Genital prolapseGenital prolapse

Dr. Rupak BhattaraiDr. Rupak Bhattarai

Support to the Uterus-Support to the Uterus- Pubo-cervical ligament:Pubo-cervical ligament: The The pubocervical ligamentpubocervical ligament is a ligament is a ligament

connecting the side of the connecting the side of the cervix to the to the pubic symphysis..

Transverse cervical(“cardinal Transverse cervical(“cardinal ligament”)ligament”)

Extend from cervix and lateral parts of the fornix Extend from cervix and lateral parts of the fornix to the lateral walls of pelvis ( ischial spine).to the lateral walls of pelvis ( ischial spine).

Uterosacral ligament:Uterosacral ligament: Pass superiorly and slightly posteriorly from sides Pass superiorly and slightly posteriorly from sides

(base) of cervix to middle of sacrum; palpable (base) of cervix to middle of sacrum; palpable during rectal examduring rectal exam

Round ligament:Round ligament: attaches anteroinferiorly to uterotubal attaches anteroinferiorly to uterotubal

junctionjunction

Broad ligament:Broad ligament: These are 2 layered folds of peritoneum which suspend the These are 2 layered folds of peritoneum which suspend the

uterus to the lateral pelvic walluterus to the lateral pelvic wall It has anterior & posterior layers. A free upper border, It has anterior & posterior layers. A free upper border,

lower, medial & laterallower, medial & lateral Superiorly the 2 layers are continuous over the uterine tubeSuperiorly the 2 layers are continuous over the uterine tube Inferiorly & laterally the 2 layers spread out to cover the Inferiorly & laterally the 2 layers spread out to cover the

pelvic floorpelvic floor

Genital prolapse-Genital prolapse-It refers to the downward displacement of It refers to the downward displacement of

the uterus or vagina from its normal the uterus or vagina from its normal anatomical position.anatomical position.

Etiology of prolapse-Etiology of prolapse- These are usually seen during vaginal These are usually seen during vaginal

delivery with consequent injury to the delivery with consequent injury to the supporting structures.supporting structures.

1.Premature bear down effort prior to the 1.Premature bear down effort prior to the full dilatation of the cervix.full dilatation of the cervix.

2.Application of the forceps or ventouse 2.Application of the forceps or ventouse prior to the full dilatation of cervix.prior to the full dilatation of cervix.

Precipitate labour.Precipitate labour. Early resumption of activites after delivery Early resumption of activites after delivery

which increases intra abdominal pressure which increases intra abdominal pressure before they gain their normal tone.before they gain their normal tone.

Repeated childbirth at frequent intervals.Repeated childbirth at frequent intervals. Increase in the intrabdomial pressure as in Increase in the intrabdomial pressure as in

chronic cough and constipation.chronic cough and constipation.

Clinical typesClinical types

1.Vaginal prolapse:1.Vaginal prolapse: Anterior wall:Anterior wall: A) A) CystoceleCystocele-is a medical condition that occurs -is a medical condition that occurs

when the tough fibrous wall between a woman's when the tough fibrous wall between a woman's bladder and her and her vagina (the (the pubocervical fascia) ) is torn by childbirth, allowing the bladder to is torn by childbirth, allowing the bladder to herniate into the vagina. herniate into the vagina. Urethroceles often occur often occur with cystoceles.with cystoceles.

CystoceleCystocele

B) B) UrethroceleUrethrocele-is the -is the prolapse of the of the female urethra into the vagina. Weakening female urethra into the vagina. Weakening of the tissues that hold the urethra in of the tissues that hold the urethra in place cause it to move and to put pressure place cause it to move and to put pressure on the vagina, leading to the descent of on the vagina, leading to the descent of the anterior distal wall of the the anterior distal wall of the vagina.Urethroceles often occur with vagina.Urethroceles often occur with cystoceles, (involving the bladder as well cystoceles, (involving the bladder as well as the urethra).In this case, the term used as the urethra).In this case, the term used is a cystourethrocele.is a cystourethrocele.

