Pelvic organ Neocities V2

<h3>Hi, and welcome to the most thrilling time of the posting.</h3> Hide your excitement and let's [[begin| start]]. <img src="/Pelv_org_prol/3_1_start.jpg">

Oh no.... That is not the correct diagnosis. Pelvic organ prolapse has three compartments. 1. Anterior compartment : Bladder (cystocele), urethra (urethrocele) 2. Middle compartment: Uterus, cervix, vagina (uterovagnial prolpase) 3. Posterior compartment: Rectum (rectocele), small intestine (enterocele) <img src="/Pelv_org_prol/3_3_obgyn-uterine-prolapse4.jpg"> Try again ;-) (track: 'evil laugh', 'play') (track: 'evil laugh', 'volume', 0.4)

Oh yesss. That is correct. Pelvic organ prolapse has three compartments. 1. Anterior compartment : Bladder (cystocele), urethra (urethrocele) 2. Middle compartment: Uterus, cervix, vagina (uterovagnial prolpase) 3. Posterior compartment: Rectum (rectocele), small intestine (enterocele) <img src="/Pelv_org_prol/3_3_obgyn-uterine-prolapse4.jpg"> Now for the second question...Ready? What further RELEVANT history would you obtain from Mrs. Kane to determine her risk factors for her prolapse? [[1. History of occupation which requires heavy weight lifting, types of contraception, chronic cough.]] [[2. History of pelvic tumors, parity, mode of deliveries, birth weights.]] [[3. History of menopause, Hormone replacement therapy, multiple sexual partners]] [[4. History of Human Papilloma Virus (HPV infection), family members having a similar problems or connective tissue disorders, smoking.]] (track: 'Bingo', 'play') (track: 'Bingo', 'volume', 0.4)

Uhh ohh Usage or not usage of Contraception is not included in the risks factors for pelvic organ prolapse. Risk factors includes: 1. large babies, 2. prolonged second stage, and instrumental delivery menopause 3. chronic increase in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting, or pelvic mass 4. pelvic surgery 5. Congenital factors: abnormal collagen metabolism, for example, in Ehlers–Danlos syndrome. Never mind, there is always a second chance. Try again :-) (track: 'sad', 'play') (track: 'sad', 'volume', 0.4)

Yessss. You are good. Risk factors include: 1. Large babies, 2. Prolonged second stage, and instrumental delivery menopause 3. Chronic increase in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting, or pelvic mass 4. Pelvic surgery 5. Congenital factors: abnormal collagen metabolism, for example, in Ehlers–Danlos syndrome. Don't forget to ask the histories of her symptoms too, such as: • Dragging sensation, discomfort, and heaviness within the pelvis, feeling of ‘a lump coming down’, dyspareunia, backache. • Any decibitus ulcers on cervix • Urinary symptoms &nbsp - Urinary urgency and frequency &nbsp - Incomplete bladder emptying &nbsp - Urinary retention • Bowel symptoms &nbsp - Constipation &nbsp - Difficulty with defecation (may digitally reduce it to defecate). Now... Another challenge [[Click here|examination]] (track: 'Success', 'play') (track: 'Success', 'volume', 0.4)

Uhh ohh Multiple sexual partners is included in the risks factors for pelvic organ prolapse. Risk factors includes: 1. large babies, 2. prolonged second stage, and instrumental delivery menopause 3. chronic increase in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting, or pelvic mass 4. pelvic surgery 5. Congenital factors: abnormal collagen metabolism, for example, in Ehlers–Danlos syndrome. Never mind, there is always a second chance. Try again :-) (track: 'sad', 'play') (track: 'sad', 'volume', 0.4)

