This document provides information on pelvic organ prolapse. It defines prolapse as the descent of genital organs through the pelvic floor. It describes the three levels of pelvic support and the types of prolapse that can occur at each level. Symptoms, signs, grading systems, etiology related to childbirth, and risk factors are outlined. Both conservative treatments like pelvic floor exercises and pessaries as well as various surgical repair options to correct prolapse in the anterior, posterior, and apical compartments are summarized.
4. Definition
Genital prolapse is the descent of one or more of the genital
organ (urethra, bladder, uterus, rectum or Douglas pouch or
rectouterine pouch”) through the fasciomuscular pelvic floor
below their normal level.
Vaginal prolapse can occur without uterine prolapse but the
uterus cannot descent without carrying the vagina with it.
5.
6. Supports of PELVIS-De Lancey
Level 1(proximal suspension)
(cervix and upper vagina):
Suspensory axis
Uterosacrals and Cardinal ligaments
Defect apical prolapse (UV Prolapse , enterocele, and
vault prolapse )
7. Level II(lateral attachements)
(mid vaginal support)
Attachment axis
Anterior-pubocervical fascia
Posteriorly :rectovaginal fascia
main supports-arcus tendinus fascia pelvis & arcus
tendinus recto vaginalis
Defects paravaginal & pararectal defects
8. Level III(distal fusion)
• Lower vaginal supports –fusion axis
• Urogenital diaphragm and the perineal body
• Endopelvic fascia
• Defects—posteriorlyRectocele & perineal descent
anteriorly urinary incontinence
9. ETIOLOGY
Vaginal delivery
Prolonged second stage
Rapid successive vaginal delivery
Delivery of macrosomic baby
Instrumental delivery
Premature straining before
complete cervical dilatation
12. Baden-Walker System
The system has five degrees/grades
0 – No prolapse
1 – Leading edge of prolapsed structure descends
halfway to vaginal introitus (hymen)
2 – Leading edge of prolapsed structure descends to the
vaginal introitus
3 – Leading edge of prolapsed structure(s) protrudes up
to halfway outside the vagina
4 – Leading edge of prolapsed structure(s) protrudes
more than halfway outside the vagina
20. Types of prolapse:
1)Vaginal Prolapse:
1) Anterior vaginal wall prolapse:
a. cystocele
b. urethrocele.
c) cysto-urethrocele.
21. 2) Posterior vaginal wall prolapse:
a) enterocele
b)rectocele
c) Perineal descent
22.
23.
24. 3) Vault prolapse:
(descent of the vaginal vault, where the top of the
vagina descends )or inversion of the vagina) after
hysterectomy.
* Vault prolapse is more likely to occur after subtotal than
after total hysterectomy.
25.
26. Symptoms of prolapse:
1. sensation of weakness in the perineum.
2. a mass which appears on straining. and
disappears when she lies down.
3.Discharge ( if ulcer)
27. 3.Urinary symptoms
Urgency and frequency
Stress incontinence.
Inability to micturate unless the anterior vaginal
wall is pushed upwards by the patient's fingers.
4.Rectal symptoms-
incontinence,
incomplete emptying,
straining during defecation,
urgency,
digital pushing
28. 5. Backache,.
6. Leucorrhoea is caused by the congestion and
associated by chronic cervicitis.
7.Sexual dysfunction-dyspareunia,decreased
lubrication
29. Signs
ASSESSMENT OF PROLAPSE
Examined in the lithotomy position- empty bladder
Stress incontinence must be looked for on a full bladder
3 compartment- assessed seperately
Anterior compartment—sims speculum(retracting the
posterior vaginal wall
Middle compartment—by noting the descent of uterus
Posterior compartment-sims speculum (retracting the
anterior vaginal wall)
30. Cystocele and urethrocele looked for by retracting
posterior vaginal wall
Enterocele
Retract the posterior vaginal wall with sims.
Hold the posterior lip of cervix with vulsellum or allis
Cervix is kept reduce at the level ischial spine
Speculum is then slowly withdrawn as the patient is asked to
cough-- bulge appears from above downwards
Rectal examination—ask the patient to strain
Impulse on tip of finger—enterocele
Pulp of finger-rectocele
31. BIMANUAL EXAMINATION
To rule out pelvic mass
ASSESSMENT OF PELVIC FLOOR MUSCLES
Pubococcygeus assessed at 4 and 8 ‘0 clock position
PR Examination – to assess the tone of anal sphincter
PUDENDAL NERVE SENSATION
32. DECUBITUS ULCER
Seen in long standing prolapse
on most dependent part
Cause—venous stasis
Healing is rapid
Non healing ulcer—malignancy should be excluded
33. INVESTIGATIONS:
USG-to rule out pelvic mass and hydronephrosis
renal function test—long standing prolapse
Urodynamic investigations—in case of associated
incontinence
34. DIFFERENTAIL DIAGNOSIS
Gartners cyst- retention cyst – remnants of wolffian duct
Urethral diverticulum
Large fibroid polyps
Chronic inversion
Elongation of cervix
35. Prevention
Proper intra-natal care (during delivery):
Avoid aetiological factors as straining during the first stage(before
full cervical dilatation)
Avoid the application of forceps before full cervical dilatation;
Episiotomy should be done when indicated to avoid hidden perineal
lacerations
Avoid fundal pressure to deliver the placenta.
36. Proper post-natal care (after delivery):
Accurate repair of perineal tears or
episiotomies
Avoidance of occurrence of R.V.F.
Correction of retroversion during the
puerperium
Encourage pelvic floor exercises and other
postnatal ex‘s
prevent puerperal constipation
Care of general health to prevent debility and
bad general health.
GENERAL MEASURES ;treatment of chronic cough
& constipation , correction of obesity
37. MANAGEMENT
CONSERVATIVE MX
Pelvic floor muscle training
PESSARIES—indications
High risk for surgery
Not willing for surgery
Pregnancy
lactation
38. Pessaries
2 types
SUPPORT –Ring pessary
SPACE FILLING-Gelhorn and cube pessary
Ask the patient to cough—to ensure pessary is in place
Ensure that she is able to void urine before leaving clinic
FOLLOW UP
initial—at 2 weeks
First year- 3monthly
afterwards-- 6 monthly
44. 1)WARD- MAYO REPAIR
Vaginal hysterectomy with PFR
Performed where childbearing is complete
Combined with
Enterocele(Mc Call culdoplasty)
Cystocele (anterior colporrhaphy)
Rectocele(colpoperineorrhaphy) correction
45. Mc Call culdoplasty
Approximation of uterosacral
ligaments in the midline so as to
oblieterate the peritoneum of
the posterior cul-de-sac as high
as possible
fixation of uterosacrals to the
vault
46. 2)SACROSPINOUS COLPOPEXY
In case of procidentia
3) ABDOMINOSACROCOLPOPEXY
Abdominal method of apical suspension
4) LE FORT OPERATION/COLPOCLEISIS
Elderly women with medical problems
Total obliteration of vagina –suturing anterior posterior
denuded vagina
47. MANCHESTER /FOTHERGILL’S OPERATION
Women who completed family
Who wishes to retain the uterus
Procedure –anterior colporrhaphyligation of cardinal
ligaments amputation of cervix suturing the cardinal
ligaments to the front of cervix( Fothergills
stitch)reforming the lips of cervix using the vagina
(sturmdorf suture)
Preserves menstrual and reproductive function
48.
49. SHIRODKAR EXTENDED MANCHESTER OR VAGINAL SLING
OPERATION
Modification of Fothergills procedure
Cervical amputation is avoided
Best for women with strong uterosacrals