details of pelvic organ prolapse in PPT

1. Pelvic organ Prolapse
DR H.K.CHEEMA
M.D. A.C.M.E
FAIMER FELLOW
PROFESSOR &Head
OBG,PIMS, Jalandhar

2. Normal anatomy of Uterus
The uterus is located inside the pelvis immediately
dorsal to the urinary bladder and ventral to
the rectum . The human uterus is pear-shaped
and about 3 in. (7.5 cm) long. The uterus can be
divided anatomically into 3 segments=
1. Body or corpus
2. Isthmus
3. cervix

4. Normal postion of uterus and vagina
• The uterus and vagina lie in middle of pelvis.
• Anteriorly: urinary bladder and urethra.
• Posteriorly: colon,rectum and anal canal.
• The perineal body is interposed b/w lower part
of the posterior vaginal wall and the anal canal.
• In 80 % of women the uterus is anteverted and
anteflexed
• In 20% of women it may be retroverted

5. Female Anatomy

6. ANATOMY
The uterus is normally anteverted, anteflexed.
• Version: is the angle between the longitudinal
axis of cervix, and that of the vagina.
• Flexion: is the angle between the longitudinal
axis of the uterus, and that of the cervix.
• The external os lies at the level of ischial
spines.

7. Positions of uterus
Retroverted uterus
Anteverted uterus

8. Supports of Uterus
The uterus is held in this position and at this level
by supports conveniently grouped under three
tier systems.
UPPER TIER: It primarily maintained the ante-
verted position. The responsible structures are:
• Endo-pelvic fascia covering the uterus.
• Round ligaments.
• Broad ligaments with intervening pelvic cellular
tissues.

9. Supports of uterus

10. Broad Ligament

11. Supports of Uterus
MIDDLE TIER: The strongest support of uterus.
The responsible structures are :
• Peri-cervical ring- it includes pubocervical
ligaments and vesico-vaginal septum anteriorly,
cardinal ligaments laterally, uterosacral
ligaments and the rectovaginal septum
posteriorly.
• Pelvic cellular tissues.

12. Peri-cervical ring

13. Supports Of Uterus

14. Supports of Uterus
LOWER TIER: This gives the indirect support to
uterus. It is principally given by
the pelvic floor muscles (Levator Ani),
Endopelvic fascia
Perineal body
Urogenital diaphragm.

15. Pelvic Floor Muscles
Urogenital
diaphragm
Levator
ani
muscle

16. The Pelvic Diaphragm
• The pelvic diaphragm (pelvic floor) is composed of:
1. Levator ani muscle
i. Iliococcygeus
ii. Pubococcygeus
2. The coccygeus and
3. Pyriformis
• This is the most important muscular support of pelvic
organs.

17. Supports of uterus and vagina
Uterine supports
 Cardinal ligaments: major support of uterus and vault of vagina..
 Attached medially to supravaginal part of the cervix and vault of vagina
and laterally to lateral pelvic wall.
 Uterosacral ligament: responsible for keeping uterus in anteverted
postion
 Attached anteriorly to supra vaginal party of cervix and vault of vagina and
posteriorly to fascia in front of sacral vertebrae
Pubocervical fascia: extension of cardinal ligaments
 This fascia is attached to supravaginal part of cervix ,runs forward below
the base of bladder ,splits into two to allow for the passage of urethra and
is attached to the body of pubic bones

18. Vaginal support
 Cardinal ligaments:on each side attached to vault of vagina and
supravaginal part of cervix.
 Levator ani muscles:provide support to lower part of vagina
 Urogenital diaphram and perianal muscles : hold vagina in its
postion
 Pubocervical fascia: provide support to anterior vaginal wall
 Perineal body and rectovaginal fascia:
 the structures support the posterior vaginal wall
 Posterior vaginal wall:
 provide support to anterior vaginal wall in erect postion

19. Uterine support

20. Pelvic ligaments under stretch during
prolpase

21. Deep endopelvic connective tissue
▪ 6 pericervical ligaments:
▪ 2 uterosacral ,
▪ 2 cardinal ,
▪ 2 pubocervical ligaments
▪ 1 pericervical ring
▪ 2 septa:
▪ Pubocervical septum or fascia &
▪ Rectovaginal septum or fascia (fascia of
Otto)