Posterior wall:Posterior wall: RectoceleRectocele:-results from a tear in the :-results from a tear in the

rectovaginal septum (which is normally a rectovaginal septum (which is normally a tough, fibrous, sheet-like divider between tough, fibrous, sheet-like divider between the rectum and vagina). Rectal tissue the rectum and vagina). Rectal tissue bulges through this tear and into the bulges through this tear and into the vagina as a hernia. There are two main vagina as a hernia. There are two main causes of this tear: childbirth, and causes of this tear: childbirth, and hysterectomy.hysterectomy.

Enterocele:-Enterocele:-Laxity of the upper Laxity of the upper third of the posterior vaginal wall third of the posterior vaginal wall results in herniation in the pouch of results in herniation in the pouch of douglas and contain omentum or douglas and contain omentum or even intestine.even intestine.

Uterine prolapseUterine prolapse

1.First degree-The uterus descend 1.First degree-The uterus descend down from the normal anatomical down from the normal anatomical position (i.e external os at the level position (i.e external os at the level of the ischial spines) but external os of the ischial spines) but external os still remains inside the vagina.still remains inside the vagina.

2.Second degree-The external os 2.Second degree-The external os protudes outside the vaginal introitus protudes outside the vaginal introitus but uterine body still inside.but uterine body still inside.

3.Third degree (Procidentia ,complete 3.Third degree (Procidentia ,complete prolapse)-The uterine body descends to lie prolapse)-The uterine body descends to lie outside the introitus.outside the introitus.

Predisposing factorsPredisposing factors

Congenital pelvic floor weaknessCongenital pelvic floor weakness Difficult or traumatic labourDifficult or traumatic labour • • Multiparity - traumaMultiparity - trauma • • Chronic disorders – chronic obstructiveChronic disorders – chronic obstructive

airway, constipations, strainingairway, constipations, straining • • Abdominal tumoursAbdominal tumours • • Obesity, smoking, heavy liftingObesity, smoking, heavy lifting • • Steroids, menopause, pelvic surgerySteroids, menopause, pelvic surgery

Changes that may occur after Changes that may occur after prolapse prolapse

Vaginal mucosa:Vaginal mucosa:

The vaginal mucosa becomes The vaginal mucosa becomes stretched and if exposed to the air stretched and if exposed to the air for long time becomes thickened and for long time becomes thickened and dry with surface keratinization.dry with surface keratinization.

Decibutis ulcer:Decibutis ulcer: Trophic ulcer always found at the Trophic ulcer always found at the

dependent part of the prolapsed mass dependent part of the prolapsed mass lying outside the introituslying outside the introitus

There is initial surface keratinisation –There is initial surface keratinisation –

cracks-infection-sloughing and ulceration.cracks-infection-sloughing and ulceration.

There is diminished circulation due to the There is diminished circulation due to the constriction of the prolapsed mass by constriction of the prolapsed mass by vaginal opening and narrowing of the vaginal opening and narrowing of the vessels by the stretching effect.vessels by the stretching effect.

Cervix:Cervix:The supravaginal portion of the cervix The supravaginal portion of the cervix

becomes Elongated due to the strain becomes Elongated due to the strain imposed by the pull.imposed by the pull.

Obstruction to the urinary tract due to the Obstruction to the urinary tract due to the huge cystocele which causes obstructive huge cystocele which causes obstructive uropathy and leads to hypertrophy of the uropathy and leads to hypertrophy of the bladder walls.bladder walls.

The kinking of distal ureter in procedentia The kinking of distal ureter in procedentia leads to hydronephrosis and hydroureter.leads to hydronephrosis and hydroureter.

There may be infection of the bladder There may be infection of the bladder producing pyelitis or pyelonephritis.producing pyelitis or pyelonephritis.

Incarceation: Incarceation: Infection of the Infection of the paravaginal and cervical tissues makes paravaginal and cervical tissues makes the entire prolapsed mass odematous and the entire prolapsed mass odematous and congested and as a result the mass is congested and as a result the mass is irreducible.irreducible.

Peritonitis: Peritonitis: The peritoneal infection may The peritoneal infection may occur through the posterior vaginal wall.occur through the posterior vaginal wall.

CLINICAL FEATURESCLINICAL FEATURES

Symptoms:Symptoms:

Feeling of something coming out per Feeling of something coming out per vagina .vagina .

Initially it is reducible but later it becomes Initially it is reducible but later it becomes irreducible.irreducible.

