubricated speculum should then be inserted into the vagina to reduce the prolapse for a proper examination of the vaginal canal and cervix. A digital exam can determine pelvic floor strength as well as rectal tonicity, and a bimanual exam can determine if there are any adnexal masses or tenderness to the pelvic area.

Uterine Prolapse risk factors rx

Risk factors: multiparity, age, decreasing estrogen levels, trauma Rx: Kegel exercises, pessary, surgery

A 60-year-old woman presents with a complaint of vaginal fullness that is exacerbated by prolonged standing and relieved by lying down. On exam, you note a soft, reducible mass protruding into the introitus. Which of the following is the most common risk factor for the suspected diagnosis?

childbirth and pregnancy

What is the most commonly encountered form of pelvic organ prolapse?

cystocele

A 68-year-old multiparous woman presents to the clinic with complaints of vaginal fullness and urinary incontinence. She reports no recent pelvic trauma or surgeries. On exam, you note a vaginal bulge through the introitus and soft anterior fullness of the vaginal wall. Urinalysis reveals a few normal epithelial cells. A funnel-shaped bladder is seen on transabdominal ultrasound. Which of the following is the most likely diagnosis?

cystocele Cystocele refers to a prolapse of the posterior bladder into the anterior vagina, often due to pelvic floor injury during childbirth. Common causes include genetic predisposition, prior prolapse surgery, and connective tissue diseases. Risk factors for cystocele include pregnancy, vaginal delivery, advanced age, obesity, multiparity, menopause, and diabetes mellitus. Patients present with a vaginal bulge or fullness, pressure, or heaviness, with concurrent urinary incontinence, incomplete emptying, urinary frequency, urgency, or retention. Patients usually will push up the bladder in order to void. A physical exam reveals a vaginal bulge, especially when examined in a standing position. Internal examination reveals anterior fullness of the vaginal wall. Diagnosis is made clinically, whereas pelvic organ prolapse quantification is a staging system that quantifies the extent and location of the prolapse. Transabdominal ultrasound may demonstrate a funnel-shaped bladder. Additional testing that may be needed includes the cotton swab test, voiding cystourethrogram, and cystometrogram. Treatment of a cystocele consists of conservative management (weight reduction, pelvic floor and Kegel exercises, pessaries) and surgical interventions (anterior vaginal colporrhaphy, tension-free vaginal tape procedure).

Uterine prolapse occurs when there is

damage and weakness to the pelvic floor structures that support the pelvic organs. Childbearing is a leading risk factor due to muscle and nerve damage to the pelvic region caused by the stretching and tearing that can occur during labor and birth. Multiparous women are at high risk of uterine prolapse. This condition can also be caused by genital atrophy, hypoestrogenism, pelvic tumors, sacral nerve disorders, and diabetic neuropathy. Other associated conditions include obesity, chronic coughing, smoking, and constipation, all of which cause an increase in intra-abdominal pressure.

A 23-year-old woman presents to the emergency department with right-sided abdominal pain, nausea, and vomiting that began suddenly about 30 minutes ago after she went to a group exercise class. She was recently diagnosed with polycystic ovarian disease. Upon physical examination, she does not have any tenderness to palpation to her abdomen or pelvis and there are no palpable masses or evidence of distension. A pregnancy test is negative. Which of the following is the best way to definitively diagnose her condition?