Uhh ohh HPV infection can not lead to pelvic organ prolapse. Risk factors includes: 1. large babies, 2. prolonged second stage, and instrumental delivery menopause 3. chronic increase in intra-abdominal pressure, resulting from factors such as obesity, chronic cough, constipation, heavy lifting, or pelvic mass 4. pelvic surgery 5. Congenital factors: abnormal collagen metabolism, for example, in Ehlers–Danlos syndrome. Never mind, there is always a second chance. Try again :-) (track: 'sad', 'play') (track: 'sad', 'volume', 0.4)

:-( I am sorry. Examinations that we need to concentrate on are: 1. BMI 2. Respiratory system to exclude any chronic respiratory diseases 3. Abdominal examination to exclude any pelvic mass 4. Pelvic examination Read about pelvic organ prolapse examination <a href="/Pelv_org_prol/3_pelvic organ prolapse examination KPP.pdf" target="_blank">here</a></li> (track: 'witch', 'play') (track: 'witch', 'volume', 0.4)

Exactly ! Fantastic Examinations that we need to concentrate on are: 1. BMI 2. Respiratory system to exclude any chronic respiratory diseases 3. Abdominal examination to exclude any pelvic mass 4. Pelvic examination Read about pelvic organ prolapse examination <a href="/Pelv_org_prol/3_pelvic organ prolapse examination KPP.pdf" target="_blank">here</a></li> Now you are entering into next step. Now try [[this|What are the organs and ligaments involved with this condition]] (track: 'yess', 'play') (track: 'yess', 'volume', 0.4)

Exactly ! Fantastic Examinations that we need to concentrate on are: 1. BMI 2. Respiratory system to exclude any chronic respiratory diseases 3. Abdominal examination to exclude any pelvic mass 4. Pelvic examination Read about pelvic organ prolapse examination <a href="/Pelv_org_prol/3_pelvic organ prolapse examination KPP.pdf" target="_blank">here</a></li> Now you may move on to the next part. Try [[this|What are the organs and ligaments involved with this condition]] (track: 'yess', 'play') (track: 'yess', 'volume', 0.4)

Here is your next question. What are the organs and ligaments involved/ weakened with this condition? [[1. Sacrospinous ligament]] [[2. Sacrococcygeal ligament]] [[3. Uterosacral ligament]] [[4. Sacrotuberous ligament]]

:-( Sad.....You forgot your basic sciences There are three levels of support: Level 1: The cervix and upper third of the vagina are supported by the cardinal (transverse cervical) and uterosacral ligaments. These are attached to the cervix and suspend the uterus from the pelvic side wall and sacrum respectively. Level 2: The mid portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls. Level 3: The lower third of the vagina is supported by the levator ani muscles and the perineal body. The levator ani, together with its associated fascia, is termed the pelvic diaphragm. The axis of the vagina is also important. It normally lies in a horizontal plane, flat on the levator muscles. This protects it during coughing and other activities that increase intra-abdominal pressure. That's OK, hopefully you'll remember now. Go back and try again. (track: 'no dear', 'play') (track: 'no dear', 'volume', 0.4)

Hey, you are good. You remembered your basic sciences. Bravo. There are three levels of support: Level 1: The cervix and upper third of the vagina are supported by the cardinal (transverse cervical) and uterosacral ligaments. These are attached to the cervix and suspend the uterus from the pelvic side wall and sacrum respectively. Level 2: The mid portion of the vagina is attached by endofascial condensation (endopelvic fascia) laterally to the pelvic side walls. Level 3: The lower third of the vagina is supported by the levator ani muscles and the perineal body. The levator ani, together with its associated fascia, is termed the pelvic diaphragm. The axis of the vagina is also important. It normally lies in a horizontal plane, flat on the levator muscles. This protects it during coughing and other activities that increase intra-abdominal pressure. Now.... Take a deep breath and go to next level by clicking [[here|types and grading of this condition]] (track: 'Basic rock 135', 'play') (track: 'Basic rock 135', 'volume', 0.4)

For this case, choose the correct type and grading of pelvic organ prolapse by Baden Walker's classification. [[1. Descent to hymenal ring : first Degree]] [[2. Descent within vagina: Second Degree]] [[3. Descent beyond hymenal ring/outside introitus: Third Degree]]

