Genital Prolapse

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Genital Prolapse

  1. 1. ‫الرحيم‬ ‫الرحمن‬ ‫ا‬ ‫بسم‬‫الرحيم‬ ‫الرحمن‬ ‫ا‬ ‫بسم‬ International University of AfricaInternational University of Africa Faculty of MedicineFaculty of Medicine and Health Sciencesand Health Sciences Genital prolapseGenital prolapse Presented by:Presented by: Dr. Alwaleed M.AlfakiDr. Alwaleed M.Alfaki Gya. & Obs.Gya. & Obs. www.doctor.sdwww.doctor.sd
  2. 2. Genital ProlapseGenital Prolapse --Genital prolapse is a herniaGenital prolapse is a hernia --It is defined as a protrusion of a pelvic organ orIt is defined as a protrusion of a pelvic organ or structure beyond its normal anatomicalstructure beyond its normal anatomical boundariesboundaries.. TypesTypes:-:- 11..Uterine prolapseUterine prolapse 22..Vaginal prolapseVaginal prolapse 33..Vault prolapseVault prolapse www.doctor.sdwww.doctor.sd
  3. 3. Uterine prolapseUterine prolapse:-:- - Descent of the uterus & the cervix .Descent of the uterus & the cervix . - Usually due to weakness of the cervicalUsually due to weakness of the cervical ligament.ligament. - 3degrees of uterine descent are recognized .3degrees of uterine descent are recognized . a)a) First degree :-First degree :- Slight descent of the uterus but the cervix remainSlight descent of the uterus but the cervix remain with in the vagina .with in the vagina . www.doctor.sdwww.doctor.sd
  4. 4. b) Second degreeb) Second degree:-:- The cervix projects through the vulva on startingThe cervix projects through the vulva on starting or standingor standing.. c) Third degree (procidentiac) Third degree (procidentia(( The entire uterus prolapse out side the vulvaThe entire uterus prolapse out side the vulva.. The whole vagina or at least the whole of itsThe whole vagina or at least the whole of its anterior wall is invertedanterior wall is inverted.. 22..Vaginal prolapseVaginal prolapse:-:- Divided to anterior wall prolapse & posterior wallDivided to anterior wall prolapse & posterior wall prolapseprolapse.. www.doctor.sdwww.doctor.sd
  5. 5. i) Anterior wall prolapsei) Anterior wall prolapse a) Cystocele :-a) Cystocele :- - the bladder base descends with the upper 2/3 of- the bladder base descends with the upper 2/3 of the anterior vaginal wall .the anterior vaginal wall . - It represents a weakness in the investing fascia .It represents a weakness in the investing fascia . b) Urethrocele :-b) Urethrocele :- - The urethra descends with the lower third of theThe urethra descends with the lower third of the anterior vaginal wall.anterior vaginal wall. - Usually due to loss of support by the puboUsually due to loss of support by the pubo cervical fascia & more important the posteriorcervical fascia & more important the posterior pubourethral ligament .pubourethral ligament . www.doctor.sdwww.doctor.sd
  6. 6. ii) Posterior vaginal wallii) Posterior vaginal wall prolapseprolapse - It can affect the upper or lower vagina .It can affect the upper or lower vagina . - It represents increased hiatus between the leftIt represents increased hiatus between the left & right portion of the levator ani muscle .& right portion of the levator ani muscle . a) Enterocele :-a) Enterocele :- due to upper posterior wall prolapse & Usuallydue to upper posterior wall prolapse & Usually associated with herniation of pouch of douglasassociated with herniation of pouch of douglas & its content (bowel & omentum) .& its content (bowel & omentum) . www.doctor.sdwww.doctor.sd
  7. 7. b) Rectoceleb) Rectocele:-:- prolapse of the rectum through the lowerprolapse of the rectum through the lower posterior vaginal wallposterior vaginal wall.. c) Vault prolapsec) Vault prolapse:-:- prolapse of the vaginal vault afterprolapse of the vaginal vault after hysterectomy (inversion of the vaginahysterectomy (inversion of the vagina( .( . www.doctor.sdwww.doctor.sd
  8. 8. AetiologyAetiology:-:- It is due to failure of one or more of the supportsIt is due to failure of one or more of the supports of the uterus & vagina .of the uterus & vagina . Predisposing factors :-Predisposing factors :- 1) Congenital weakness of uterine & vaginal1) Congenital weakness of uterine & vaginal supports .supports . - Operates in both nulliparous & multiparousOperates in both nulliparous & multiparous prolapse .prolapse . - Nulliparous prolapse is very rare & usuallyNulliparous prolapse is very rare & usually associated with spina bifida (detects inassociated with spina bifida (detects in innervation)innervation) www.doctor.sdwww.doctor.sd
