Genital prolapse


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Genital prolapse

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Genital prolapse

  1. 1. Prof. Aboubakr Elnashar Benha University Hospital Aboubakr Elnashar
  2. 2. Genital support I. Cervical ligaments (Main uterine support) 1. Cardinal: from supravaginal cervix & vaginal vault to lateral pelvic wall 2. Uterosacral: to 3rd piece of the sacrum. 3. Pubocervical, pubourethral, puborectal ligaments: to back of s. pubis II. Pelvic floor muscles: Mainly levator ani, iliococcygeus III. Anteveresion of the uterus: Longitudinal axis of the uterus is perpendicular to that of the vagina Aboubakr Elnashar
  3. 3. a horizontal vaginal axis: The vaginal lies in a nearly horizontal axis when the woman is standing. Hence any intra-abdominal downward force will appose the vagina on the pelvic floor muscles preventing descent. This is aided by fascial and ligamentous support around the vagina which hold it in place. This support is divided into three levels: a. upper vagina (vault) is supported by uterosacral and cardinal ligaments, b. middle vagina is supported by levator ani muscles via fascial attachments to the arcus tendineus (“white line”), and c. lower vagina (introitus) is supported by urogenital diaphragm via pubourethral and pubocervical ligaments and posteriorly to the perineal body. Aboubakr Elnashar
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  5. 5. Diagram showing the normal horizontal axis of vagina and three levels of support for the vagina10 and anatomy of pelvic floor10 Aboubakr Elnashar
  6. 6. Aboubakr Elnashar
  7. 7. Aboubakr Elnashar
  8. 8. DEFINITION  Prolapse: from the Latin prolapsus, a slipping forth falling or slipping out of place of a part or viscus.  Pelvic organ prolapse: descent of the pelvic organs into the vagina, often accompanied by urinary, bowel, sexual, or local pelvic symptoms. pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia downward decent of uterus &/or vagina  Procidentia: from Latin procidere - to fall Procidentia: third degree uterine prolapse.Aboubakr Elnashar
  9. 9. Incidence Difficult to determine {many women do not seek medical advice}. half of parous women lose pelvic floor support, resulting in some degree of prolapse, and that of these women 10­20% seek medical care. The chance of a woman having a prolapse increases with age. Therefore, the incidence of prolapse will rise as life expectancy increases. Aboubakr Elnashar
  10. 10. Causes and contributing factors Congenital: nulliparous (virginal) Bladder exstrophy Collagen defects (type IV Ehlers­Danlos syndrome, Marfan syndrome) Race (white people have a higher risk) Anatomy (congenitally short vagina) Childbirth Sucessive vaginal deliveries Straining during 1st stage of labor Forceps before full cevical dilatation Prolonged 2nd stage of labor •Trauma Denervation Aboubakr Elnashar
  11. 11. Raised intra­abdominal pressure Chronic obstructive airway disease Straining, constipation, heavy lifting Post menopause Oestrogen deficiency: atrophy of cervical ligaments Iatrogenic Pelvic surgery (hysterectomy, colposuspension, sacrospinous fixation) Aboubakr Elnashar
  12. 12. TYPES  Vaginal Anterior: Cystocele: upper part containing base of the bladder Urethrocele: lower part containing urethtera Posterior: Enterocele: upper part containing peritoneum of D.P & loops of intestine Rectocele: lower part containing aterior rectal wall Vault: prolapse of upper vagina after hysterectomy  Uterine: First degree: external os below ischial spines but not outside the vulva Second degree: cervix but not the whole uterus protrudes from the vulva Third degree: complete procidentia: whole protrudes from the vulvaAboubakr Elnashar
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  16. 16. Cystourethrocele is the most common type of prolapse, followed by uterine descent and then rectocele. Urethroceles are rare. Aboubakr Elnashar
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  20. 20. Vault prolapse Aboubakr Elnashar