direct visualization at the time of surgical evaluation Ovarian torsion occurs when there is a complete or partial rotation of the ovary on the ligaments that support it, causing compromise of the blood supply to and out of the ovary due to the compression of the arteries and veins that are connected to it. Chronic compression of these vessels can lead to enlargement and edema of the ovaries, ischemia, and an increase in the risk of infarction and necrosis. Risk factors include pregnancy and being of reproductive age. An ovarian mass such as an ovarian cyst or ovarian neoplasm also increases the risk of torsion. The right ovary is more commonly affected than the left. Patients may present with sudden onset of one-sided pelvic pain that is associated with nausea and vomiting. The pain can be precipitated by activity such as vigorous exercise or intercourse. A physical examination may reveal a low-grade fever in some patients, as well as tachycardia or elevated blood pressure associated with severe pain. An abdominal and pelvic exam may be negative for palpable masses. Since torsion risk is increased in pregnancy, all patients should take a pregnancy test, which will also exclude the possibility of an ectopic pregnancy. Imaging studies such as transvaginal and transabdominal ultrasounds may reveal an enlarged ovary compared to the contralateral ovary. An ultrasound with Doppler analysis will help to determine if blood flow is impaired. Pain may also be elicited with contact of the affected ovary with the ultrasound probe during the examination. There may also be a "string of pearls" finding that is associated with polycystic ovarian syndrome. Magnetic resonance imaging and computed tomography scanning can also be helpful if further imaging is required and will also show an enlarged, swollen ovary as well as surrounding tortuous or coiled vessels (which is only visualized if these studies are done with contrast). Definitive diagnosis is made by direct visualization of the torsion at the time of surgical evaluation. Surgery to correct the torsion either laparoscopically or manually via laparotomy is the mainstay of treatment of this condition to preserve ovarian function in premenopausal women. A salpingo-oophorectomy can be considered in postmenopausal women and required if there is a suspicious ovarian mass present. Medications such as high-dose estrogen oral contraceptives can be helpful to prevent the formation of ovarian cysts. Immediate evaluation and treatment of this condition is difficult due to nonspecific symptoms on presentation but is imperative for preserving ovarian function.

A 60-year-old G6P6 woman presents to the gynecology clinic complaining of pelvic pressure and vaginal bulging. She also reports a sensation of incomplete emptying following bowel movements. Physical examination reveals prolapse at the posterior vaginal wall. Which of the following additional findings is most consistent with the most likely diagnosis?

fecal incontinence Pelvic organ prolapse (pelvic floor muscle disease) is the herniation of pelvic organs either to or beyond the vaginal walls. The organs involved in pelvic organ prolapse include the rectum, intestine, uterus, and vaginal vault. Pelvic organ prolapse can be categorized into anterior compartment prolapse, posterior compartment prolapse, and apical prolapse. Rectocele is a term used when the rectum is the organ prolapsing. Rectoceles usually manifest with either posterior or apical prolapse. However, posterior or apical prolapse can also be caused by the prolapse of other organs. Therefore, it is difficult to definitively diagnose a rectocele based on history and exam findings. Risk factors for pelvic organ prolapse include increased parity, advanced age, and obesity. Women with pelvic organ prolapse may be asymptomatic or have symptoms that significantly impact daily life. The most common symptoms are vaginal and pelvic bulging or pressure. In addition, women may complain of urinary, bowel, or sexual symptoms. Urinary symptoms may include stress urinary incontinence or obstructive symptoms, such as slow urinary stream, the need to manually reduce the bulge to urinate, and symptoms of overactive bladder (frequency, urgency, urge incontinence). Bowel symptoms may include fecal urgency, incomplete emptying, constipation, and fecal incontinence. Sexual symptoms may include dyspareunia and decreased libido. Rectoceles are more commonly associated with bowel symptoms than bladder symptoms. The diagnosis of pelvic organ prolapse is made clinically during a pelvic exam. Prolapse of the apex or posterior vaginal wall is suggestive of a possible rectocele. It is important to correlate exam findings with the patient's history since asymptomatic women do not require treatment. Patients with symptomatic pelvic organ prolapse can be managed expectantly, with conservative management, or with surgical treatment. Expectant management is reserved for women who do not desire any treatment. Conservative management is generally first line because surgical treatment has the risk of complications or recurrence. Conservative treatment consists of vaginal pessaries and pelvic floor muscle exercises. Surgical treatment is indicated in women who prefer initial surgical treatment or who do not improve with conservative treatment. There are vaginal and abdominal surgical approaches with and without graft materials.

