Gynecology topic for MBBS Pelvic organ prolapse management

1. Pelvic Organ Prolapse –
Management

2. Complications
1. Kinking of ureter
2. UTI
3. Ca vagina

3. Mx of decubitus ulcer
1. Smear for cytology
2. Colposcopy and directed biopsy
3. Reduction of prolapse
4. Oestrogen cream - if postmenopausal

4. Conservative management
1. Mild degrees of prolapse
2. Unfit for surgery or unwilling for surgery
3. Childbearing not complete
4. In pregnancy
5. Awaiting for surgery

5. 1. Pelvic floor muscle training
 Kegel’s exercises
2. Life style measures
• Lose weight, avoid weight lifting
• Stop smoking
• Treat c/c cough & constipation
3. Vaginal Pessaries

6. Vaginal Pessaries
 Indications –
1. Unfit / unwilling for surgery
2. Awaiting for surgery
3. Pregnancy
4. Lactation
5. For decubitus ulcer to heal

7. 1. Support pessaries
 Smith – Hodge pessary or
Ring pessary
 Stage I & II
2. Space filling pessaries
 Gelhorn and Cube pessaries
 Advanced stages
 More support

9. Complications
1. Vaginal discharge
2. Vaginal irritation
3. Erode vaginal ------ fistula
4. Ca vagina

10. Surgical Management

11.  Anterior Compartment
 Posterior compartment
 Middle compartment
 Enterocele
 Nulliparous prolapse

12.  Reconstructive
 Obliterative
Le Fort’s Colpocleisis

15. Anterior Compartment
1. Anterior cystocele
 Midline defect
2. Paravaginal defect / lateral cystocele
 Detachment from arcus tendinus fascia

17. Anterior Colporrhaphy
 Plication of pubo-vesico-cervical fascia
 Inverted T shaped incision
 Hzntal – bladder sulcus
 Vertical - to just below ext urethral meatus
 Cut vesicocervical ligament, push bladder up
 Bladder buttressing
 Site specific repair – pubocervical fascia to
arcus tendineus

20. Paravaginal repair
1. Abdominal
2. Vaginal
3. Laparoscopic
 Approximating vagina and arcus tendinus fascia pelvis

21. Posterior Compartment
1. Posterior colporrhaphy
2. Site specific repair
3. Perineorrhaphy

22. Posterior Coplorrhaphy
 Plication of rectovaginal fascia
 Pair of allis forceps – either side, at lower labium minora
 3rd forceps – on post vaginal wall midline, above bulge
 Horizontal incision – dissect vaginal mucosa from prerectal fascia
 Vertical incision – to apex
 Approximate prerectal fascia in midline

23.  Anterior plication of pubococcygeus also
 Perineorrhaphy
 Repair of perineal body

25. Middle compartment
 Uterine prolapse
 Vault prolapse
 Enterocele

26. Vaginal Hysterectomy
 Ward Mayo repair
 Uerovaginal prolapse – childbearing complete

27. Anterior colporrhaphy ,
push up bladder
Extend cervical incision
posterior - open POD
Uterus delivery anteriorly

28.  1st clamp – Uterosacral & Cardinal lig
 2nd clamp – Uterine vessels
 3rd clamp – round ligament, f.tube, ovarian lig
 Enterocoele correction
 Close peritoneum – Purse string suture

30. Vaginal vault prolapse
 Vaginal Approach
1. Sacrospinous colpopexy - vaginal vault to sacrospinous
ligament
2. McCalls Culdoplasty - approximation of uterosacral lig ;
vaginal vault to uterosacral ligament
3. Iliococcygeus Colpopexy - vaginal vault to iliococcygeus
4. Uterosacral lig suspension - vaginal vault to uterosacral lig

32.  Abdominal Approach –
1. Abdominal Sacrocolpopexy – vaginal vault to anterior
sacral ligament
2. Abdominal uterosacral suspension – vaginal vault to utero sacral
ligamants
 Laparoscopic –
1. Laparoscopic Sacrocolpopexy – vaginal vault to anterior sacral lig

33. Sacrospinous Colpopexy
 In Procidentia & Vault prolapse
 Vault of Vagina to sacrospinous ligament

34. Abdominal Sacrocolpopexy
 Y shaped mesh
 Long arm – anterior longitudinal ligament
 Short arms – ant & post vagina
 In Nullipara – Sacro hysteropexy
 Uterocervical jn – ant long. ligament

35. Le Fort’s Colpocleisis
 Obliterative procedure
 In elderly women unfit for repair operation
 Remove vaginal epi suture ant & post walls
 Laterally tunnels
 Disdav- vaginal intercourse not possible

37. Manchester / Fothergill’s
operation
 In women completed family , but wish to retain uterus
 In lesser degrees of UV prolapse, with supravaginal elongation of
pelvis
 Prior dilatation of cervix

38. Anterior colporrhaphy
Isolate & ligate cardinal ligament
Amputation of cervix
Suture cardinal lig to front of cervix –
Fothergills’s stitch
Reforming lips of cervix – Sturmdorf
sutures

39.  Shirodkar’s extended –
 Cervical amputation avoided
 Uterosacral ligaments – as slings – infront of cervix

40. Enterocoele
 Vaginal –
1. McCall’s Culdoplasty
 Open cul de sac – dissect high – excise
 Approximate uterosacral lig – to vaginal vault

41. Abdominal
1. Vaginal vault ----- Uterosacral ligament
2. Halban procedure –
 AP sutures b/w post vagina & peritoneum over rectosigmoid
3. Moscowitz procedure
 Concentric sutures – uterosacrals & peritoneum..

42. Nulliparous prolapse
1. Abdominal Sacrohysteropexy – uterocervical jn to anterior
longitudinal ligament
2. Purandare’s sling operation – cervix to anterior abdominal wall
(fascia)
3. Shirodkar’s sling procedure – cervix to anterior long ligament
4. Khanna’s posterior sling – cervix to ASIS

43. Associated Stress
Incontinence
 Vaginal – Tension Free Vaginal tape
 Polypropylene mesh kept under midurethra
 Abdominal – Burch’s colposuspension
 At level of bladder neck ---- ileopectineal lig / cooper’s
ligament