You are almost right....But..... Here is a correct Baden Walker's classification: 1st Degree: Prolapse extends halfway down the vagina. 2nd Degree: Prolapse extends to the hymenal ring. 3rd Degree: Prolpase extends beyond the hymenal ring but not maximal descent. 4th Degree or procedential: Prolpase extends beyond the hymenal ring with maximal descent. <img src="/Pelv_org_prol/3_4_Baden walker.jpg"> Try again ;-) (track: 'wakeup', 'play') (track: 'wakeup', 'volume', 0.4)

You are almost right....But..... Here is the correct Baden Walker's classification: 1st Degree: Prolapse extends halfway down the vagina. 2nd Degree: Prolapse extends to the hymenal ring. 3rd Degree: Prolpase extends beyond the hymenal ring but not maximal descent. 4th Degree or Procedential: Prolpase extends beyond the hymenal ring with maximal descent. <img src="/Pelv_org_prol/3_4_Baden walker.jpg"> Try again ;-) (track: 'wakeup', 'play') (track: 'wakeup', 'volume', 0.4)

That's correct. You are smart ! Here is a correct Baden Walker's classification: 1st Degree: Prolapse extends halfway down the vagina. 2nd Degree: Prolapse extends to the hymenal ring. 3rd Degree: Prolpase extends beyond the hymenal ring but not maximal descent. 4th Degree or procedential: Prolpase extends beyond the hymenal ring with maximal descent. <img src="/Pelv_org_prol/3_4_Baden walker.jpg"> Now, let's see if you can get this too. Click [[here|Investigations]] (track: 'music box', 'play') (track: 'music box', 'volume', 0.4)

You chose the wrong answer. You need to do Urine FEME to exclude UTI for Mrs Kane. Read the question again. Question you are asked is "The following are investigations with the correct justifications that you would request for Mrs. Kane, EXCEPT for" Do you see the word "EXCEPT" ?? Yeah, that's the trap...ahhh hahh now you realise it. Go back and try again. (track: 'oh', 'play') (track: 'oh', 'volume', 0.4)

You chose the wrong answer. You need to perform pelvic ultrasound to exclude pelvic mass for Mrs Kane. Read the question again. Question you are asked is "The following are investigations with the correct justifications that you would request for Mrs. Kane, EXCEPT for" Do you see the word "EXCEPT" ?? Yeah, that's the trap...ahhh hahh now you realise it. Go back and try again. (track: 'oh', 'play') (track: 'oh', 'volume', 0.4)

You chose the wrong answer. You need to do Full blood count, Chest X Ray, ECG for preop assessment for Mrs Kane. Read the question again. Question you are asked is "The following are investigations with the correct justifications that you would request for Mrs. Kane, EXCEPT for" Do you see the word "EXCEPT" ?? Yeah, that's the trap...ahhh hahh now you realise it. Go back and try again. (track: 'oh', 'play') (track: 'oh', 'volume', 0.4)

That's it. You made the right choice. You might need to do a urodynamic study NOT to confirm the degree of prolapse, but to investigate further if Mrs Kane has urinary incontinence. Degree of prolapse is assessed by clinical pelvic examination. Here is what a basic urodynamic study looks like <img src="/Pelv_org_prol/3_5_Urodynaemic 1b.jpg" /> <img src="/Pelv_org_prol/3_6_urodynaemic 2.png" /> You are coming very close to your trophy in this game. [[Enter the next level|treatment]] (track: 'one cheer', 'play') (track: 'one cheer', 'volume', 0.4)

The following are investigations with the correct justifications that you would request for Mrs. Kane, EXCEPT for [[1. Urine FEME to exclude UTI]] [[2. Pelvic ultrasound to exclude pelvic mass]] [[3. Full blood count, Chest X Ray, ECG for preop assessment]] [[4. Urodynamic study to confirm the degree of prolapse]]