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  22. 22. Pelvic Organ Prolapse Quantification (POPQ). Diagram of reference points used in POPQ measurements. Aa is the distance of 3 cm from the anterior vaginal wall to the hymen. Aboubakr Elnashar
  23. 23. Line and grid representation of measurements obtained using POPQ. Aboubakr Elnashar
  24. 24. The vagina • Thickend wall: oedma & congesion • Keratinization: exposure • Trophic ulcer: congestion, friction, menopausal atrophy The cervix 1. Hypertophy: congestion, chronic cervicitis 2. Trophic ulcers 3. Elongation of supravaginal cervix: in vagino uterine prolapse: vagina descend: pulls the cervix: supravaginal part attached to the stronger upper part of the cardinal ligament resists Pathological changes Aboubakr Elnashar
  25. 25. Symptoms often asymptomatic & clinical examination may not necessarily correlate with symptoms. Symptoms are often related to the site and type Symptoms common to all types of prolapse are a feeling of dragging, or a lump in the vagina, or something coming down. 1. Urinary symptoms Stress incontinence Frequency (diurnal and nocturnal) Urgency and urge incontinence Hesitancy Poor or prolonged urinary stream Feeling of incomplete emptying Manual reduction to start or complete emptying Positional changes to start or complete emptyingAboubakr Elnashar
  26. 26. 2. Bowel symptoms Difficulty in defecation Incontinence of flatus, liquid stool, or solid stool Urgency of defecation Digitation or splinting of vagina, perineum, or anus to complete defecation Feeling of incomplete evacuation Rectal protrusion during or after defecation (rectal prolapse) Aboubakr Elnashar
  27. 27. 3. Sexual symptoms Inability to have or infrequent coitus Dyspareunia Lack of satisfaction or orgasm Incontinence during sexual activity Aboubakr Elnashar
  28. 28. 4. local symptoms a. Feeling of pressure or heaviness in the vagina b. Pain in the vagina or perineum c. Sensation or awareness of protrusion from the vagina d. Low back pain, which is eased with lying down e. Abdominal pressure or pain f. Blood stained and purulent discharge Aboubakr Elnashar
  29. 29. Signs I. General: 1. Exclude anaemia 2. Chest: chronic bonchitis II. Abdominal: 1. Renal angle: hydronephrosis or tenderness 2. Nulliparous prolapse: Spina bifida, visceroptosis, hernia Aboubakr Elnashar
  30. 30. III. Pelvic: • Inspection & digital palpation: a. Old perineal tear b. Prolapsed structures: type of prolapse, degree of uterine prolapse, changes in vagina & cervix. c. Stress incotinence d. Tone of levator ani: 2 fingers in the vagina & the thumb on the perineum while the patient is asked to contract the muscles e. Enterocele: impulse on cough & gurgling sensation Aboubakr Elnashar
  31. 31. 2. Bimanual Examination Size & position of uterus & adenxa 3. Speculum Examination: Cervical lesion 4. Sounding: Detect supravaginal elongation of the cervix 5. P.R.: In enterocele the rectum is not forming part of the prolapse Position: left lateral or standing position—with a Sims' speculum, inserting it along the posterior vaginal wall to assess the anterior wall and vault and vice versa. Uterine descent can be assessed by traction with a single toothed vulsellum. Aboubakr Elnashar
  32. 32. D.D Cystocele 1. Gartner cyst: anterolateral in vagina, incomperessible, catheter: normal uretheral direction 2. Uretheral diverticulum: pressure on the mass, urine from external meatus Rectocele 1. Dermoid cyst: incompressible, PR: rectum not mass 2. Enterocele: arises from upper part of the posterior vaginal wall, gurgling & impulse on cough, PR: rectum not part of mass, PR+PV: on straining the rectum is pushed back 2nd & 3rd uterine prolapse 1. Congenital elongation of portio-vaginalis: vaginal vault is at its normal level, deep fornices 2. Fibroid polyp, Chronic inversion: absent external os Aboubakr Elnashar
  33. 33. WHEN TO TREAT ?  Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse )  Interferes with the normal activity of the woman  The patient seeks treatment Aboubakr Elnashar
