TEALE FENNING

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

A 65 year old woman has developed a vaginal vault prolapse 20 years after a vaginal hysterectomy for benign disease.

How may her vaginal vault prolapse have been prevented at the time of hysterectomy? (3)

How will you assess her? (5)

Evaluate the treatment options available to her. (12)

Xerxes I · Posted: Thu Aug 14, 2008 8:58 pm Post subject:

A 65 year old woman has developed a vaginal vault prolapse 20 years after a vaginal hysterectomy for benign disease.

How may her vaginal vault prolapse have been prevented at the time of hysterectomy? (4)
A more than 2 cm descent of the vaginal cuff scar is defined as vault prolapse. It's incidence is reported to be between 10-20% after vaginal hysterectomy and is likely to be higher depending on the length of time from the operation.
McCull's culdoplasty- approcimation of uterosacral ligaments by continuous stitches) is thought to be of benefit to increase the risk of vaginal vault prolapse at the time of vaginal hysterectomy. If there is significant uterine prolapse (i.e Cervix coming down to itroitus), sacrospinous fixation is recommended at the time of vaginal hysterectomy.
stitching the uterosacral ligaments to the vaginal vault (i.e. tying the two pedicles together and to the vault is also likely to be helpful in prevention.
Most of the evidence for the prevention of VVP!! is from case series and retrospective studies.

How will you assess her? (4)

Histrory, does it bother her? Any urinary symptoms?
Look for new reasons for increased intraabdominal pressure. It is not unusual for VVP to happen 20 years down the line but I had two patients recently, both turned out to have cancer. one ovarian, one bowel, they were both 90 something with procedentia and vault prolapse.]
So in history I would also mention change in bowel habit, weght loss etc.
Although if only 4 points (which i think should be 7) I would concentrate on the main things, ie the PoPQ which I have never used and the QoL questionnaire which is really irrelevant!!
I would also mention Ascites, cough, bimanual, pelvic ultrasound if any suggestion of anything, Urodynamics if urinary dysfunction.... not really.

Evaluate the treatment options available to her. (12)

Abik · Posted: Sun Aug 17, 2008 8:23 pm Post subject:

S????
What happened - did you fall asleep?

Don't stop, doing so well.

Nick - do you think that introductory sentences gain marks? I notice that Xerxes always puts one in which nicely starts the answer but I wasn't sure was time-efficient?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

i have always given intro sentences, don't know if they help. considering the lack of space with this new format of questions, wonder if one should 'waste' space on these.

let's see what Nick thinks.

r

p.s-- hope u have been well.
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

Xerxes, I will give my version of the marking scheme tomorrow.

I have the same doubts about the use of an opening sentence. I think probably good to show you know why it's an important subject, might wake the bored examiner up, but no points gained for it.

I'm also not sure your first statement about the definition is correct. I don't actually understand the definition that the RCOG uses in the new green top guideline, please see my question under "guidelines" that I posted last week. They define it as "descent of the vaginal cuff scar below a point that is 2 cm less than the total vaginal length above the plane of the hymen".

Could they have explained it any more complicated?? I interpreted that as the cuff being within 2 cm distance above the hymen , or any distance below the hymen, rather than 2 cm descent. But you may well be right, I just don't know! If you are right, why don't they just say "descent of 2 cm or more"?

Can anyone explain what the definition means?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

I am not giving the definition a try.

have tried thinking about the new definition whilst examining patients but when do we actually use a measuring tape in clinic? also say a patient was left with too short a vaginal length i.e. the vault started much lower than average, there is 1.5 cm decent and the patient is symptomatic, will you not treat it as vault prolapse? i would.

Shocked

r
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

Yes, could not agree any more! Let's forget about the definition.

Will give out my version of answers soon, am off to the gym now..

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

A 65 year old woman has developed a vaginal vault prolapse 20 years after a vaginal hysterectomy for benign disease.

How may her vaginal vault prolapse have been prevented at the time of hysterectomy? (3)

McCall culdplasty: Approximating the uterosacral ligaments using a continuous suture, to obliterate the peritoneum of the posterior cul-de-sac as high as possible, is recommended to prevent enterocele formation. (1)

Suturing the cardinal and uterosacral ligaments to the vaginal cuff is recommended to prevent vault prolapse. (1)

Sacrospinous fixation at the time of hysterectomy is recommended if the vault descends to the introitus during closure. (1)

How will you assess her? (5)

Assessment of impact on quality of life, using a validated questionnaire. (1)
Urinary symptoms/incontinence. Urodynamics if so, especially if considering surgery, as surgery may exarcerbate/unmask incontinence. (1)
Woman's wishes regarding treatment. Sexually active/wishes to retain functional vagina. (vaginal if Bristolian) (1)

Examination: Identify all pelvic floor defects, to enable their surgical repairs. Asses vaginal lenght & width. Assess occult stress incontinence by reducing prolapse. (and stand back) Abdominal palpation to assess presence of mass.(3)

Evaluate the treatment options available to her. (12)

Conservative:
There is no evidence that pelvic floor exercises help.
Ring pessaries tend to fail.
Shelf pessaries preclude intercourse and require changing every 6 months. Risks are vault ulceration, calcium disposition and erosion and fistula formation. Suitable for physically frail women, who are unfit for surgery or if surgery is declined. (1)

Medical:

HRT/local oestrogen won't alleviate symptoms. It may improve atrophic changes and may reduce the risks associated with pessary use. (1)

Surgical:

Anterior & posterior vaginal wall repair are inadequate. (1)

Abdominal sacrocolpopexy and sacrospinous fixation are both effective. Both have risks of infection, haemorrhage requiring transfusion and bladder inury.
Sacrocolpopexy has a longer operation time and recovery. It can be done as an open procedure and combined with other open procedures, or it can be done laparoscopically. It is better for the sexually active woman, as it is associated with less dyspareunia. There is also less recurrence. There are added risks of ureter and bowel injuries.
Sacrospinous fixation is performed vaginally, is quicker, but has a higher failure rate. It is associated with more vaginal pain and dyspareunia, UTI's, catheter use and incontinence. It requires adequate vaginal length and vault width. It can be combined with anterior or posterior repairs. risk of pudendal nerve injury. (5)

If there is urodynamic stress incontinence, the above procedures can be combined with colposuspension or TVT. Prophylactic incontinence surgery is not routinely recommended. (1)

Colpocleisis is safe, effective and an option for women who do not wish to retain sexual function. It has a short operation time, a low incidence of recurrence and can be done under local anaesthetic. (2)

There is insufficient evidence to recommend total mesh reconstruction or vault suspension to the anterior abdominal wall. Iliococcygeus fixation is not recommended. (1)

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

Nick Raine-Fenning · Posted: Sat Sep 06, 2008 7:38 am Post subject:

Hey - this was a pretty good spot Maud!

Hope the practice and discussion here helped you on the big day.

Maud · Joined: 11 Oct 2007 Posts: 73 Location: Bristol

mrcog2010 · Joined: 08 Jul 2008 Posts: 32

thanks alot maud for ur answer, can u give us a referance plz ?

rpwalavalkar · Teale Fenning Administrator Joined: 20 Jul 2006 Posts: 966

Nick Raine-Fenning · Posted: Sun Sep 07, 2008 9:20 am Post subject:

mrcog2010 · Joined: 08 Jul 2008 Posts: 32