gynaecology.Genital prolapse.(dr.rojan)


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gynaecology.Genital prolapse.(dr.rojan)

  1. 1. Presented by: Dr. Rozhan Yassin khalil FICOG,CABOG,HDOG,MBChB Genital prolapse
  2. 2. : Introduction <ul><li>Up to half of the normal female population will develope uterovaginal prolapse during their lifetime. </li></ul><ul><li>Twenty percent of these women will be symptomatic and need treatment . </li></ul><ul><li>As the population of the world continues to increase in age, the prevalence of pelvic floor dysfunction is likely to increase. </li></ul>
  3. 3. : Structure and function of the pelvic floor <ul><li>The pelvic floor functions to support the pelvic and abdominal viscera and help maintain control of their contents. </li></ul><ul><li>It has two major components which are interdependent: </li></ul><ul><li>the muscle and facia. </li></ul>
  4. 4. Muscle: <ul><li>Levator ani muscles consist of pubococcygeus , coccygeus and ileococcygeus muscles on each side which together form a muscular floor to the pelvis. </li></ul><ul><li>The striated muscle of levator ani is under voluntary control but is a unique striated muscle in having a resting tone. </li></ul>
  5. 5. Muscle: <ul><li>Contraction of the muscles results in a forward elevation of the pelvic floor which is important in their role in continence. </li></ul><ul><li>This forward elevation helps to increase the angulation between bladder and urethra anteriorly and rectum and anal canal posteriorly . Increase in this angulation is one of the fundamental mechanisms which aid continence </li></ul>
  6. 6. Muscle: <ul><li>When the intra-abdominal pressure rises levator ani muscles contract and provide additional support and outlet resistance to the bladder and rectum. </li></ul><ul><li>This reflex response to intra-abdominal pressure rises also requires an intact innervation. </li></ul><ul><li>Damage to the pelvic floor muscle innervation is likely to impair the pelvic floor muscle responses. </li></ul>
  7. 7. Fascia: <ul><li>Fascia envelopes levator ani, attaches it to bone at its origin and holds the two muscles together in the midline. </li></ul><ul><li>The urethra, vagina and rectum perforate this midline fascia. </li></ul><ul><li>Thus, the pelvic viscera are supported both by the levator ani muscle below and the fascial attachments which are condensed in some areas and are often referred to as ligaments – the uterosacral, cardinal and round ligaments being examples. </li></ul>
  8. 8. Fascia: <ul><li>any factor that influences the strength or integrity of pelvic floor fascia will influence the function of the pelvic floor. </li></ul><ul><li>These factors may be congenital (such as hyperelasticity of the collagenous component of fascia ) or environmental , such as stretching or tearing of fascia during childbirth or heavy lifting. </li></ul>
  9. 9. Pathophysiology of pelvic floor dysfunction Muscle <ul><li>The striated muscle of the pelvic floor, undergoes a gradual denervation with age . </li></ul><ul><li>This denervation will result in a gradual weakening of the muscle over time . </li></ul><ul><li>Pelvic floor muscle denervation is increased by vaginal delivery , particularly if the active second stage of labour is prolonged . </li></ul><ul><li>Caesarean section may offer some protection from this injury. </li></ul>
  10. 10. Pathophysiology of pelvic floor dysfunction Muscle <ul><li>The site of pelvic floor muscle denervation during childbirth is unclear. It has been proposed that stretching of the pudendal nerve at the ischial spine results in nerve injury . </li></ul><ul><li>  </li></ul><ul><li>In neurological diseases like multiple sclerosis , pelvic floor muscle may behave unpredictably ranging from inappropriate relaxation causing incontinence to spasm resulting in voiding dysfunction. </li></ul>
  11. 11. factors have a significant influence on pelvic floor support: . <ul><li>1.CONGENITAL. </li></ul><ul><li>2.AGE </li></ul><ul><li>3.CHILDBIRTH INJURY. </li></ul><ul><li>4.ENDOCRINE . </li></ul>