Upon further history taking, physical examination and investigation, you find out that Ms Kane has no known medical problems except for diabetes mellitus on metformin 500 mg TDS. Her HbA1C is 4%. Abominal examination is unremarkable. Pelvic examination shows third degree prolpase with mild cystocele. No urinary leakage is found. Investigations results are within the normal limits. She is still sexually active. What BEST treatment option you would like to offer to Mrs Kane? [[1. Abdominal hysterectomy with anterior repair]] [[2. Vaginal hysterectomy with anterior repair]] [[3. Vaginal ring pessary]] [[4. Vaginal shelf/ Gellhorn pessary]]

Oh no, that is not the best option for Mrs Kane. You are right that surgery is the best option for her as she is fit for surgery and it is already at least 3rd Degree prolpase. However, regarding the approach, the best is the vaginal approach as almost the whole uterus is prolapsing out already. And yes, you need the anterior repair for her cystocele. No worries... Try again. (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.4)

Yessss, that is the best option for Mrs Kane. You are right that surgery is the best option for her as she is fit for surgery and it is already at least 3rd Degree prolpase. In addition, regarding the approach, the best is the vaginal approach as almost the whole uterus is prolapsing out already. And yes, you need the anterior repair for her cystocele. However, if she has an ulcer, you need to treat with oestrogen cream before you do the surgery. Click [[here|answers for treatment]] to read about her treatment options before we move on to the next part. (track: 'Success', 'play') (track: 'Success', 'volume', 0.4)

Oh no, that is not the best option for Mrs Kane. Mrs Kane is very fit for surgery and it is already at least 3rd Degree prolpase. Ring pessaries are considered only if your patient is not fit for surgery or she refuses surgery. No worries... Try again. <img src="/Pelv_org_prol/3_7_ring pessary 1.jpg" /> <img src="/Pelv_org_prol/3_8_ring pessary 2.jpg" /> (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.4)

Oh no, that is not the best option for Mrs Kane. Mrs Kane is very fit for surgery and it is already at least 3rd Degree prolpase. Pessaries are considered only if your patient is not fit for surgery or she refuses surgery. Another point to note: Mrs Kane is still sexually active, remember. Shelf pessary or Gellhorn should be used in sexually active patients. If she needs pessaries, ring pessaries are of good choice provided that she is not for surgery. No worries... Try again. Shelf pessaries/ Gellhorn <img src="/Pelv_org_prol/3_9_shelf pessay.jpg" /> Shelf pessary vs ring pessary <img src="/Pelv_org_prol/3_10_ring vs gelhorn_pessary.jpg" /> Try again ;-) (track: 'oh no', 'play') (track: 'oh no', 'volume', 0.4)

FINAL QUESTION NOW: You have successfully managed Mrs Kane, congratulations. A new patient has just walked in.... Mrs Julie, a 30-year-old teacher has the same complaint as Ms Kane, that 'something is protruding' from the introitus, noticed over the past 1 month. She is normally fit and well. She has one child delivered vaginally. Her mother suffered from pelvic organ prolapse. Local examination reveals a 2nd degree uterovaginal prolapse with no cystocele and no rectocele. You have completed proper history taking, risk assessment, physical examination and investigations like you did with Mrs Kane. Pelvic examination reveals 2nd Degree uterovaginal prolapse with no cystocele and no rectocele. The rest are unremarkable. After proper assessment, you suspected that congenital factors, eg abnormal collagen metabolism, play a role in Mrs Julie's uterovaginal prolapse. What BEST definitive managment you would like to offer Mrs Julie? [[1. Vaginal hysterectomy]] [[2. Abdominal hysterectomy]] [[3. Manchester repair]]