What are the risk factors for pelvic organ prolapse?

increased parity, advancing age, obesity, and increased intra-abdominal pressure.

Procidentia

is the most severe form of this condition and occurs when the uterus protrudes through the genital hiatus.

A 52-year-old woman presents to her gynecologist with reports of vaginal pressure, dyspareunia, urinary retention, and the sensation that something is falling out of her vagina. Her urinalysis is unremarkable. Speculum examination reveals an anterior vaginal wall prolapse. Which of the following physical examination findings is associated with a risk factor for the most likely diagnosis?

joint hypermobility Joint hypermobility is associated with certain connective tissue disorders such as Ehlers-Danlos syndrome, which is associated with an increased risk for developing a cystocele.

A 63-year-old woman presents to the gynecology clinic for a routine wellness exam. Physical examination reveals a bulging of the apex of the vaginal vault. Which of the following is recommended to prevent this condition?

kegel exercises Pelvic organ prolapse is a condition marked by herniation of pelvic organs from their normal anatomic location through the vaginal walls. The bladder, rectum, uterus, and vaginal vault are most frequently involved, but the intestines may also be affected. Risk factors include advanced age, increased parity, and obesity. Pelvic organ prolapse is often categorized by the compartment of the vagina that a structure is prolapsing against. Prolapse can be divided into the anterior compartment, posterior compartment, and the apex of the vaginal canal. Prolapse against the anterior vaginal wall is often due to a cystocele (bladder prolapse), prolapse against the posterior vaginal wall is often due to a rectocele (rectal prolapse), and prolapse of the vaginal apex is often due to uterine prolapse. Patients with pelvic organ prolapse may be asymptomatic or complain of vaginal bulging or pressure, urinary symptoms, bowel symptoms, and sexual symptoms. The diagnosis is made clinically based on pelvic examination findings. Patients should be educated that the following lifestyle measures and conservative interventions may reduce the risk of pelvic organ prolapse: weight loss, treatment of chronic constipation, avoidance of heavy lifting, and Kegel exercises to strengthen the pelvic floor muscles. The treatment options of women with symptomatic pelvic organ prolapse include conservative treatment and surgical treatment. Conservative treatment consists of the preventive interventions and a vaginal pessary. Vaginal pessaries are silicone objects in various shapes or sizes that can be inserted vaginally to support the pelvic organs. They must be regularly removed, cleaned, and replaced. Conservative treatment is recommended prior to surgical treatment because there are possible complications associated with surgery. The surgical approaches vary widely, but reconstructive surgery is the most common approach. Surgeries may be performed vaginally or abdominally. The rate of recurrence of symptoms or the need for repeat surgery for pelvic organ prolapse is about 30%.

Uterine prolapse

occurs when the apical aspect of the vagina, which supports the uterus, descends into the vaginal canal. Uterine prolapse is associated with anterior, posterior, and lateral compartment prolapse as well.

A 28-year-old woman presents to the emergency department with acute left-sided pelvic pain and vomiting. Physical examination reveals left-sided lower abdominal tenderness. Urine pregnancy test is negative. The transvaginal ultrasound reveals an enlarged and rounded left ovary with decreased Doppler flow to the left ovary. Which of the following is the most likely diagnosis?