  12. 12. : 1.CONGENITAL <ul><li>Congenital differences in collagen behaviour are clinically evident in women who have increased joint elasticity. </li></ul><ul><li>  Women with hyperextensible joints will develope uterovaginal prolapse at an earlier age. Such women often excel at sports requiring increased joint elasticity (such as gymnastics) and they develop fewer striae gravidarum during pregnancy because of increased skin elasticity. </li></ul>
  13. 13. : 2.AGE <ul><li>The fascia of the pelvic floor will provide weaker support with advancing years. </li></ul><ul><li>Gynaecologists repairing the pelvic floor often recognize that the tissues used for building a repair are of poor quality and are poorly vascularized. </li></ul><ul><li>The repair after surgery will heal with less strength and more slowly. The recurrence of prolapse seen after surgery in one out of three cases must in some part be due to a deterioration of fascial strength with age. </li></ul>
  14. 14. : 3.CHILDBIRTH INJURY <ul><li>Most women recognize that their pelvic floor is different after vaginal delivery. </li></ul><ul><li>regaining the tone and shape of their anterior abdominal wall is also often a difficult challenge. </li></ul><ul><li>These changes are due to a combination of muscle and fascial changes. whether pelvic floor fascia stretches or tears during pregnancy and childbirth. </li></ul><ul><li>  </li></ul>
  15. 15. : 4.ENDOCRINE <ul><li>The menstrual cycle, pregnancy and the menopause are the most significant endocrine events which may influence pelvic floor fascia. </li></ul><ul><li>Women often declare that prolapsed symptoms are worse around the time of menstruation. </li></ul><ul><li>This is thought to be secondary to higher progesterone levels increasing fascial elasticity. </li></ul>
  16. 16. : 4.ENDOCRINE <ul><li>women examined at the time of menstruation will have a higher stage of prolapse than at other times of the cycle. </li></ul><ul><li>During pregnancy, prolapse symptoms will be more evident in the first trimester but diminish as the pregnant uterus enlarges out of the pelvis. </li></ul><ul><li>The prevalence of uterovaginal prolapse increases after the menopause </li></ul>
  17. 17.   Uterovaginal prolapsed: <ul><li>Description </li></ul><ul><li>Prolapse is normally divided into anterior, uterine/vault, posterior compartments. </li></ul><ul><li>anterior vaginal wall prolapse is still commonly called a cystocoele and posterior prolapse a rectocoele or enterocoele . </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  18. 18. Symptoms: <ul><li>Prolapse classically produces a sensation of fullness in the vagina or a visible or palpable lump at the introitus. </li></ul><ul><li>Low backache is a common symptom but is also commonly experienced by women who do not have prolapse . </li></ul><ul><li>  </li></ul><ul><li>Vaginal atrophy , if present, will exacerbate many prolapse symptoms and should be treated as a first priority with topical oestrogens unless clinically contraindicated . </li></ul><ul><li>  </li></ul>
  19. 19. URINARY SYMPTOMS : <ul><li>Anterior vaginal wall prolapse may result in a range of urinary symptoms . </li></ul><ul><li>While women who have anterior prolapse may have stress incontinence, particularly if the urethra is not well supported, </li></ul><ul><li>they may also have voiding dysfunction secondary to kinking of the urethra. </li></ul>
  20. 20. URINARY SYMPTOMS <ul><li>Voiding dysfunction may result in </li></ul><ul><li>1. frequency (due to incomplete bladder emptying), </li></ul><ul><li>2. hesitancy . </li></ul><ul><li>3. a poor urinary stream . </li></ul><ul><li>4 recurrent urinary infection with accompanying frequency, urgency and urge incontinence. </li></ul>
  21. 21. BOWEL SYMPTOMS: <ul><li>Posterior vaginal wall prolapse may be associated with a range of bowel symptoms . </li></ul><ul><li>Constipation is a common symptom in women and may contribute to obstructed defaecation. </li></ul><ul><li>Posterior vaginal wall prolapsed does not normally result in ano-rectal incontinence </li></ul>
  22. 22. : COITAL SYMPTOMS <ul><li>Prolapse often does not interfere with normal sexual activity. </li></ul><ul><li>many women feel unhappy with the vaginal discomfort experienced through the sexual activity. </li></ul><ul><li>  </li></ul><ul><li>Some couples find that the loss of tone in the vagina leads to sexual dissatisfaction for both parties. </li></ul><ul><li>  </li></ul><ul><li>  </li></ul><ul><li>  </li></ul>