  34. 34. HOW TO TREAT ?  NON-SURGICAL Methods: -Limited Role  PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium).  HORMONE REPLACEMENT, both systemic and local.  PESSARY TREATMENT for temporary relief  During Pregnancy, Pureperium & Lactation  When Operation is Unsafe due to Extreme Senility/Debility and Diseases  Preoperatively  For therapeutic test Aboubakr Elnashar
  35. 35.  SURGICAL TREATMENT: - RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.  It is the definitive & curative treatment of Prolapse.  It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first  Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.  Meticulous and through examination under anaesthesia should be done before deciding the surgery. Aboubakr Elnashar
  36. 36.  Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement.  Absolute haemostasis is mandatory.Diathermy should be liberally used.  Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable.  Catheter for more than 48 hrs should be exceptional.  Strict antibiotic prophylaxis is essential Aboubakr Elnashar
  37. 37. VAGINAL OPERATIONS FOR PROLAPSE  Anterior colporrhaphy  Posterior colporrhapry- High / Low  Enterocele repair  Perineorrhaphy  Amputation of cervix  Paravaginal repair  Hysterectomy with or without Colporrhaphy / Perineorrhaphy Aboubakr Elnashar
  38. 38. VAGINAL OPERATIONS FOR PROLAPSE  Manchester/ Fothergill’s operation & Shirodkar’s modification  Uterus/Cervix suspension/fixation  Vaginal vault suspension/fixation  Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse  Vaginectomy ?  Colpocleisis ? Aboubakr Elnashar
  39. 39. Anterior colporrhaphy & Urethroplasty  For correction of Cystocele & Urethrocele  Incision- Midline / Inv.T / Elliptical  Excision of vagina according to the size & site of laxity  Avoid shortening &/or narrowing of vagina  Closure with interrupted sutures Aboubakr Elnashar
  40. 40. Posterior colporrhaphy & Enterocele repair  For correction of Enterocele & Rectocele  Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures.  Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential  Excision of vagina should be tailor made  Perineorrhapy to be done only if perineal body is torn Aboubakr Elnashar
  41. 41. Perineorrhaphy  Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear  Performed along with post. colporrhaphy  Aim-Reconstruction of the Perineal body and reduction of gaping introitus.  Can cause Dyspareunea  Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles Aboubakr Elnashar
  42. 42. Vaginal Hysterectomy with/without Vaginal repair  Indicated when uterus needs removal, in old age & in total prolapse.  Patient’s consent is mandatory knowing that there are alternatives to hysterectomy.  Usually combined with Ant. & Posterior colporrhaphy.  Perineorrhaphy is not mandatory but case specific.  Vault suspension is an essential step.  If sexual function is not needed narrowing of vaginal canal should be done.Aboubakr Elnashar
  43. 43. Amputation of cervix  Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm )  To be done only as a part of Fothergill’s repair/sling operations.  Adequate cervical dilatation - a prerequisite  Bladder displacement is a must  Excision of cervix should not exceed 2 cm  Likely to affect reproductive life  Long-term complications are real risks Aboubakr Elnashar
  44. 44. Fothergill’s operation  It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required.  It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must.  Post. Colporrhaphy to be performed only if Ent/Rectocele is present  Perineorrhaphy is usually not required Aboubakr Elnashar
  45. 45.  Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help.  Technically difficult operation, requiring high degree of surgical skill.  Threat of short-term complications.  Real possibilities of long term complications.  Recurrence/Failure.  Sling operations are better alternatives  HAS A BLEAK FUTURE Aboubakr Elnashar
  46. 46. ABDOMINAL OPERATIONS FOR PROLAPSE  Sling operations  Closure or repair of enterocele  Sacrocolpopexy  Anterior Colpopexy  Colposuspension  Paravaginal repair Aboubakr Elnashar
