This document discusses the management of genital prolapse. It defines prolapse as the downward descent of the uterus and/or vagina due to weakened pelvic floor support structures. The main types of prolapse are cystocele, urethrocele, rectocele, enterocele, and vault prolapse. Treatment options include pelvic floor exercises, pessaries, and various surgical procedures to reconstruct the pelvic floor like anterior and posterior colporrhaphy, vaginal vault suspension, and abdominal sacrocolpopexy. The goal of treatment is to surgically correct the defects causing the prolapse and restore normal pelvic anatomy and function.

1. MANAGEMENT OF GENITAL
PROLAPSE
Mr Neba
20 March, 2023 1

2. ♣ The pelvic floor, closing the outlet of the
pelvis is made up of a number of muscular
and facial structures  the most important of
which is the LEVATOR ANI.
♣ These structures are pierced by the
RECTUM, VAGINA & URETHRA.  passing
through the exterior of the body
♣ These structures are supported in place by:
- ligaments
- condensation of facia

3. ♣ A relaxed vaginal outlet is usually a
sequel to mere  OVERSTRETCHING
of the perineal supporting tissues as a
result of previous parturition
 Muscular atony and loss of elastic
tissue in later life  lack of
hormone
 DENERVATION due to damage to
perineal or pelvic nerves  delivery
and pelvic surgery

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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

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CAUSE
WEAKNESS OF THE SUPPORTS OF THE UTERUS &
VAGINA
Precipitating / Exaggerating / Unmasking Causes -
INCREASED INTRA ABDOMINAL PRESSURE
Chronic cough
Chronic Constipation
Heavy Wt.Lifting / domestic Work
Obesity, Ascitis
WEAKNESS OF THE SUPPORTS & MUSCLES
Chronic ill health, malnutrition dysentery, anemia
Inadequate rest during pureperium
Menopause

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TYPES OF PROLAPSE
Vaginal
Anterior –cystocele &
urethrocele
Posterior - Enterocele &
Rectocele
Vault Prolapse - a special
term applied to the
prolapse of upper vagina
Uterine/Utero-vaginal-
Acquired or Congenital.
First degree.
Second degree &.
Third degree-(total Prolapse
/ complete procidentia).
However Procidentia is
often used only to denote
third degree uterine
prolapse.

7. TYPES OF GENITAL PROLAPSE
PELVIC ORGAN PROLAPSE (POP)
1. CYSTOCELE
= As a result of defect in the pubo-cervical facial plane which
support the bladder anteriorly
= it tends to permit the bladder to sag down below and
beyond the uterus
2. URETHROCELE:
= when the defective facia involves the urethra
3. RECTOCELE
= due to attenuation in the pararectal facia
 permits the rectum to bulge through
4. ENTEROCELE:
= Peritoneal hernial sac along the anterior surface of the
rectum
= Often contains loops of small intestine

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EFFECTS OF PROLAPSE
NO SYMPTOM- mild & moderate prolapse.
Discomfort & disability.
Sexual Dysfunction.
URINARY- Frequency, Dysuria, Stress
incontinence, infection.
Incomplete emptying of rectum.
Discharge.
Backache.
Ulceration & Infection.

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WHEN TO TREAT ?
Should be treated only when it is symptomatic (Be
certain symptoms are due to Prolapse )
Interferes with the normal activity of the woman
The patient seeks treatment

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HOW TO TREAT ?
NON-SURGICAL Methods: -Limited Role
PELVIC FLOOR REHABILITATION (pelvic muscle
exercises, galvanic stimulation, physiotherapy, rest in
the purperium).
HORMONE REPLACEMENT, both systemic and
local.
PESSARY TREATMENT for temporary relief
During Pregnancy, Pureperium & Lactation
When Operation is Unsafe due to Extreme
Senility/Debility and Diseases
Preoperatively
For therapeutic test

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HOW TO TREAT ?
SURGICAL TREATMENT: -
RECONSTRUCTIVE SURGERY is invariably
needed and has to be a COMBINATION OF
PROCEDURES to correct the multiple defects.

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SURGICAL TREATMENT
It is the definitive & curative treatment of
Prolapse.
It is a cold operation. So complete investigation
should be done & all existing diseases & disorders
should be treated first.
Pre operative pessary/tampoon & or Hormone
treatment should be given as indicated.
Meticulous and through examination under
anaesthesia should be done before deciding the
surgery.