There may be variable discomfort that the There may be variable discomfort that the mass comes out when she walks.mass comes out when she walks.

Backache or dragging pain in the pelvis.Backache or dragging pain in the pelvis.

Urinary symptoms like difficulty in Urinary symptoms like difficulty in passing urine,incomplete passing urine,incomplete evacuation .evacuation .

If infection----- urgency ,frequency.If infection----- urgency ,frequency.

Stress incontinence i.e while doing Stress incontinence i.e while doing strenous work there is dribbling of strenous work there is dribbling of urine.urine.

Bowel symptom in presence of rectocele Bowel symptom in presence of rectocele like difficulty in passing stool and feeling like difficulty in passing stool and feeling of incomplete evacuation of the faeces.of incomplete evacuation of the faeces.

Excessive white or blood stained Excessive white or blood stained discharged per vaginum if there is discharged per vaginum if there is associated vaginits or decibutis ulcer.associated vaginits or decibutis ulcer.

SignsSigns When you ask the patient to cough it raises When you ask the patient to cough it raises

the intra-abdomial pressure leading to:the intra-abdomial pressure leading to:

Bulge in anterior vaginal wall in case of Bulge in anterior vaginal wall in case of cystocele.cystocele.

Bulging of the anterior and lower 1/3Bulging of the anterior and lower 1/3rdrd of of vagina in case of cystourethocele,vagina in case of cystourethocele,

Bulging of the posterior vaginal wall in case Bulging of the posterior vaginal wall in case o f rectocele and enterocele.o f rectocele and enterocele.

Pinch Test:Pinch Test:

Cough impulse in uterine prolapse Cough impulse in uterine prolapse leads to the expulsion of the mass leads to the expulsion of the mass PV.PV.

In case of first degree prolapse In case of first degree prolapse examination is made by introducing examination is made by introducing speculum and one may see the speculum and one may see the cervical descent below the level of cervical descent below the level of ischial spines.ischial spines.

Treatment:Treatment:

Conservative:Conservative: In case if first degree uterine prolapse In case if first degree uterine prolapse

pelvic floor exercise can be done.pelvic floor exercise can be done.

In case of 2In case of 2ndnd or 3 or 3rdrd degree ring degree ring pessasary treatment can also be pessasary treatment can also be done if the patient doesn’t want have done if the patient doesn’t want have any operation.any operation.

For Incarceation:For Incarceation:

For Ulcer:For Ulcer:

Surgical operation :Surgical operation :

Anterior colporaphy:Anterior colporaphy: Surgical procedure to correct cystocele Surgical procedure to correct cystocele

and uretheocele. and uretheocele. It involves making a cut in the front It involves making a cut in the front

(anterior) wall of the vagina so the bladder (anterior) wall of the vagina so the bladder and/or urethra can be pushed back into and/or urethra can be pushed back into place. place.

Once this is done, stitching together Once this is done, stitching together existing tissues to provide a new support existing tissues to provide a new support for the bladder and urethra. for the bladder and urethra.

Colpoperinorraphy:Colpoperinorraphy: Surgical procedure to repair the prolapse Surgical procedure to repair the prolapse

of the posterior part of vaginal wall i.e of the posterior part of vaginal wall i.e rectocele and enterocele. rectocele and enterocele.

The operation is done through the vagina. The operation is done through the vagina. A cut is then made in the back (posterior) A cut is then made in the back (posterior) wall of the vagina and the rectum and/or wall of the vagina and the rectum and/or small bowel is pushed back into place small bowel is pushed back into place stitching together the existing tissues to stitching together the existing tissues to create a new support for the prolapsed create a new support for the prolapsed organ(s) and then removes some of the organ(s) and then removes some of the tissue from the vaginal wall to make it tissue from the vaginal wall to make it stronger. stronger.

Pelvic floor repair(PFR):Pelvic floor repair(PFR): It includes the combination of anterior It includes the combination of anterior

colporraphy or colpoperinorraphhy.colporraphy or colpoperinorraphhy.

Fothergills operation:Fothergills operation: To corect the uterine descent associated To corect the uterine descent associated

with cystocele and urethrocele with with cystocele and urethrocele with preservation of uterus is done.preservation of uterus is done.

Vaginal hystrectomy with PFR.Vaginal hystrectomy with PFR.