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04 genital prolapse isam

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genital prolapse

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04 genital prolapse isam

  1. 1. Genital Prolapse Dr. Isameldin Elamin MD DOWH MBBS Assistant professor Obstetrics & Gynaecology Department
  2. 2. Definition  A prolapse is a protrusion of an organ or structure beyond its normal confines.  Prevalence of 41–50 per cent of women over the age of 40 years.  The annual incidence of surgery for POP is within the range of 15–49 cases per 10 000 women years.
  3. 3. Pathophysiology Of Prolapse  The uterus and vagina are supported by: o Ligaments and fascia, from the pelvic side walls. o Levator Ani muscles. o Posterior angulation of the vagina.
  4. 4. Pathophysiology of prolapse…CONT.  Important ligaments and fascia: o The uterosacral–cardinal complex. o The pubocervical fascia. o The rectovaginal fascia.  Damage to any of these mechanisms will contribute to prolapse.
  5. 5. Aetiology of prolapse  The maintenance of position need intact: o Connective tissue. o Levator ani muscles. o Nerve supply.  All are affected by: o Pregnancy and childbirth. o Ageing.
  6. 6. Aetiology of prolapse…CONT.  Types: o Congenital. o Acquired.  The main factor in both types is connective tissue defects.  Why congenital type? Because: o Prolapse can occurs in nulliparous women.(2%). o Genital prolapse is rare in afro-caribbean women.
  7. 7. Aetiology of prolapse…CONT.  Causes of a acquired type: o Vaginal delivery.  Due to the damage of the nerve, levator ani and fascia. o More parity. o Pregnancy.  Due to progesterone and relaxin. o Increase in intra-abdominal pressure.  (E.g. Chronic cough or constipation).
  8. 8. Aetiology of prolapse…CONT.  Ageing due to: o Loss of collagen. o Weakness of fascia and connective tissue. o Oestrogen deficiency in post-menopause.  Postoperative. o Poor vaginal vault support at the time of hysterectomy.  Gynaecological surgery: o such as colposuspension.
  9. 9. Classification  Anterior vaginal wall prolapse: o Urethrocele:  Urethral descent, o Cystocele:  Bladder descent . o Cystourethrocele:  Descent of bladder and urethra.
  10. 10. Classification ..CONT.  Posterior vaginal wall prolapse: o Rectocele: rectal descent. o Enterocele: small bowel descent.  Apical vaginal prolapse: o Uterovaginal: uterine descent with inversion of vaginal apex.  Vault prolapse: o post-hysterectomy inversion of vaginal apex.
  11. 11. Grading  Three degrees of prolapse: o 1st: descent within the vagina o 2nd: descent to the introitus o 3rd: descent outside the introitus.  Procidentia: o Third-degree uterine prolapse.
  12. 12. Clinical features  History: o Enquire about aetiological factors. o Ask about symptoms: o Non-specific symptoms:  Lump.  Local discomfort.  Backache.  Bleeding/infection.  Dyspareunia or apareunia.  Renal failure.
  13. 13. Clinical features…CONT.  Specific symptoms:  Cystourethrocele: o Urinary frequency and urgency. o Voiding difficulty. o Urinary tract infection. o Stress incontinence.  Rectocele: o Incomplete bowel emptying. o Passive anal incontinence.
  14. 14. Clinical features…CONT.  Abdominal examination for: o Organomegaly or abdominopelvic mass.  Vaginal examination: o Examine the patient in the dorsal position. o Look for:  Prolapse  Ulceration.  Atrophy.
  15. 15. Clinical features…CONT.  Vaginal pelvic examination for: o Pelvic mass. o Assess vaginal walls. o Assess cervical descent. o Put patient in left lateral position. o Ask him to strain. Use a Sims speculum.  Do rectal and vaginal examination to differentiate rectocele from enterocele
  16. 16. Differential diagnosis:  For anterior wall prolapse: o Dermoid vaginal cyst. o Urethral diverticulum.  For uterovaginal prolapse: o Large uterine polyp.
  17. 17. Prevention  Shortening the second stage of delivery.  Reduce traumatic delivery.
  18. 18. Investigations  No essential investigations.  If urinary symptoms: o Urine microscopy. o Cystometry and cystoscopy.  If renal failure suspected: o Serum urea and creatinine . o Renal ultrasound.  In obstructed defaecation: o MR proctography.
  19. 19. Treatment  Treatment depends on: o The patient’s wishes. o Fitness of patient. o Coital function. o Prior treatment.  Correct obesity.  Treat chronic cough.  Treat constipation.  If ulcerated : o give topical oestrogen, biopsy, then pessary.
  20. 20. Treatment…CONT.  Uterovaginal prolapse:  If no symptoms: o Observation or conservative.  If mild symptoms o Pelvic floor physiotherapy  Conservative therapy is by: o Silicon rubber-based ring pessaries. o Shelf pessaries are rarely used.
  21. 21. Treatment….CONT.  Complication of pessaries : o Vaginal ulceration.  Indications for pessary treatment are: o Patient’s wish. o As a therapeutic test. o Childbearing not complete. o Medically unfit. o During and after pregnancy (awaiting involution). o While awaiting surgery.
  22. 22. Surgical teartment  The aim is to restore anatomy and function.  Types of operations: o Vaginal. o Abdominal.  Coital function is determinant factor to choose the type and operation.
  23. 23. Surgical teartment …CONT.  Cystourethrocele: o Anterior repair (colporrhaphy) is the most commonly performed surgical procedure. o Should be avoided if there is concurrent stress incontinence.  Procedure: o Incision made. o Defect identified and closed. o Redundant tissue removed.
  24. 24. Surgical teartment …CONT.  Rectocele: o Procedure is posterior repair (colporrhaphy).  Enterocele: o Peritoneal sac excised. o Pouch of Douglas is closed.
  25. 25. Surgical teartment …CONT.  Uterovaginal prolapse:  Uterine preserving surgery when: o Woman wishes to preserve her uterus. o Woman wants further children.  Options uterine preserving surgery are: o Hysterosacropexy:  A mesh between the cervix and the anterior longitudinal ligament on the sacrum.
  26. 26. Surgical teartment …CONT.  The manchester repair: o Amputating the cervix and using the uterosacral cardinal ligament complex to support the uterus.  Complications: o Cervical stenosis. o Cervical incompetence.
  27. 27. Surgical teartment …CONT.  Le fort colpocleisis: o Partial closure of the vagina used when:  Patient unfit .  Patient not sexually active.  Total mesh procedure using an introducer device.
  28. 28. Procedures involving hysterectomy  Vaginal hysterectomy.  Total abdominal hysterectomy and sacrocolpopexy.  Subtotal abdominal hysterectomy and sacrocervicopexy.
  29. 29. Treatment of Vault Prolapse  Sacrocolpopexy.  Sacrospinous ligament fixation.
  30. 30. Further reading  http://www.uptodate.com.  Gynaecology by ten teachers 19 editions.  Essential of obstetrics and gynaecology. Hacker & Moore, fifth edition
  31. 31. THANK YOU

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