vaginal prolapse


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vaginal prolapse

  1. 1. Management Of Genital Prolapse Associate Professor Semyatov S.M. Department of Obstetrics and Gynecology with course Perinatology Peoples’ Friendship University of Russia, Moscow
  2. 2. DEFINITION Prolapse/Procidentia is downward decent of uterus &/or vagina. (Procidentia is from Latin procidere - to fall). It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia. It is not a disease but a disabling condition.
  3. 3. CAUSE <ul><li>WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA </li></ul><ul><li>Precipitating / Exaggerating / Unmasking Causes - </li></ul><ul><ul><li>INCREASED INTRA ABDOMINAL PRESSURE </li></ul></ul><ul><ul><ul><li>Chronic cough </li></ul></ul></ul><ul><ul><ul><li>Chronic Constipation </li></ul></ul></ul><ul><ul><ul><li>Heavy Wt.Lifting / domestic Work </li></ul></ul></ul><ul><ul><ul><li>Obesity, Ascitis </li></ul></ul></ul><ul><ul><li>WEAKNESS OF THE SUPPORTS & MUSCLES </li></ul></ul><ul><ul><ul><li>Chronic ill health, malnutrition dysentery, anemia </li></ul></ul></ul><ul><ul><ul><li>Inadequate rest during pureperium </li></ul></ul></ul><ul><ul><ul><li>Menopause </li></ul></ul></ul>
  4. 4. TYPES OF PROLAPSE <ul><li>Vaginal </li></ul><ul><li>Anterior –cystocele & urethrocele </li></ul><ul><li>Posterior - Enterocele & Rectocele </li></ul><ul><li>Vault Prolapse - a special term applied to the prolapse of upper vagina </li></ul><ul><li>Uterine/Utero-vaginal- Acquired or Congenital. </li></ul><ul><ul><li>First degree. </li></ul></ul><ul><ul><li>Second degree &. </li></ul></ul><ul><ul><li>Third degree-(total Prolapse / complete procidentia). </li></ul></ul><ul><li>However Procidentia is often used only to denote third degree uterine prolapse. </li></ul>
  5. 5. EFFECTS OF PROLAPSE <ul><li>NO SYMPTOM- mild & moderate prolapse. </li></ul><ul><li>Discomfort & disability. </li></ul><ul><li>Sexual Dysfunction. </li></ul><ul><li>URINARY- Frequency, Dysuria, Stress incontinence, infection. </li></ul><ul><li>Incomplete emptying of rectum. </li></ul><ul><li>Discharge. </li></ul><ul><li>Backache. </li></ul><ul><li>Ulceration & Infection. </li></ul>
  6. 6. WHEN TO TREAT ? <ul><li>Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse ) </li></ul><ul><li>Interferes with the normal activity of the woman </li></ul><ul><li>The patient seeks treatment </li></ul>
  7. 7. HOW TO TREAT ? <ul><li>NON-SURGICAL Methods: -Limited Role </li></ul><ul><ul><li>PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium). </li></ul></ul><ul><ul><li>HORMONE REPLACEMENT, both systemic and local. </li></ul></ul><ul><ul><li>PESSARY TREATMENT for temporary relief </li></ul></ul><ul><ul><ul><li>During Pregnancy, Puerperium & Lactation </li></ul></ul></ul><ul><ul><ul><li>When Operation is Unsafe due to Extreme Senility/Debility and Diseases </li></ul></ul></ul><ul><ul><ul><li>Preoperatively </li></ul></ul></ul><ul><ul><ul><li>For therapeutic test </li></ul></ul></ul>
  8. 8. HOW TO TREAT ? <ul><li>SURGICAL TREATMENT: - RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects. </li></ul>
  9. 9. SURGICAL TREATMENT <ul><li>It is the definitive & curative treatment of Prolapse. </li></ul><ul><li>It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first. </li></ul><ul><li>Pre operative pessary/tampoon & or Hormone treatment should be given as indicated. </li></ul><ul><li>Meticulous and through examination under anaesthesia should be done before deciding the surgery. </li></ul>
  10. 10. SURGICAL TREATMENT <ul><li>Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement. </li></ul><ul><li>Absolute haemostasis is mandatory. Diathermy should be liberally used. </li></ul><ul><li>Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable. </li></ul><ul><li>Catheter for more than 48 hrs should be exceptional. </li></ul><ul><li>Strict antibiotic prophylaxis is essential </li></ul>
  11. 11. VAGINAL OPERATIONS FOR PROLAPSE <ul><li>Anterior colporrhaphy </li></ul><ul><li>Posterior colporrhapry- High / Low </li></ul><ul><li>Enterocele repair </li></ul><ul><li>Perineorrhaphy </li></ul><ul><li>Amputation of cervix </li></ul><ul><li>Paravaginal repair </li></ul><ul><li>Hysterectomy with or without Colporrhaphy / Perineorrhaphy </li></ul>