  23. 23. Classification: <ul><li>1 Dislocation of the urethra —the urethra is displaced </li></ul><ul><li>downwards and backwards off the pubis. It may be also dilated becoming an urethrocoele. </li></ul><ul><li>2 Cystocoele —hernia of the bladder trigone . </li></ul><ul><li>3 Uterine prolapse —descent of the uterus and cervix. </li></ul>
  24. 24. Classification : <ul><li>4 Enterocoele or pouch of Douglas hernia—a prolapse of the upper part of the posterior vaginal wall. </li></ul><ul><li>The hernia contains the peritoneum of the pouch of Douglas often with a loop of bowel. </li></ul><ul><li>5 Rectocoele —a prolapse of the lower part of the posterior vaginal wall due to weakness of the levatores ani; the rectum bulges into the vagina. </li></ul>
  25. 25. Uterine prolapse ( Three degree): <ul><li>(a) First degree with a descent of the uterus , but the cervix remains within the upper vagina. </li></ul><ul><li>(b) Second degree uterine descent when the cervix reaches down to the vulva on straining, but does not pass through it. </li></ul><ul><li>(c) Third degree or procidentia when the cervix and some or all of the uterus is prolapsed outside the vaginal orifice </li></ul>
  26. 26. 3 rd degree vaginal prolapse ( procidentia)
  27. 27.   Investigation of prolapse symptoms: <ul><li>  EXAMINATION: </li></ul><ul><li>Abdominal examination should be performed to exclude an intra-abdominal mass. </li></ul><ul><li>Abimanual pelvic examination or ultrasound should exclude a pelvic mass and delineate the size of the uterus and ovaries if present. </li></ul><ul><li>The patient should be examined in the horizontal position, conventionally in the left lateral position with a Sims speculum . </li></ul>
  28. 28.   EXAMINATION: <ul><li>If prolapse is not evident, even with a Valsalva manoeuvre, the patient should be examined in the upright position. </li></ul><ul><li>Many women are only aware of their symptoms after a long period in the upright position. An early morning clinic appointment may preclude detection of the prolapse. Some clinicians examine women in the lithotomy position . </li></ul>
  29. 29. URODYNAMICS STUDIES: <ul><li>If a woman has significant urinary symptoms urodynamics may help define cause of symptoms . </li></ul><ul><li>if urodynamics indicate obstructed voiding there is a good prognosis for surgical repair of the cystocoele resolving the voiding dysfunction . </li></ul>
  30. 30. PROCTOGRAPHY: <ul><li>An rectocoele may result in obstructed defaecation. </li></ul><ul><li>Proctography can give some insight into factors which may be contributing to difficulty with defaecation and may help avoid unnecessary, unhelpful vaginal operations . </li></ul>
  31. 31. Treatment: of genital prolapse: <ul><li>CONSERVATIVE: </li></ul><ul><li>Some women elect for non-surgical treatment of their prolapse either because: </li></ul><ul><li>1 the prognosis offered for treatment is not sufficiently attractive </li></ul><ul><li>2 they are unfit for surgery </li></ul><ul><li>3 they wish to delay surgical treatment for other reasons. </li></ul><ul><li>  </li></ul>
  32. 32. Conservative treatment may involve : <ul><li>1.Lifestyle advice: </li></ul><ul><li>This may include advice on diet and weight loss including avoidance of caffeine containing drinks , water intake , fibre content , laxative use and modification of drug regimes , e.g. diuretics. </li></ul><ul><li>Avoidance of high-impact exercise and lifting may improve symptoms . </li></ul>
  33. 33. 2.Pelvic floor physiotherapy.: <ul><li>While it is unlikely that advanced prolapse will be helped by pelvic floor exercises, </li></ul><ul><li>earlier stage prolapse may be improved sufficiently to avoid further intervention. </li></ul>
  34. 34. : 3.Vaginal pessary <ul><li>Vaginal pessaries have been available in some form for 4000 years . </li></ul><ul><li>Currently in the UK the most frequently used pessary is the polypropylene ring pessary. </li></ul><ul><li>The most appropriate anatomical configuration for the ring pessary has not been defined but if there is little or no posterior perineal support the ring pessary will often not be retained. </li></ul>
