How do you describe prolapse?
Baden-Walker System
“Half way system”
0 = above ischial spines
1 = half way to hymen
2 = at the hymen
3 = half was past the hymen
4 = maximum descent
Risk factors for pelvic organ prolapse?
Obesity
Multiparity/Vaginal deliveries
Chronic constipation
Genetics
Age/menopausal status
Non-surgical treatment of POP?
- Address constipation
- Pelvic Floor PT
- Vaginal Estrogen
- Pessary
Assessment of POP?
Hx: bulge/pressure symptoms, voiding/defactory dysfunction, sexual dysfunction
PE: Abdominal and pelvic. Split speculum exam
Voiding trial to assess PVR, send UA/UCx
Backfill for cough stress test
Non-surgical managment of POP?
Address modifiable risk fastors: weight loss, smoking cessation, constipation
Vaginal estrogen
Pevlic floor PT
Pessary trial
Risks of pessary?
Risk of devascularization/erosion = 9%
If this happens, remove pessary for 2 weeks and use vaginal estrogen
Increase breaks when using pessary or get different pessary size
Different between Le Fort partial colpoclesis and complete colpectomy?
Le Fort= uterus remains inside
Complete colpectomy = no uterus, vaginal walls are plicated together
Dictate a Le Fort Paritial Colpoclesis
- Patient placed in high lithotomy, foley catheter placed. Tenacula placed on cervix
- Marking pen used to draw rectangles on the vaginal mucosa anteriorly and posteriorly, 2 cm from the cervix (mucosa left on the lateral sides to form channels)
- 1% lidocaine w/ epi injected into vaginal mucosa to aid in dissection
- A scalpel is used to incise anterior vaginal mucosa over the rectangle
- Edges are then dissected off and the epithelialum is separted from the muscularis with sharp/blunt dissection
- This is repeated in the postierior vaginal walls, mucosa is removed
- Achieve hemostasis w/ cautery
- Secure red rubber catheter by suturing to bring the leading edges of anterior and posterior rectangles together
- Bring the lateral edges together over the catheter, ensuring the catheter is still able to move freely
- The prolapse is the sequentially reduced using a series of purse string sutrues ~ 1 cm apart, 2-0 vicryl
- Once prolapse is completely reduced, the mucosal edges are then reapproximated
- Again, ensuring rubber catheter can move freely
- Perinopharrphy: Allis clamps placed at the lateral edges of the genital hiatus, inverted triangle insized with scalpel
- Bulbocarvernosa muscles on each side brought together with 0-vicryl
- Skin closed wtih 2-0 vicryl
- Cysto/rectal exam
Risk factors for recurrent prolapse
Age < 60
BMI > 26
Pre op Stage 3-4 prolpase
Dictate posterior colphorrhaphy
- Inject local w/ epi
- Inverted T (horizontal part along hymen) is incise
- Vaginal mucosa dissected of muscularis w/ sharp/blunt dissection
- Rectal vaginal fascia is plicated in the midline using interrupted suture using 2-0 vicryl
- Ensure suture hasn’t perofrated into the rectum
- Excessive vaginal mucosa is removed using scissors
- Vaginal mucosa is closed using continuous 2-0 vicryl suture
Dictate a perinorrpaphy
- Inverted triangle along the posterior vestibule and perineal body
- Inject local
- 0-vicryl interrupted suture to bring edges together
- Skin closed with 2-0 vicryl suture
Dictate a TVH
- Dorsol lithotomy, SCDs, prep/drape, 2 g cefazolin
- Insert foley catheter
- Weight speculum in posterior vaginal vault
- Cervix is grasped with tenaculum on A/P sides
- Local anesthestic w/ epi injected at the cervicovaginal junction
- With downward traction, and circumferential incision was made in the vaginal mucosa and the cervico-vaginal junction
- Entry into posterior cul de sac with mayo scissors curving upward. Insert long weighted speculum
- Anterior colpotomy - vaginal mucosa grasped and tented up and sharp/blunt dissect is done to separate the vaginal mucosa from the cervical stroma. Peritoneum is identified and entery sharply. Deaver retractor is placed.
- Visualize the uterosacral ligaments, clamp and ligate w/ 0-vicryl suture. Tag for furutre McCall’s culdoplasty.
- Cardinal ligaments are identified, clamped, cut and suture ligated.
- Uterine arteries where clamped and ligated
- Broad ligament is clamped, cut and sutures
- Uteroovarian/round ligament is clamped/cut/sutured. Place two sutures (suture tie followed by suture ligation medial to the first)
- Uterus is delivered, evaluate for bleeding
- Uterosacral ligaments are incorporated into the angle of the vaginal cuff at time of closure
How do you assess urethral hypermobility?
Q tip test (can use catheter)
Urethra moves > 30 degrees with valsalva
Abnormal PVR?
Measuring > 150 cc
Normal bladder capacity?
350 cc
Benefits of a LeFort Colpocleisis?
- Comorbidities that prohibt a more extensive procedure
- No longer having vaginal intercourse
- 98% success rates
- Low recurrence rates