  47. 47. Abdominal Sling operations  Indicated when the ligaments are extremely weak as in nulipara & young women.  Preserves reproductive function.  Principle-With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis.  Amp.of Cx should also be done if Utereocervical length >12.5cm.  Cystocele/Rectocele repair if needed can be done vaginally before or after.  Enterocele repair can also be done abdominally. Aboubakr Elnashar
  48. 48.  It is a major abdominal operation & Synthetic material is costly & not widely available in India.  Types-.  Shirodkar’s posterior sling.  Purandare’s anterior cervicopexy.  Khanna’s sling.  Virkud’s composite sling. Aboubakr Elnashar
  49. 49. Shirodkar’s sling  Tape is fixed to the post. Aspect of isthmus & sacral promontory  Anatomically most correct but difficult to perform  Risks of complication Aboubakr Elnashar
  50. 50. Purandare’s cervicopexy  Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall  Easy to perform  Dynamic support Aboubakr Elnashar
  51. 51. Virkud’s composite sling operation  Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side  Utrosacral ligament is plicated  Technically easy Aboubakr Elnashar
  52. 52. Khanna’s sling operation  Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine  Easier to perform and safer  But tape is superficial  Risk of infection Aboubakr Elnashar
  53. 53. Abdominal Colpopexy / Colposuspension  Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy.  Major abdominal operation & technically difficult.  Sexual function is preserved.  Methods-.  Sacrocolpopexy.  Ant.Colpopexy.  Colposuspension.Aboubakr Elnashar
  54. 54. Sacrocolpopexy  Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum  Enterocele repair can be done if required Aboubakr Elnashar
  55. 55. Ant.Colpopexy  Corrects ant. vag laxity & stress inc.  Useful at abdominal hysterectomy / for vault prolapse.  Extra peritoneal supra pubic approach if done alone.  Enterocele repair if required.  Vagina stitched to the ileo-pectineal ligaments. Aboubakr Elnashar
  56. 56. Vault / Colposuspension  Vault is fixed to the abdominal wall by a facial strip or merseline tape Aboubakr Elnashar
  57. 57. LAPAROSCOPIC SURGERY PROLAPSE  Advantages of M I S-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar  Can all types of prolapse be treated?- Yes.  Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery  However extended period of rest is essential  Expertise is needed  Presently cannot be widely practised  This is the surgery of the future today Aboubakr Elnashar
  58. 58.  PROCEDURES:-  Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair  VH / LAVH / LH / TLH + Colposuspension  VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction  Rectocele repair & levatorplasty  Enterocele repair with suturing of uterosacral ligaments  Colpopexy- Ant / Post Aboubakr Elnashar
  59. 59. Laparoscopic Cervicopexy/sling Operations  All types of sling operations can be better performed by laparoscopy  Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)  Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy Aboubakr Elnashar
  60. 60. Laparoscopic Vault suspension/ Culdoplasty)  Can be done with VH / LAVH / LH / TLH  Corrects mild laxity  Prevents vault prolapse Aboubakr Elnashar
  61. 61. Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH  An alternative to Ward-Mayo’s operation  Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension  Lap. levator plication if needed  Enterocele repair and suturing of uterosacral ligaments if needed  Retro pubic Colposuspension (Bruch) if required Aboubakr Elnashar
  62. 62. Laparoscopic Rectocele repair & Levatoroplasty  Rectovaginal space is opened & rectum dissected  Interrupted sutures given in the levator in the midline  Enterocele repair done if indicated  Vaginal vault suspension done Aboubakr Elnashar
  63. 63. Laparoscopic Enterocele repair  Rectovaginal space is opened, sac excised and purse string suture given  Uterosacral ligament sutured Aboubakr Elnashar
  64. 64. Laparoscopic Post Colpopexy / Sacrocolpopexy  Indicated for vault prolapse  Enterocele if present is first repaired  Prolene mesh is fixed to the vault & 3rd- 4th sacral vertebrae, under the peritoneum in the Rt.para rectal space Aboubakr Elnashar
  65. 65. Aboubakr Elnashar