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SURGICAL TREATMENT
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.
Absolute haemostasis is mandatory.Diathermy should be
liberally used.
Vaginal suturing should be with interrupted stitches.
Synthetic absorbable fine sutures are preferable.
Catheter for more than 48 hrs should be exceptional.
Strict antibiotic prophylaxis is essential

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VAGINAL OPERATIONS FOR PROLAPSE
Anterior colporrhaphy
Posterior colporrhapry- High / Low
Enterocele repair
Perineorrhaphy
Amputation of cervix
Paravaginal repair
Hysterectomy with or without Colporrhaphy /
Perineorrhaphy

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VAGINAL OPERATIONS FOR PROLAPSE
Manchester/ Fothergill’s operation & Shirodkar’s
modification
Uterus/Cervix suspension/fixation
Vaginal vault suspension/fixation
Retro-rectal levatorplasty and post. anal repair for
associated rectal prolapse
Vaginectomy ?
Colpocleisis ?

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Anterior colporrhaphy & Urethroplasty
For correction of Cystocele & Urethrocele
Incision- Midline / Inv.T / Elliptical
Excision of vagina according to the size & site of
laxity
Avoid shortening &/or narrowing of vagina
Closure with interrupted sutures

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Posterior colporrhaphy & Enterocele repair
For correction of Enterocele & Rectocele
Enterocele repair can be done either by vaginal or
abdominal route depending on the associated
procedures.
Approximation of uterosacral ligaments for
enterocele & prerectal fasciae and levator for
rectocele with interrupted sutures is essential
Excision of vagina should be tailor made
Perineorrhapy to be done only if perineal body is
torn

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Perineorrhaphy
Not an Operation for prolapse, but Indicated only
for associated old 2nd degree perineal tear
Performed along with post. colporrhaphy
Aim-Reconstruction of the Perineal body and
reduction of gaping introitus.
Can cause Dyspareunea
Essential steps - Excision of the scar tissue &
approximation of levator ani & superficial perineal
muscles

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Vaginal Hysterectomy with/without Vaginal
repair
Indicated when uterus needs removal, in old age & in total
prolapse.
Patient’s consent is mandatory knowing that there are
alternatives to hysterectomy.
Usually combined with Ant. & Posterior colporrhaphy.
Perineorrhaphy is not mandatory but case specific.
Vault suspension is an essential step.
If sexual function is not needed narrowing of vaginal
canal should be done.

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Amputation of cervix
Not for Prolapse.Indicated only for cervical
elongation (Uterocervical length >12.5 Cm )
To be done only as a part of Fothergill’s
repair/sling operations.
Adequate cervical dilatation - a prerequisite
Bladder displacement is a must
Excision of cervix should not exceed 2 cm
Likely to affect reproductive life
Long-term complications are real risks

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Fothergill’s operation
It is the operation of choice in uncomplicated
Utero-vaginal prolapse when uterus is to be
preserved but NO future child bearing is required.
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.
Post. Colporrhaphy to be performed only if
Ent/Rectocele is present
Perineorrhaphy is usually not required

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Fothergill’s operation
Not useful if ligaments are weak & Uterus is of
normal size. Purandare’s modification may help.
Technically difficult operation, requiring high
degree of surgical skill.
Threat of short-term complications.
Real possibilities of long term complications.
Recurrence/Failure.
Sling operations are better alternatives
HAS A BLEAK FUTURE

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ABDOMINAL OPERATIONS FOR
PROLAPSE
Sling operations
Closure or repair of enterocele
Sacrocolpopexy
Anterior Colpopexy
Colposuspension
Paravaginal repair

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Abdominal Sling operations
Indicated when the ligaments are extremely weak as in
nulipara & 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.
Amp.of Cx should also be done if Utereocervical length
>12.5cm.
Cystocele/Rectocele repair if needed can be done
vaginally before or after.
Enterocele repair can also be done abdominally.

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Abdominal Colpopexy / Colposuspension
Indicated when vault prolapse occurs after
hysterectomy or vaginal laxity is to be corrected at
abdominal hysterectomy.
Major abdominal operation & technically difficult.
Sexual function is preserved.
Methods-.
Sacrocolpopexy.
Ant.Colpopexy.
Colposuspension.

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Sacrocolpopexy
Vault is fixed to 3rd & 4th sacral vertebrae with a
facial strip / proline mesh under the peritoneum to
the right of rectum
Enterocele repair can be done if required

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Ant.Colpopexy
Corrects ant. vag laxity & stress inc.
Useful at abdominal hysterectomy / for vault
prolapse.
Extra peritoneal supra pubic approach if done
alone.
Enterocele repair if required.
Vagina stitched to the ileo-pectineal ligaments.

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Vault / Colposuspension
Vault is fixed to the abdominal wall by a facial
strip or merseline tape

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