22. Newer concept of pelvic
organ support
• De-Lancey’s
Biomechanical support

23. De-Lancey’s Biomechanical support
• De-lancey’s level of vaginal support
– LEVEL I – suspends upper vagina and cervix from
pelvic sidewall via the cardinal and the utero-sacral
ligaments
– LEVEL II – created by vaginal attachments to arcus
tendineus and support from Pubocervical & Recto
vaginal fascia.
– LEVEL III – support is created by the levator ani
Muscles & ligaments
De Lancey JOL Clin Ob Gyn 36: 897-909

25. definition
• POP

26. Pelvic Organ Prolapse(POP)
Herniation of one or more pelvic organs(uterus,
vaginal apex, bladder, rectum)and its associated
vaginal segment from its normal location.

27. Utero-vaginal prolapse(UV prolapse)
• It means downward descent of the vagina and uterus. There
may be prolapse of both or vagina only.
• Most women have prolapse but only 20% have symptomatic
prolapse.

28. Genital Prolapse
• Genital prolapse is the descent of one or more
of the genital organ (urethra, bladder, uterus,
rectum or Pouch of Douglas or rectouterine
pouch) through the fasciomuscular pelvic floor
below their normal level
• Vaginal prolapse can occur without uterine
prolapse but the uterus cannot descend without
carrying the vagina with it.

30. Uterine prolpase

31. Prevalence
• One of the most common Gynaecological disorder
• 3rd most common cause of Gynaecological surgery
• esp Post –Menopausal women
• Lifetime risk for age 80yrs >10%

32. TERMINOLOGY
1.anterior vaginal wall prolapse
2.posterior vaginal wall prolapse
3.uterine prolapse
4.vaginal vault prolapse(after hysterectomy)

33. Anterior vaginal wall prolapse
• Prolapse of the upper part of the anterior
vaginal wall with the base of the bladder is
called cystocele
• Prolapse of the lower part of the anterior
vaginal wall with the urethra is called
urethrocele.
• Complete anterior vaginal wall prolapse is called
cysto-urethrocele.

34. Anterior vaginal wall prolapse
• Weakness in the
–Supports of the bladder neck
–Urethero vesical junction
–Proximal urethra
• Caused by
–Weakness of pubocervical fascia and
pubourethral ligaments

35. Prolapse

36. cystocele urethrocele
Anterior vaginal wall prolapse

37. Posterior vaginal wall prolpase
 Enterocele :
Prolapse of the upper 1/3 of the posterior vaginal wall
Due to close proximity of pouch of douglas to the posterior fornix of vagina
, it also descents along with prolpase of upper part of the vagina.
 Rectocele:
Prolapse of lower 2/3 of the posterior vaginal wall along with lower part of
the rectum

38. Posterior vaginal wall prolpase
enterocele rectocele

40. classification and grading
The anterior and posterior vaginal wall prolapse is usually
described as
 Minor degree
 Moderate degree
 Major degree

41. Uterine descent
• Utero-vaginal (the uterus descends first
followed by the vagina): This usually occurs in
cases of virginal and nulliparous prolapse due to
congenital weakness of the cervical ligaments.
• Vagino-uterine (the vagina descends first
followed by the uterus):This usually occurs in
cases of prolapse resulting from obstetric
trauma.

42. Degree of uterine descent
• 1st degree: The cervix descends below its
normal level on straining but does not protrude
from the vulva. The external os still remains
inside the vagina.
• 2nd degree: The external os protrudes outside
the vaginal introitus but the uterine body still
remains inside the vagina.
• 3rd degree: The uterine cervix and body
descends to lie outside the introitus.
• Procidentia- involves prolapse of the uterus
with eversion of the entire vagina.

43. Uterine prolapse

45. Vault prolapse
• Descent of the vaginal vault, where the top
of the vagina descends (or inversion of the
vagina) after hysterectomy.

48. STAGING OF POP

49. Pelvic organ prolapse quantitative
(POP-Q) exam
• In 1996, by the ICS
• POPQ system describes the location and
severity of prolapse using segments of the
vaginal wall and external genitalia, rather
than the terms cystocele, rectocele, and
enterocele

52. POP-Q =Imp. Points
• Every measurement is in relation to Hymen.
• Above hymen minus points, below it, + points.
• Patient-either standing/ lithotomy position.
• Asked to do valsalva manoeuvre (max straining)
• Even under anaesthesia, it can be done.
• Wooden PAP spatula with markings for
measurement.
• Total nine specific sites
• Ist, TVL after reduction of prolapse
• Then Aa, Ba, Ap, Bp,C, D, gh, pb are measured.