  12. 12. VAGINAL OPERATIONS FOR PROLAPSE <ul><li>Manchester/ Fothergill’s operation & Shirodkar’s modification </li></ul><ul><li>Uterus/Cervix suspension/fixation </li></ul><ul><li>Vaginal vault suspension/fixation </li></ul><ul><li>Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse </li></ul><ul><li>Vaginectomy ? </li></ul><ul><li>Colpocleisis ? </li></ul>
  13. 13. Anterior colporrhaphy & Urethroplasty <ul><li>For correction of Cystocele & Urethrocele </li></ul><ul><li>Incision- Midline / Inv.T / Elliptical </li></ul><ul><li>Excision of vagina according to the size & site of laxity </li></ul><ul><li>Avoid shortening &/or narrowing of vagina </li></ul><ul><li>Closure with interrupted sutures </li></ul>
  14. 14. Posterior colporrhaphy & Enterocele repair <ul><li>For correction of Enterocele & Rectocele </li></ul><ul><li>Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures. </li></ul><ul><li>Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential </li></ul><ul><li>Excision of vagina should be tailor made </li></ul><ul><li>Perineorrhapy to be done only if perineal body is torn </li></ul>
  15. 15. Perineorrhaphy <ul><li>Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear </li></ul><ul><li>Performed along with posterior colporrhaphy </li></ul><ul><li>Aim-Reconstruction of the Perineal body and reduction of gaping introitus. </li></ul><ul><li>Can cause Dyspareunea </li></ul><ul><li>Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles </li></ul>
  16. 16. Vaginal Hysterectomy with/without Vaginal repair <ul><li>Indicated when uterus needs removal, in old age & in total prolapse. </li></ul><ul><li>Patient’s consent is mandatory knowing that there are alternatives to hysterectomy. </li></ul><ul><li>Usually combined with Ant. & Posterior colporrhaphy. </li></ul><ul><li>Perineorrhaphy is not mandatory but case specific. </li></ul><ul><li>Vault suspension is an essential step. </li></ul><ul><li>If sexual function is not needed narrowing of vaginal canal should be done. </li></ul>
  17. 17. Amputation of cervix <ul><li>Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm ) </li></ul><ul><li>To be done only as a part of Fothergill’s repair/sling operations. </li></ul><ul><li>Adequate cervical dilatation - a prerequisite </li></ul><ul><li>Bladder displacement is a must </li></ul><ul><li>Excision of cervix should not exceed 2 cm </li></ul><ul><li>Likely to affect reproductive life </li></ul><ul><li>Long-term complications are real risks </li></ul>
  18. 18. Fothergill’s operation <ul><li>It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required. </li></ul><ul><li>It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must. </li></ul><ul><li>Post. Colporrhaphy to be performed only if Ent/Rectocele is present </li></ul><ul><li>Perineorrhaphy is usually not required </li></ul>
  19. 19. Fothergill’s operation <ul><li>Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help. </li></ul><ul><li>Technically difficult operation, requiring high degree of surgical skill. </li></ul><ul><li>Threat of short-term complications. </li></ul><ul><li>Real possibilities of long term complications. </li></ul><ul><li>Recurrence/Failure. </li></ul><ul><li>Sling operations are better alternatives </li></ul><ul><li>HAS A BLEAK FUTURE </li></ul>
  20. 20. ABDOMINAL OPERATIONS FOR PROLAPSE <ul><li>Sling operations </li></ul><ul><li>Closure or repair of enterocele </li></ul><ul><li>Sacrocolpopexy </li></ul><ul><li>Anterior Colpopexy </li></ul><ul><li>Colposuspension </li></ul><ul><li>Paravaginal repair </li></ul>
  21. 21. Abdominal Sling operations <ul><li>Indicated when the ligaments are extremely weak as in nullipara & young women. </li></ul><ul><li>Preserves reproductive function. </li></ul><ul><li>Principle - With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis. </li></ul><ul><li>Amp.of Cx should also be done if Utereocervical length >12.5cm. </li></ul><ul><li>Cystocele/Rectocele repair if needed can be done vaginally before or after. </li></ul><ul><li>Enterocele repair can also be done abdominally. </li></ul>
  22. 22. Abdominal Sling operations <ul><li>It is a major abdominal operation & Synthetic material is costly & not widely available in India. </li></ul><ul><li>Types-. </li></ul><ul><ul><li>Shirodkar’s posterior sling. </li></ul></ul><ul><ul><li>Purandare’s anterior cervicopexy. </li></ul></ul><ul><ul><li>Khanna’s sling. </li></ul></ul><ul><ul><li>Virkud’s composite sling. </li></ul></ul>
  23. 23. Shirodkar’s sling <ul><li>Tape is fixed to the post. Aspect of isthmus & sacral promontory </li></ul><ul><li>Anatomically most correct but difficult to perform </li></ul><ul><li>Risks of complication </li></ul>