  35. 35. 3.Vaginal pessary <ul><li>Pessaries such as the ring can normally allow sexual intercourse without problems . </li></ul><ul><li>Space occupying pessaries such as the shelf pessary preclude normal sexual relations and are therefore unsuitable for sexually active women. </li></ul><ul><li>The shelf pessary may be particularly helpful for uterine or vaginal vault prolapse . </li></ul><ul><li>Careful examination, at least every 6 months is advisable and topical oestrogens may reduce the risk of ulceration and erosion. </li></ul><ul><li>  </li></ul>
  36. 36. Vaginal pessary
  37. 37. SURGICAL : <ul><li>Over the last 100 years surgery has been considered to be the treatment of choice for uterovaginal prolapse . </li></ul><ul><li>a desirable outcome should include more than a satisfactory anatomical result. Functional outcome may be more important to the patient. </li></ul><ul><li>  </li></ul>
  38. 38. Anterior vaginal wall prolapsed : <ul><li>In 1909, White described the vaginal repair to repair a cystocoele . </li></ul><ul><li>Four years later Kelly described the anterior vaginal repair with a central placation of the pubocervical fascia . </li></ul><ul><li>  </li></ul><ul><li>The Kelly operation became the treatment of choice for anterior prolapsed partly because of the simplicity of the procedure . </li></ul><ul><li>  </li></ul>
  39. 39. Complications : <ul><li>1.5% developed stress incontinence and 5% detrusor overactivity postoperatively. </li></ul><ul><li>2.Long-standing voiding problems occurred in less than 1%. </li></ul><ul><li>3.Post-operative pyrexia developed in 10% </li></ul><ul><li>  </li></ul><ul><li>The use of support materials in primary repairs would certainly not appear to be justified. </li></ul>
  40. 40. Posterior vaginal wall prolapsed : <ul><li>The classical posterior vaginal repair involves not only plication of the fascia underlying the vaginal skin but also a central plication of the fascia overlying the pubococcygeus muscle even including the muscle itself. </li></ul><ul><li>  </li></ul>
  41. 41. Uterine prolapsed: <ul><li>The current conventional approach to uterine prolapse when awoman no longer wishes to have children is a 1. vaginal hysterectomy with any additional repair to the vaginal walls as appropriate. </li></ul><ul><li>The vaginal vault is then supported by reattaching the uterosacral/cardinal ligaments to the vagina . </li></ul>
  42. 42. 2.The Manchester repair : <ul><li>is now less popular but also employed the cardinal ligaments brought together anterior to the cervix which was amputated as part of the operation. </li></ul><ul><li>The use of the uterosacral/cardinal ligaments has the fundamental problem that it is the weakness of these ligaments that has contributed to the development of the prolapse. </li></ul>
  43. 43. 3.Uterine conservation: <ul><li>There is no evidence that uterine conservation, either by abdominal sacrohysteropexy or sacrospinous hysteropexy provides a lower risk of prolapsed recurrence. </li></ul>
  44. 44. Vaginal vault prolapsed: <ul><li>Vaginal vault prolapse occurs in approximately 5% of women after hysterectomy . </li></ul><ul><li>Most studies indicate that an equal proportion of women have had an abdominal or a vaginal hysterectomy which, given that abdominal hysterectomy is performed more frequently than vaginal, suggests that vaginal hysterectomy predisposes to vault prolapse . </li></ul>
  45. 45. vault prolapse <ul><li>Failure to treat extensive vault prolapse may lead to ulceration and less commonly bowel extrusion. </li></ul><ul><li>Vaginal vault prolapse may be treated surgically by a vaginal sacrospinous colpopexy or </li></ul><ul><li>an abdominal (or laparoscopic) sacrocolpopexy . </li></ul><ul><li>  </li></ul>
  46. 46. vault prolapse <ul><li>  Colpocleisis : </li></ul><ul><li>the vaginal lumen is completely occluded, may be used rarely in women who are unfit for major surgery and in whom conservative measures have failed. </li></ul><ul><li>Strips of vaginal skin are removed from anterior and posterior vaginal walls and the two are sutured together . </li></ul>
  47. 47. Thank you