53. • Nine specific sites are considered. Hymen is taken as the fixed point. The plane of hymen is defined
as the zero level. Leading point of prolapse may be above (proximal) or below (distal) to the plane
of hymen. Prolapse measurements (cm) are recorded as negative numbers when above and
positive numbers when lies below the plane of hymen. Organ prolapse is measured with a wooden
PAP spatula with markings. The woman may be examined in lithotomy or standing position (or
even under anesthesia). She may be asked to do some maneuvers (valsalva) to demonstrate the
prolapse maximally. Total vaginal length (TVL) is measured after reducing the prolapse while rest of
the measurements are done when the prolapse is seen maximally.

55. ETIOLOGY
Pelvic Organ Prolapse

56. Aetiology of Prolapse
1. Primary cause
2. Precipitating Factors
The primary cause of prolapse
is weakness of the supporting structures of
the uterus and vagina, usually as a result of
the trauma of childbirth.

57. Causes of utero-vaginal prolapse
UV prolapse is primarily due to the weakness of
the support , it maybe because of the following
causes:
1.Congenital weakness
2.Acquired defect
3.Menopause atrophy
4.Activiting factors

58. Etiology
Congenital weakness
Most important cause of UV prolapse in nulliparous
women
Inherent weakness of support in members of same
family
Racial and genetic factor(most common in white
races)
Patients with spina bifida are prone to have
prolapse

59. ETIOLOGY
Acquired defect
 Multiparous (99 percent)
 Due to overstretching of the ligaments or injury to nerves
and supports
 Vaginal birth not only weakens the uterine support but it
also predisposes to high risk of urinary and faecal
incontinence
 Prolonged labour
 Forceps delivery
 Pressure on fundus during delivery of the placenta(Crede’s
method)
 Puedendal nerve injury during child birth
 ventouse ( vaccum extractor)

60. CAUSES
Menopausal atrophy
Atrophy of the genital tract and its supports due
to withdrawal of estrogen , after menopause
The prolapse is seen usually within 1-2 years of
menopause
Null-parous UV prolapse also gets worsened
after the menopause.

61. Precipitating factors
▪ ↑ intra abdominal pressure
▪ ↑ weight of the uterus
▪ Traction of the uterus by vaginal prolapse or by a large cervical
polyp
▪ Obesity(40%--75%)
▪ Smoking
▪ Pulmonary disease (chronic coughing)
▪ Constipation (chronic straining)
▪ Occupational activities
(frequent or heavy lifting)

63. Symptoms of Prolapse
• Pelvic floor disorders become symptomatic
through either of two mechanisms:
1. Mechanical difficulties produced by the
actual prolapse,
2. Bladder or bowel dysfunction, disrupting
either storage or emptying.

64. SYMPTOMS
Common complaints are
• Something coming out of vagina(commonest symptom)
• Lower abdominal pain (dull &dragging)
• Backache (relieved by lying in the bed)
• Vaginal discharge
• Urinary symptoms
➢ frequency of micturation
➢ difficulty in micturation
➢ stress incontinence
➢ acute retention of urine
• Difficulty in empting of bowels
• Coital difficulties

65. SIGNS
• Usually visible during inspection of vulva
• Patients having stress incontinence should be
observed with full bladder
• Rectal examination will also differentiate
between rectocele and enterocele.

66. Signs
• When you ask the patient to cough it raises the intra-
abdominal pressure leading to:
Bulge in anterior vaginal wall in case of cystocele.
Bulging of the anterior and lower 1/3rd of vagina in
case of cysto-urethocele,
Bulging of the posterior vaginal wall in case of
rectocele and enterocele.
Stress incontinence
• Pinch Test:

67. Pathological changes associated with
prolapse
• Elongation and hypertrophy of cervix
• Keratinisation of vaginal epithelium(thick and white)
• Decubitus ulcerations
• Incarceration
• Complications of urinary tract include
❖ Residual urine increased
❖ Urinary tract infections and calculi due to stagnation of
urine
❖ Due to straining during micturation bladder hypertrophy
takes place.
❖ Hydero-ureter and hydro-nephrosis leading to renal failure
in long standing cases.