  24. 24. Purandare’s cervicopexy <ul><li>Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall </li></ul><ul><li>Easy to perform </li></ul><ul><li>Dynamic support </li></ul>
  25. 25. Virkud’s composite sling operation <ul><li>Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side </li></ul><ul><li>Utrosacral ligament is plicated </li></ul><ul><li>Technically easy </li></ul>
  26. 26. Khanna’s sling operation <ul><li>Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine </li></ul><ul><li>Easier to perform and safer </li></ul><ul><li>But tape is superficial </li></ul><ul><li>Risk of infection </li></ul>
  27. 27. Abdominal Colpopexy / Colposuspension <ul><li>Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy. </li></ul><ul><li>Major abdominal operation & technically difficult. </li></ul><ul><li>Sexual function is preserved. </li></ul><ul><li>Methods-. </li></ul><ul><ul><li>Sacrocolpopexy. </li></ul></ul><ul><ul><li>Ant.Colpopexy. </li></ul></ul><ul><ul><li>Colposuspension. </li></ul></ul>
  28. 28. Sacrocolpopexy <ul><li>Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum </li></ul><ul><li>Enterocele repair can be done if required </li></ul>
  29. 29. Ant.Colpopexy <ul><li>Corrects ant. vag laxity & stress inc. </li></ul><ul><li>Useful at abdominal hysterectomy / for vault prolapse. </li></ul><ul><li>Extra peritoneal supra pubic approach if done alone. </li></ul><ul><li>Enterocele repair i f required. </li></ul><ul><li>Vagina stitched to the i leo-pectineal ligaments. </li></ul>
  30. 30. Vault / Colposuspension <ul><li>Vault is fixed to the abdominal wall by a facial strip or merseline tape </li></ul>
  31. 31. LAPAROSCOPIC SURGERY PROLAPSE <ul><li>Advantages of M I S -small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar </li></ul><ul><li>Can all types of prolapse be treated?- Yes. </li></ul><ul><li>Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery </li></ul><ul><li>However extended period of rest is essential </li></ul><ul><li>Expertise is needed </li></ul><ul><li>Presently cannot be widely practised </li></ul><ul><li>This is the surgery of the future today </li></ul>
  32. 32. LAPAROSCOPIC SURGERY PROLAPSE <ul><li>PROCEDURES:- </li></ul><ul><ul><li>Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair </li></ul></ul><ul><ul><li>VH / LAVH / LH / TLH + Colposuspension </li></ul></ul><ul><ul><li>VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction </li></ul></ul><ul><ul><li>Rectocele repair & levatorplasty </li></ul></ul><ul><ul><li>Enterocele repair with suturing of uterosacral ligaments </li></ul></ul><ul><ul><li>Colpopexy- Ant / Post </li></ul></ul>
  33. 33. Laparoscopic Cervicopexy/sling Operations <ul><li>All types of sling operations can be better performed by laparoscopy </li></ul><ul><li>Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair) </li></ul><ul><li>Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy </li></ul>
  34. 34. Laparoscopic Vault suspension/ Culdoplasty) <ul><li>Can be done with VH / LAVH / LH / TLH </li></ul><ul><li>Corrects mild laxity </li></ul><ul><li>Prevents vault prolapse </li></ul>
  35. 35. Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH <ul><li>An alternative to Ward- Mayo’s operation </li></ul><ul><li>Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension </li></ul><ul><li>Lap. levator plication if needed </li></ul><ul><li>Enterocele repair and suturing of uterosacral ligaments if needed </li></ul><ul><li>Retro pubic Colposuspension (Bruch) if required </li></ul>
  36. 36. Laparoscopic Rectocele repair & Levatoroplasty <ul><li>Rectovaginal space is opened & rectum dissected </li></ul><ul><li>Interrupted sutures given in the levator in the midline </li></ul><ul><li>Enterocele repair done if indicated </li></ul><ul><li>Vaginal vault suspension done </li></ul>
  37. 37. Laparoscopic Enterocele repair <ul><li>Rectovaginal space is opened, sac excised and purse string suture given </li></ul><ul><li>Uterosacral ligament sutured </li></ul>
  38. 38. Laparoscopic Post Colpopexy / Sacrocolpopexy <ul><li>Indicated for vault prolapse </li></ul><ul><li>Enterocele if present is first repaired </li></ul><ul><li>Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the R t. p ara rectal space </li></ul>
  39. 39. Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today. THANK YOU