2. Preventive
General measures
Antenatal
&intranatal care Postnatal care
* Avoid strenuous
* Encourage early activities, chr.
* To avoid injury to
cough, constipation
the supporting ambulation
& heavy weight
structures during * Encourage pelvic lifting
time of vaginal
floor exercise by * Avoid future
delivery either
sspontaneous or
squeezing the pelvic pregnancy too soon
instrumental floor muscles in the & too many by
puerperium contraceptive
practise
3. Conservative: Pessary treatment
Limitations
It is never curative and only be palliative
It can cause vaginitis
Pessary needs to be changed every 3 months
The wearing of pessary is not comfortable to some
women and may cause dyspareunia
If the vaginal orifice is very patulous, the pessary is
often not retained.
A forgotten pessary can be the cause of ulcer, rarely
carcinoma of vagina and a vesicovaginal fistula
A pessary does not cure urinary stress incontinence
4. Indications:
A young woman planning a pregnancy
During early pregnancy
Puerperium
Temporary use while clearing infection and decubitus ulcer
A woman unfit for surgery
In case a woman refuses for surgery
Ring pessary is made of soft plastic polyvinyl chloride &
available in different sizes.
5. Surgery
Type of surgery offered to the patient with prolapse
depends on the age of patient, her desire to retain
the uterus either for reproductive or menstrual
function, her menstrual history, general condition
as well as the degree of uterine prolapse and
uterine abnormality
Aim:
Relieve symptoms
Restore anatomy
Restore sexual function
7. Anterior Colporrhaphy
To correct cystocele & urethrocele.
Principles: to excise a portion of the relaxed ant. Vaginal
wall, to mobilise the bladder and push it upwards after
cutting the vesicocervical ligament. The bladder is then
permanently supported by plicating the endopelvic fascia
under the bladder neck in the midline.
Preliminaries:
↓ GA/ EA
Pt in lithotomy position
Vulva and vagina are to be swabbed with antiseptic solution
Perineum to be draped with sterile towel and legs with leggings
Bladder is to be emptied by metal catheter
Vaginal examination is done to assess the type and degree of prolapse.
8.
9. Perineorrhaphy/ Colpoperineorrhaphy
Designed to repair the prolapse of post.vaginal wall.
its uses and extent of repair are employed in:
Relaxed perineum – the operation is extended to repair the torn perineal
body.
Rectocele – correct rectocele by tightening the pararectal fascia
Enterocele – high perineorrhaphy is to be done right upto the
cervicovaginal junction along with correction of enterocele.
Lax vagina over the rectocele is excised, and rectovaginal fascia
repaired after reducing the rectocele.
Approximation of medial fibres of levetor ani helps to restore the
calibre of hiatus urogenitalis, restore perineal body & provide
adequate perineum separating the hiatus urogenitalis from the anal
canal
Commonly combined with ant.corrporaphy, or vaginal hysterectomy
requiring PFR, & as part of Fothergill’s repair
10. Fothergill’s repair/ Manchester operation
Combines an ant.colporrhaphy with amputation of cervix, sutures
the cut ends of the Mackenrodt ligaments in front of the
cervix, covers the raw area on the amputated cervix with vaginal
mucosa and follows it up with colpoperineorraphy.
Preserves menstrual and childbearing functions
Fertility reduced because of the amputation of the cervix causing
loss of cervical mucus.
Suitable for women under 40 who are desirous of retaining their
menstrual and reproductive function.
Cervical amputation may lead to incompetent cervical os, habitual
abortions or preterm deliveries.
Excessive fibrosis → cervical stenosis and dystocia during labour
Rarely cause haematometra.
Recurrence may occur following vaginal delivery
11. Shirodkar’s procedure
Modified Fothergill’s operation
Ant. Colporraphy performed, attachment of Mackenrodt ligaments
to cervix on each side is exposed.
Vaginal incision is then extended posteriorly round the cervix.
POD is opened, uterosacral ligaments identified and divided close
to the cervix.
The stumps of these ligaments are crossed and stiched together in
front of cervix.
High closure of the peritoneum of POD is carried out.
Cervix is not amputated, rest of operation similar to Fothergill’s
operation
12. Vaginal hysterectomy with PFR
Women more than 40 yrs
Have completed her family
No longer keen on retaining her childbearing & menstrual
functions
Steps:
Circular insicion over cervix, below bladder sulcus & vagina mucosa
dissected off the cervix all around.
POD identified post & peritoneum incised
Bladder pushed upwards until uterovesical peritoneum is visible &
incised
Mackenrodt & uterosacral ligament are clamped, cut & pedicles
transfixed
Uterine vessels are identified, clamped,cut & ligated
Upper portion of broad ligament holding uterus contains round &
ovarian ligament & fallopian tube identified, clamped, cut & pedicle
transfixed.
Uterus removed
13. Peritoneal cavity is closed with purse-string suture
Ant. Colporraphy & post colpoperineorraphy is performed as
required.
Vaginal is packed with betadine pack for 24 hrs
Cathetherize for 48 hrs.
Complications:
Hemorrhage
Sepsis
Anaesthesia risks
UTI
Rarely trauma to bladderand rectum.
Vault prolapse as late sequela
Dyspareunia caused by short vagina
14. Le Fort’s repair
Reserved for the very elderly menopausal ptwith advanced
prolapse or for those considered unfit for any major surgical
procedure.
Pap smear & pelvic sonography to r/o pelvic pathology prior to
procedure
Procedure can be performed under sedation & LA or EA.
Flaps of vagina from ant & post vaginal walls are excised, the raw
areas apposed with catgut sutures
Wide area of adhesion is created in the midline prevents uterus
from prolapsing, small tunnels on either side permitting drainage
of discharge.
Operation limits marital function, not to be advised to women with
active married life.
Contraindicated in menstruating woman,a woman with diseased
cervix and uterus.
15. 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.
Operation in common practise:
Abdominocervicopexy
Shirodkar’s abdominal sling operation
Khanna’s abdominal sling operation
16. Vault prolapse
Delayed complication of both abdominal and vaginal
hysterectomy when supporting structure become weak
and deficient.
Also a result of failure to identify and repair an
enterocele during hysterectomy.
Treatment:
Right transvaginal sacrospinous colpopexy
Transabdominal sacral colpopexy
Colpocleisis
Le forte
Laparoscopic colpopexy
Abdominoperineal surgery
Ring pessary.