  9. 9. 2. Injury sustained during child birth repeaetd2. Injury sustained during child birth repeaetd delivery leads to over stretching anddelivery leads to over stretching and denervation of the supporting tissue .denervation of the supporting tissue . 3. Atrophy of the supporting tissue at the3. Atrophy of the supporting tissue at the menopause due to defficency of oestrogen.menopause due to defficency of oestrogen. Activating orprecipitating factors :-Activating orprecipitating factors :- If aweakness is present the circumstanles likelyIf aweakness is present the circumstanles likely to precipitate the onset of prolapse one .to precipitate the onset of prolapse one . * Increase intra-abdominal press caused by* Increase intra-abdominal press caused by chronic cough Ascites , straining at stoolchronic cough Ascites , straining at stool ,lifting heavy weights .,lifting heavy weights . *Traction of the uterus by large cervical polyps.*Traction of the uterus by large cervical polyps. www.doctor.sdwww.doctor.sd
  10. 10. PresentationPresentation:-:- Symptoms:-Symptoms:- Dragging discomfort and a feeling of someDragging discomfort and a feeling of some thing coming down . The swelling may be thething coming down . The swelling may be the cervix , cystocele or rectocele or all the three .cervix , cystocele or rectocele or all the three . Also a feeling of bearing down sensation .Also a feeling of bearing down sensation . A cystocele or cystourethrocele can also presentsA cystocele or cystourethrocele can also presents with urinary symptoms such as stress inwith urinary symptoms such as stress in continence , urgency & frequency , &continence , urgency & frequency , & difficulty in emptying the bladderdifficulty in emptying the bladder necessitating digital pressure .necessitating digital pressure . www.doctor.sdwww.doctor.sd
  11. 11. In severe utro-vaginal prolapse the urethra mayIn severe utro-vaginal prolapse the urethra may becomes so acutely angled that retention ofbecomes so acutely angled that retention of urine results .urine results . Rectocele can also presents with backache &Rectocele can also presents with backache & difficulty in emptying the rectum (the boweldifficulty in emptying the rectum (the bowel evacuated by helding back the rectoceleevacuated by helding back the rectocele digitally) .digitally) . Uterine descend also can presents with backacheUterine descend also can presents with backache which is relived by lying down & by bloodwhich is relived by lying down & by blood stained vaginal discharge when there is astained vaginal discharge when there is a decubital ulceration .decubital ulceration . www.doctor.sdwww.doctor.sd
  12. 12. ExaminationExamination:-:- **Examination is best carried out with the patientExamination is best carried out with the patient in the left lateral position or sims position usingin the left lateral position or sims position using sims speculumsims speculum.. **The presence , type & extent of prolapse &The presence , type & extent of prolapse & presence of stress incontinence if any canpresence of stress incontinence if any can usually be determined by asking the patient tousually be determined by asking the patient to bear down or to cough during examinationbear down or to cough during examination.. **If there is doubt the patient should be asked toIf there is doubt the patient should be asked to stand or walk for some time beforestand or walk for some time before examinationexamination.. www.doctor.sdwww.doctor.sd
  13. 13. **Occasionally it is necessary to test for uterineOccasionally it is necessary to test for uterine descent by pulling the cervix with volsellumdescent by pulling the cervix with volsellum.. Hazards of prolapseHazards of prolapse:-:- Provided that there is no urinaryProvided that there is no urinary tract obstructiontract obstruction or infection prolapse carries no risk to life.or infection prolapse carries no risk to life. PreventionPrevention:-:- --Avoidance of obesity & cigaretteAvoidance of obesity & cigarette smokingsmoking.. --Appropriate use of hormone replacement therapyAppropriate use of hormone replacement therapy.. --Encourage postnatal pelvic floor exerciseEncourage postnatal pelvic floor exercise.. --Avoid long second stage of labour by doingAvoid long second stage of labour by doing Episiotomy .with low forceps ,ventouse whenEpisiotomy .with low forceps ,ventouse when neededneeded www.doctor.sdwww.doctor.sd
  14. 14. Treatment:-Treatment:- 1/Pessary treatment1/Pessary treatment:-:- --Ring pessaries are made of inert plastic , are ofRing pessaries are made of inert plastic , are of different size , can be left in place for up to onedifferent size , can be left in place for up to one yearyear.. --Shelf pessaries are helpful in severe utrovaginalShelf pessaries are helpful in severe utrovaginal prolapseprolapse.. --The two main complication of pessaries areThe two main complication of pessaries are vaginal ulceration & incarceration leading tovaginal ulceration & incarceration leading to discharge & bleedingdischarge & bleeding.. www.doctor.sdwww.doctor.sd
