This document discusses genital prolapse, including its definition, pathophysiology, classification, grading, clinical features, differential diagnosis, investigations, prevention, and treatment. Genital prolapse is a protrusion of an organ or structure beyond normal confines, with a prevalence of 41-50% in women over age 40. It is caused by damage to supporting ligaments, fascia, and muscles from childbirth, age, obesity, and other factors. Treatment depends on symptoms and may include pessaries, vaginal surgery like anterior/posterior repair, or abdominal procedures like hysterectomy with sacrocolpopexy. The goal is to restore anatomy and function while preserving coital ability.

1. Genital Prolapse
Dr. Isameldin Elamin MD DOWH MBBS
Assistant professor
Obstetrics & Gynaecology Department

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. 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. 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. 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. 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. 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. 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. Classification
 Anterior vaginal wall prolapse:
o Urethrocele:
 Urethral descent,
o Cystocele:
 Bladder descent .
o Cystourethrocele:
 Descent of bladder and urethra.

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.

13. 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.

15. 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.

16. 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.

17. 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.

18. 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

19. Differential diagnosis:
 For anterior wall prolapse:
o Dermoid vaginal cyst.
o Urethral diverticulum.
 For uterovaginal prolapse:
o Large uterine polyp.

20. Prevention
 Shortening the second stage of delivery.
 Reduce traumatic delivery.

21. 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.

22. 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.

23. 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.

25. 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.

26. 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.

27. 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.

28. Surgical teartment …CONT.
 Rectocele:
o Procedure is posterior repair
(colporrhaphy).
 Enterocele:
o Peritoneal sac excised.
o Pouch of Douglas is closed.

29. 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.

30. 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.

31. 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.

32. Procedures involving hysterectomy
 Vaginal hysterectomy.
 Total abdominal hysterectomy and
sacrocolpopexy.
 Subtotal abdominal hysterectomy and
sacrocervicopexy.

33. Treatment of Vault Prolapse
 Sacrocolpopexy.
 Sacrospinous ligament fixation.

35. Further reading
 http://www.uptodate.com.
 Gynaecology by ten teachers 19 editions.
 Essential of obstetrics and gynaecology.
Hacker & Moore, fifth edition

36. THANK YOU