Oh no, so sorry for Mrs Julie. She is only 30 years with one child. Now you have removed her uterus, she has lost her fertility. Her husband plans to meet with their lawyer to get answers from you in court. But don't worry. In this game, you can still go back to previous stage and change your management option. Try again ;-) (track: 'Punch 2', 'play') (track: 'Punch 2', 'volume', 0.4)

<tw-hook style="animation: 0.5s steps(1, end) 0s infinite alternate none running fade-in-out;">You made it, congratulations! Claim your trophy from your lecturer.</tw-hook> Right. You need to do uterine conserving surgeries for Mrs Julie, such as 1. Manchester repair (or Fothergill repair): Cervical amputation is followed by approximation and shortening of the cardinal ligaments anterior to the cervical stump. 2. Hysteropexy: Uterus and cervix are attached to sacrum using bifurcated non-absorbable mesh. Now thanks to you, both Mrs Kane and Mrs Julie are happy and healthy again. You made their days as well as my day. :-D But don't forget to read the following for better understanding and retainment of your knowledge and reasoning skills regarding pelvic organ prolapse. 1. <a href="/Pelv_org_prol/3_Uterovaginal prolapse 10 Teachers Gyanecology 18th edition, chapter 17.pdf" target="_blank">Chapter on Uterovaginal Prolapse from Gynaecology by Ten teachers</a> 2. <a href="/Pelv_org_prol/3_Pelvic organ prolapse Oxford Handbook of Obstretics & Gyneacology 3rd Ed [PDF].pdf" target="_blank">Urogynaecology chapter from Oxford Handbook of Obstetrics & Gynaecology</a> 3. <a href="/Pelv_org_prol/3_pelvic organ prolapse examination KPP.pdf" target="_blank">Examination of pelvic organ prolapse</a> 4. <a href="/Pelv_org_prol/3_Kegel exercise.pdf" target="_blank">Kegel exercise</a> <img src="/Pelv_org_prol/3_11_house-md_0004.jpg" /> Back to <a href="https://medventure.neocities.org/Semester8/index.html">Home</a> (link: "Restart Game")[(reload:)] (track: 'football', 'play') (track: 'football', 'volume', 0.4)

What further examination would you perform on Mrs. Kane? [[1. Peripheral nervous system]] [[2. Central nervous system]] [[3. Abdomen]] [[4. Respiratory system]] [[5. Pelvic examination]]

Mrs. Kane, a 55-year-old woman is admitted with a mass descending from her vagina for 3 months. She has 9 grown-up children and 16 grandchildren. On examination, her BMI is 34kg/m2 and her blood pressure is 130/80mmHg. Abdominal examination is unremarkable. Local examination reveals the presence of her cervix outside the vaginal introitus. What is your provisional diagnosis? [[1. Rectocele]] [[2. Cystocele]] [[3. Uterovaginal prolapse]] [[4. Urethrocele]] [[5. Enterocele]] <img src="/Pelv_org_prol/3_2_UVP.jpg">

Treatment options are: 1. Conservative management: pelvic floor exercise, biofeedback 2. Pessaries 3. Surgery: &nbsp&nbsp(A) Anterior compartment defect: Anterior colporrhaphy (anterior repair) &nbsp&nbsp(B) Posterior compartment defect: Posterior colpoperineorrhaphy (posterior repair) &nbsp&nbsp(C) Uterovaginal (apical) prolapse: &nbsp&nbsp&nbsp&nbsp - Vaginal hysterectomy/ abdominal hysterectomy &nbsp&nbsp&nbsp&nbsp - Manchester repair (or Fothergill repair) &nbsp&nbsp&nbsp&nbsp - Hysteropexy Click [[here| prevention]] to read about prevention of pelvic organ prolpase before we move on to the next part.

Prevention of pelvic organ prolpase Shortening the second stage of delivery and reducing traumatic delivery may result in fewer women developing a prolapse. The benefits of episiotomy and hormone replacement therapy at the menopause have not been substantiated. Now you are almost done. To move on to the next (final) part, click [[here| final]]

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