68. Decubitus ulcer
• It is atrophic ulcer, found at the dependent
part of the prolapsed mass lying outside the
introitus
• Surface keratinisation- cracks- infection-
sloughing –ulceration
• Impaired venous drainage, trauma due to
friction & tissue anoxia.
• Reduction of prolapse and daily packing for 2
weeks

70. Treatment-Decubitus Ulcer
• To relieve congestion, the prolapse can be
reposited in the vagina with the help of
tompoons or pessary and this helps in
healing of the ulcer
• Hygroscopic agents like acriflavin-glycerine
/Betadine vaginal packing can help reduce
the congestion.

71. Elongation and hypertrophy of cervix
• In prolapse uterus,sometimes Supra-vaginal
elongation of cervix occurs.
• Supra-vaginal portion of cervix—cardinal
ligaments,
• Vaginal portion of cervix ---prolapses with
vagina.
• This supravaginal portion gets stretched &
elongated, it occurs usually in 2nd/3rd degree
prolapse, not >10cm elongation can occur.

74. Incarceration Of Prolapse
• Rarely encountered, it occurs due to oedema
& congestion, prolapse becomes irreducible.
• Treatment : Head low position
• Ice- packing
• MgSO4 Packing : reduces oedema & then
prolapse is reduced.

76. COMPLICATIONS
• Keratinization of the vagina.
• Decubitus ulceration
• Hypertrophy of the cervix
• Obstructive lession of urinary tract,
Hydroureter, Hydronephrosis.
• UTI, Renal failure
• Incarceration of the prolapse.

77. Differential Diagnosis

78. 78
Gartner Duct Cyst Cystocele

79. D/D of Cystocele
Gartner duct cyst
1. Anterior or antero-lateral
2. No rugosity
3. Vaginal mucosa is tense &
shiny
4. Well defined margins
5. Not reducible
6. No impulse on coughing
7. A metal catheter tip
introduced through urethra
fails to come underneath
vaginal mucosa.
Cystocele
1. Midline anterior
2. Present
3. No
4. Ill defined margins
5. Reducible
6. Present
7. Come underneath vaginal
mucosa
79

80. D/D Uterine prolapse
1. Congenital elongation of cervix
2. Chronic inversion
3. Fibroid polyp
80

81. Diagnostic approach
• Beginning with a careful inspection of the vulva
and vagina to identify erosions, ulcerations, or
other lesions
• The extent of prolapse should be systematically
assessed

82. Examination
• Local examination
• Per speculum examination
• Per vaginal/ Bimanual examination
• Evaluation of tone of pelvic muscles
• Recto vaginal examination
• Position of patient for examination
- standing & straining
- dorsal lithotomy

83. Diagnostic approach
• The maximal extent of prolapse is
demonstrated with a standing straining
examination when the bladder is empty.
• Pelvic muscle function should be assessed after
the bimanual examination → palpate the pelvic
muscles a few centimeters inside the hymen,
along pelvic sidewalls at the 4 & 8 o’clock.
• Resting tone & voluntary contraction of the
anal sphincters should be assessed during
rectovaginal examination.

84. Evaluation of pelvic floor tone
• Place 1 or 2 fingers in the vagina and instruct the
patient to contract her pelvic floor muscles (i.e., the
levator ani muscles). Then gauge her ability to contract
these muscles, as well as the strength, symmetry, and
duration of the contraction.
• The strength of the contraction can be subjectively
graded with a modified Oxford scale (0 = no
contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 =
good, 5 = strong).

85. INVESTIGATIONS
• Routine pre operative investigations
• Urine for C/S if any symptoms suggestive if
UTI
• Urodynamic studies:
➢No urinary symptoms – not justified.
➢Do only if significant urinary symptoms.
85

86. MANAGEMENT
A) Preventive.
B) Conservative.
C) Surgery.

87. Prevention
❖ Pregnancy
❖Avoid pregnancy in quick succession
❖ Labour
❖ Stage 1
❖ Bearing down during 1st stage of labour should be avoided.
❖ Breech/forceps delivery before full cervical dilatation
should not be attempted.
❖ Stage 2
❖ Prolongation of 2nd stage should be avoided if necessary it
should be cut short by proper application of
ventous/forceps.
❖ Episiotomy should be performed at adequate time.