ovarian torsion Ovarian torsion refers to the complete or partial rotation (twisting) of an ovary on its ligamentous support, which can lead to impaired blood flow to the ovary. Adnexal torsion refers to the twisting of both the ovary and the fallopian tube. Ovarian and adnexal torsion are considered gynecologic emergencies due to the importance of rapid treatment to prevent loss of the ovary from necrosis. Ovarian torsion can occur in female patients of any age, but it is most common in reproductive-aged women. The most important risk factor for ovarian torsion is the presence of an ovarian mass, particularly masses larger than 5 cm. The classic clinical findings of ovarian torsion are acute onset of moderate or severe pelvic pain and the presence of an ovarian mass. Most patients have nausea and vomiting and do not have vaginal bleeding. The causes of the underlying adnexal mass vary and may include ovarian cysts, ovarian malignancies, and polycystic ovary syndrome. The definitive diagnosis of ovarian torsion is made by direct visualization of a rotated ovary at the time of surgical intervention. However, the decision to perform surgery is made based on the patient's clinical findings and ultrasound findings. Laboratory findings do not play a significant role in suggesting the diagnosis. However, it is important to obtain a urine or serum pregnancy test to rule out an ectopic pregnancy or other pregnancy-related complications. Leukocytosis may occur due to necrosis of the fallopian tube. The patient's hemoglobin level is usually at baseline because ovarian torsion rarely causes hemorrhage. Pelvic ultrasound is the best imaging study to assess for ovarian torsion. The classic findings on ultrasound include the affected ovary being enlarged and rounded relative to the unaffected ovary due to edema from vascular and lymphatic engorgement, ovarian masses, and decreased or absent flow within the ovary. Abdominal CT and MRI are not the most sensitive studies for ovarian torsion but can sometimes suggest ovarian torsion when performed for other reasons. Ovarian torsion is treated surgically. In premenopausal women, laparoscopy is used to detorse the ovary manually and attempt to conserve it. Ovarian cystectomy is performed if a benign mass is present. However, salpingo-oophorectomy is the recommended treatment in postmenopausal women.

A 67-year-old G6P5 woman presents to the clinic complaining of pelvic pressure that has progressively worsened for months. She also complains she cannot empty her bladder completely. She is currently sexually active. Physical examination reveals collapse of the anterior vaginal wall. Which of the following is the recommended initial treatment?

pessary

A 30-year-old multiparous woman presents with vaginal fullness and fecal incontinence. On exam, you note a bulge on the posterior vaginal wall that is worse with the Valsalva maneuver. Which of the following is the most likely diagnosis?

rectocele Rectocele is the herniation of the terminal rectum into the posterior wall of the vagina, resulting in a collapsible pouch-like fullness that passes into the introitus. Risk factors may include vaginal birth, advancing age, multiparity, genetic disposition, obesity, elevated intra-abdominal pressure, frequent constipation, and use of laxatives. Patients present with vaginal fullness, introital bulging with concurrent fecal incontinence, constipation, low back pain, and dyspareunia. Symptoms are exacerbated by standing or the Valsalva maneuver. The diagnosis of a rectocele is made clinically by the presence of a bulge in the posterior vaginal wall with concurrent symptoms, such as fecal incontinence in a woman with risk factors for rectocele. Physical exam may also reveal breaks in the rectovaginal fascia. Initial treatment of a rectocele consists of nonsurgical methods, such as high-fiber diet, weight reduction, pessary, Kegel exercises, biofeedback, and electrical stimulation. Surgical intervention (posterior colporrhaphy and colpocleisis) is performed for cases that do not respond to conservative measures. Rectocele History of childbirth, trauma, previous surgeries PE will show a vaginal bulge at posterior vaginal wall or anterior rectum wall Most commonly caused by weak pelvic muscles Management includes managing constipation (high-fiber diet), pessary device, and surgery when conservative measures fail

A 55-year-old woman presents to the office due to vaginal fullness and pressure that has gotten worse over the past year. She feels a bulge at the opening of her vagina especially after being on her feet for several hours. She is also having more difficulty urinating. She does not have any problems with defecation and does not report vaginal bleeding or pain. She is widowed and has six adult children who were delivered vaginally. Which of the following is the most appropriate next step in treatment?

refer to a specialist for pessary fitting

Pelvic organ prolapse

refers to herniation of the pelvic organs to or beyond the vaginal walls. The most commonly involved organs are the bladder, vaginal vault, uterus, rectum, and intestines. Pelvic organ prolapse can be classified based on severity using the Baden-Walker system into stages 0-4, with stage 4 the most severe.