  15. 15. --Indication of pessaries treatment areIndication of pessaries treatment are:-:-  During & after pregnancy awaiting involutionDuring & after pregnancy awaiting involution of tissues .of tissues .  As a therapeutic test to confirm that surgeryAs a therapeutic test to confirm that surgery might help .might help .  When the patient is medically unfit or refusesWhen the patient is medically unfit or refuses surgery .surgery .  for relief of symptom while the patient isfor relief of symptom while the patient is awaiting surgery .awaiting surgery . www.doctor.sdwww.doctor.sd
  16. 16. Surgical Treatment:-Surgical Treatment:- prolapse is not life threating condition but surgeryprolapse is not life threating condition but surgery has its mortality & morbidity .has its mortality & morbidity . a) Anterior repair (anterior colporrhaphy):-a) Anterior repair (anterior colporrhaphy):- - Correct cystocele or cystourethrocele .Correct cystocele or cystourethrocele . - The vaginal skin is divided in the midline , theThe vaginal skin is divided in the midline , the bladder is reflected upwards & the pubocervicalbladder is reflected upwards & the pubocervical fascia on either side inforced with interruptedfascia on either side inforced with interrupted stutures , redundant vaginal skin is excised &stutures , redundant vaginal skin is excised & vaginal skin is closed .vaginal skin is closed . - Postoperative urinary retention is common .Postoperative urinary retention is common .www.doctor.sdwww.doctor.sd
  17. 17. b)b) Posterior repair(colpo-perineorrhaphyPosterior repair(colpo-perineorrhaphy - Correct rectoceleCorrect rectocele - A vertical posterior vaginal wall incisionA vertical posterior vaginal wall incision is used to descet the posterior vaginalis used to descet the posterior vaginal wall from the rectum , the edges of thewall from the rectum , the edges of the levator ani muscles are sutured togetherlevator ani muscles are sutured together in the midline & the posterior vaginalin the midline & the posterior vaginal skin is closed .skin is closed . www.doctor.sdwww.doctor.sd
  18. 18. c) Vaginal hysterectomy with repairc) Vaginal hysterectomy with repair:-:- - It is now the standard operation for utro-It is now the standard operation for utro- vaginal prolapse .vaginal prolapse . - It is also the operation of choice when anIt is also the operation of choice when an enterocele present .enterocele present . - Best well when there is procidentia .Best well when there is procidentia . d) Manchester (fothergill) repair :-d) Manchester (fothergill) repair :- - Appropriate for the small number of women- Appropriate for the small number of women with severe utro-vaginal prolapse who wish towith severe utro-vaginal prolapse who wish to have further children .have further children . www.doctor.sdwww.doctor.sd
  19. 19. -- It combines shortening of the transverseIt combines shortening of the transverse cervicalcervical ligament with amputation of theligament with amputation of the cervix & anterior colporraphy .cervix & anterior colporraphy . -full amputation of the cervix may not be-full amputation of the cervix may not be necessary in less severe cases .necessary in less severe cases . -Caesarean section is necessary in any-Caesarean section is necessary in any subsequent pregnancy .subsequent pregnancy . e) Leefort operatione) Leefort operation www.doctor.sdwww.doctor.sd
  20. 20. Support of the uterusSupport of the uterus:-:- The uterus is held in position ofThe uterus is held in position of anteflection and anteversion by its wieghtanteflection and anteversion by its wieght , by the round ligaments which hold the, by the round ligaments which hold the fundus forwards and the uteroscaralfundus forwards and the uteroscaral ligaments which keep the supra vaginalligaments which keep the supra vaginal cervix far back in the pelvis while thecervix far back in the pelvis while the transverse cervical ligament prevent itstransverse cervical ligament prevent its descent .descent . www.doctor.sdwww.doctor.sd
  21. 21. Support of the vaginaSupport of the vagina In its upper part it is supported by the lowerIn its upper part it is supported by the lower components of the transverse cervicalcomponents of the transverse cervical ligament which fuse with its fascial sheath .ligament which fuse with its fascial sheath . - Below this it is held by the fibres of the levator- Below this it is held by the fibres of the levator ani which are inserted into its side walls by theani which are inserted into its side walls by the urogenital diaphram and by the perinealurogenital diaphram and by the perineal muscle .muscle . www.doctor.sdwww.doctor.sd

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