88. Prevention ...
❖ Stage 3
❖ Delivery of placenta by compression should be avoided(Crede`s method)
❖ Placenta should be delivered by Brandit Andrews method.
❖ Episiotomy and tear if any, should be carefully sutured
Puerperium
❖ Chronic cough and constipation should be avoided.
❖ Early ambulation help to tone up the pelvic muscles.
❖ Pelvic floor excercises should be advised.
❖ Strenous physical activity should be avoided at least for 3-6 months after delivery.
❖ After menopause: Hormone replacement may be helpful.
❖ Avoid prolonged standing, heavy lifting and chronic cough.
❖ Restart pelvic floor exercises daily.

89. Physiotherapy
• Early cases of uterovaginal prolapse are helped by pelvic
floor excercises. These are particular helpful during
puerperium while awaiting for surgery.
• Kegel designed pelvic floor excercises to tone up pelvic
musculature.
• These are isometric excercises done 3 times a day for 20
minutes each.

90. Pelvic Floor Exercise

91. Benefits of pelvic floor excercise

92. Prevention
• At hysterectomy
❖Vault suspension with utero-sacral and
cardinal ligaments.
❖Obliteration of deep cul-de –sac by
Moschowitz sutures.
❖Sacropexy in high risk situations like collagen
disorders.
❖Increase acceptability of estrogen
replacement therapy.

93. Treatment of Prolapse
Conservative treatment:
Palliative treatment by wearing a pessary is indicated in the
following conditions:
1) Slight degrees of prolapse in young patients. Operation should be
postponed until the woman has had a sufficient number of
children as long as the symptoms are mild.
2) Prolapse of the uterus in early pregnancy. The pessary is worn
until the end of the fourth month until size of the uterus will be
sufficient to prevent its descent.
3) Contraindications to operations as lactation, severe cough , or
patients refusing surgical repair.
4) Bad surgical risks as old patient with advanced diabetes or severe
hypertension.

94. Pessary

95. Pessary in situ

97. Pessary
• During pregnancy
• Immediately after pregnancy, during lactation
• When future childbearing is intended in near
future
• Refusal to operation by patient
• To promote healing in a decubitas ulcer

98. Complications of pessary
• Constipation
• Urinary incontinence
• B. vaginitis, ulceration of vaginal wall
• Cervicitis
• Carcinoma of vaginal wall
• Impaction of pessary
• Strangulation of prolapsed tissue

99. Aim of pelvic reconstructive surgery
1. To restore anatomy to relieve symptoms
2. To maintain or restore visceral function
3. To maintain or restore normal sexual
function.

100. 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

101. 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.

103. 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.colporraphy, or vaginal
hysterectomy requiring PFR, & as part of Fothergill’s repair

104. 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

105. Manchester/Fothergill’s operation
• In a women who has completed her family
• With lesser degrees of uterovaginal prolapse
with supra vaginal elongation of cervix
• but wishes to retain the uterus and opts for a
vaginal procedure
• it can be combined with AC , PC or enterocele
repair

106. Manchester/Fothergill’s operation
Dilatation & curretage
Anterior colporrhaphy
Isolation and ligation of cardinal ligaments
Amputation of cervix
Suturing the cardinal ligaments to the front of
cervix
Reforming the lips of cervix using the vagina

107. Shirodkar’s Extended Manchester operation
• Shirodkar’s Extended Manchester operation-
in a woman who wants to conceive
➢Uterus and cervix are preserved
➢Strenghthening of uterosacral ligaments
➢Best for women with strong uterosacrals

108. Shirodkar’s procedure
• Modified Fothergill’s operation
• Ant. Colporraphy performed, attachment of
Mackenrodt’s 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

109. PFR
• Anterior colporraphy
+
• Posterior colpo-perineo-rraphy

110. Vaginal hysterectomy with PFR
• Women more than 40 yrs
• Have completed her family
• No longer keen on retaining her childbearing &
menstrual functions
• Steps:
– Circular incision 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

111. • Peritoneal cavity is closed with purse-string
suture
• Ant. Colporraphy & post colpoperineorraphy is
performed as required.
• Vagina is packed with betadine pack for 24 hrs
• Cathetherize for 48 hrs.
• Complications:
– Hemorrhage
– Sepsis
– Anaesthesia risks
– UTI
– Rarely trauma to bladder and rectum.
– Vault prolapse as late sequela
– Dyspareunia caused by short vagina