A 26-year-old woman presents to the ED with sudden-onset pelvic pain, nausea, and vomiting for the past 2 hours. She reports no vaginal discharge or vaginal bleeding. Her medical history is significant for polycystic ovary syndrome. Her serum human chorionic gonadotropin is negative. Which of the following additional physical examination findings is most consistent with the suspected diagnosis?

right sided adnexal mass An ovarian torsion is a surgical emergency characterized by partial or complete rotation of the ovary on its ligamentous supports (e.g., suspensory ligament of the ovary, utero-ovarian ligament, broad ligament). In adult women, the most common cause of ovarian torsion is an ovarian mass > 5 cm. An ovarian cyst or neoplasm is a common cause of torsion. However, torsion can occur in the absence of an ovarian mass, particularly in premenarchal girls in whom the utero-ovarian ligament is elongated. Other causes of ovarian torsion include strenuous exercise or acutely increased abdominal pressure. Patients who are pregnant, are of reproductive age, or who have a history of prior torsion or ovulation induction are at increased risk of ovarian torsion. Patients typically present with pelvic pain, nausea, and vomiting. Fever and abnormal genital tract bleeding may also be present. Abdominal and pelvic tenderness may be absent, unilateral, or diffuse. An adnexal mass is almost always appreciated on pelvic exam. This patient has a history of ovarian cysts, which is the likely cause of her torsion. A right-sided adnexal mass is the most likely finding on pelvic examination. A complete blood count, electrolyte panel, and serum human chorionic gonadotropin should be ordered. Pelvic ultrasound is the first-line imaging study and may reveal an ovarian mass, heterogeneous appearance of the ovarian stroma, multiple small peripheral follicles, abnormal ovarian location, decreased or absent blood flow to the ovary, or a whirlpool sign in the ovarian vessels representing torsion of the vascular pedicle. Definitive diagnosis is made by visualization during surgery. Emergent surgical evaluation for detorsion and ovarian conservation is warranted in most cases. A benign ovarian mass may be treated with ovarian cystectomy, while an ovarian mass suspicious for malignancy may require salpingo-oophorectomy. Complications of untreated ovarian torsion include necrosis, hemorrhage, peritonitis, and infertility.

A 62-year-old woman presents to her gynecologist with reports of vaginal heaviness and sensations of incomplete bladder emptying. A pelvic examination reveals uterine prolapse. Which stage of uterine prolapse is defined by the uterus located at the level of the hymen?

stage 2 The Pelvic Organ Prolapse Quantification system is the current standard for staging of pelvic organ prolapse. Stage 1 is characterized by a pelvic organ that is > 1 cm above the hymen. Stage 2 is characterized by a pelvic organ extending from 1 cm above to 1 cm below the hymen. Stage 3 is characterized by a pelvic organ located > 1 cm past the hymen without complete uterine prolapse. Stage 4 is characterized by complete uterine prolapse.

A 72-year-old woman presents to the office with complaints of a new vaginal mass. While she was cleaning her house earlier in the day, she reports feeling a sudden fullness vaginally. She is worried her bladder is falling out. She is experiencing some discomfort that is worse when she is sitting. On physical exam, the external genitalia appear normal, and there is no frank blood. When the patient performs a Valsalva maneuver, the uterine cervix protrudes through the vaginal introitus by 5 mm. When relaxed, the prolapse is completely reduced. Bimanual exam reveals a 4 cm uterus with a smooth contour and no adnexal masses. There is anterior vaginal wall laxity. Which stage of pelvic organ prolapse is this patient experiencing?

stage 3

The term cystocele is used when the bladder prolapses through the anterior vaginal wall. The most common symptoms of a cystocele are

urinary incontinence or retention and a sensation of pelvic pressure or of the protrusion of tissue through the vagina. Patients often describe feeling as though something is falling out of their vagina. Prolapse of pelvic organs causes a sensation of pressure but not pain. Cystoceles may also cause dyspareunia. The diagnosis of a cystocele is made clinically. Complications include urinary retention, urinary tract infections, ulcerations, and vaginal bleeding.