112. WARD-MAYO REPAIR
1919,1915
• Vaginal hysterectomy + pelvic floor repair
• Combined with cystocele,enterocele or rectocele
repair
Cystocele- Ant.colporrhaphy(AC)
{Rectocele-Posterior colporrhaphy(PC)}
{Relaxed perineum-Perineo-rraphy}
Enterocele-Mc Call’s culdoplasty[Vaginal]
Moskowitz repair [abdominal]

113. Le Fort’s operation
• Le Fort’s operation In very elderly women who is
medically unfit for a repair procedure and not desirous
of vaginal intercourse.
• Colpocleisis
• Obliterative procedure
• Total colpocleisis-total obliteration of cavity
• Partial colpocleisis-some part of vaginal epithelium is
left unsutured to provide drainage tract ,useful in
women with uterus to drain cervical secretions

114. Le Fort’s repair
• Reserved for the very elderly menopausal pt with 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.

115. Abdominal Sling operations
• Indicated when the ligaments are extremely weak as in
nullipara & 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:
❖Abdomino-cervicopexy
❖Shirodkar’s abdominal sling operation
❖Khanna’s abdominal sling operation

116. 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:
• 1.Pessary
• 2.Vaginal repair(obese, elderly )
– 1Trans-vaginal sacro-spinous colpopexy
– 2.Colpocleisis
– 3.Le forte
– 4.Laparoscopic colpopexy
– 3.Abdominal repair(Gold standard treatment)
– Trans-abdominal Sacral colpo-pexy

117. Postoperative care
• Parental fluids until bowel sounds return.
• Early oral fluids are now advocated.
• Antibiotics, sedatives, metronidazole for 24 hours
IV.
• Indwelling catheter for 48 hours.
• Vaginal pack for 48 hours.
• Early ambulation
• DVT prophylaxis

118. NULLIPAROUS PROLAPSE
• More likely to have spina bifida or
connective tissue disorder
• Uterine +vaginal prolapse , may
include complete vaginal inversion
• Vaginal part of cervix is elongated.
• Mesh required for repair.
• Following repair- avoid vaginal
delivery – perform elective caesarean
section

119. MANAGEMENT
Abdominal sling operations
– (Teflon or mersilene mesh)
• Purandere’s sling operation or cervico-pexy
• Shirodkar’s sling operation
• Khanna’s sling operation

120. Genital Prolapse in Pregnancy
Effects on prolapse:
There is aggravation of the morbid anatomical
changes in prolapse such as marked hypertrophy
and edema of cervix
First degree become second degree
Cystocoele and Rectocoele become pronounced.
Effects on pregnancy:
There is increased chance of -
❖ Abortion ♦ Chorioamnionitis
❖ PROM ♦ Prolonged labour
❖ Operative interference ♦ Sub-involution

121. Treatment
During pregnancy:
If the cervix is outside the introitus - it is to be replaced
inside the vagina and is kept in position by a ring
pessary.
The patient is to lie in bed with the foot end raised.
During Labour:
The patient should be in bed.
If the head is high up and /or cervix remains
odematous, thick or undilated – Caesarean section is a
safe procedure.

122. CASE PRESENTATION
• A 58-year-old white vaginal multipara presents with pelvic
heaviness and sensation of something protruding from the vagina.
Symptoms worsen after prolonged physical exertion such as lifting
or standing. On occasion, she can feel and see something bulging
from the vaginal opening. Increasingly, she is experiencing
difficulties in emptying her bladder, and she needs to reduce the
bulge with her fingers in order to empty her bladder. She does not
have urinary leakage of any type, including leakage during physical
exercise. The patient is a heavy smoker with a history of COPD and
is obese.
• What is the most likely diagnosis?
• How will you proceed with this case?
• What are the advises you would like to give to this lady?
• What is the most probable cause of this disease in this patient?

123. Case based learning
• Young nulliparous woman, 3rd degree U-V
prolapse, no cystocele, no rectocele, no stress
incontinence, utero-cervical length 3”
• Diagnosis and treatment
• 24 yrs old,Para 1 with 1st/2nd degree U-V
prolapse
• Treatment
• Lactating woman with prolapse---

124. CBL
• 30 yr old multipara—uterine prolapse
• Management of choice
• 14 weeks pregnancy with 3rd degree U-V
prolapse
• Management of choice
• 65 yrs female –procidentia.past H/O
MI,DM,HT ---ideal treatment—
• Best management of vault prolapse ---

125. Thank You