3. DEFINITION
• Descent of one or more of the genital organs
below their normal anatomical position.
• Prolapse is a condition in which organs, which
are normally supported by the pelvic floor,
namely the bladder, bowel and uterus,
herniate or protrude into the vagina due to
weakness in their supporting structures.
4. Epidemiology
• Common Problem in Women
– 50% of parous women have some prolapse, 10-20% have
symptoms
• 11% Lifetime Risk for Surgery
– Of these, 29% require repeat surgery
• 5-7% Develop Post-Hysterectomy Vault Prolapse
5. ANATOMY-SUPPORTS OF THE UTERUS
AND VAGINA
The normal position of the uterus is maintained mainly by 3 factors:
1. The cervical ligaments: consist of 3 pairs:
• The Mackenrodt’s/tranverse cervical/cardinal ligament; the most important part
• The uterosacral ligaments
• The Pubocervical ligaments
2. The pelvic floor muscles:
The levator ani muscles is the most important & consists of 3 parts:
– The ischio-coccygeus muscle
– The ilio-coccygeus muscle
– The pubo-coccygeus muscle; the most important part
Others include obturator internus, coccygeus .
3. The anteverted position of the uterus/posterio
Angulation of the vagina.
13. Supports of the vagina
Three Levels of Support:
(DeLancey)
• Level I (upper level):
– Cardinal/Uterosacral ligaments
• Level II (middle level):
– Pubocervical fascia anteriorly
– Rectovaginal fascia posteriorly
– Levator ani muscles (through the arcus
tendineus fasciae pelvis)
• Level III (lower level):
– Perineal membrane
– Urogenital Diaphragm
14. RISK FACTORS
• Increased intra-abdominal pressure.
• Chronic cough.
• Chronic constipation.
• Weight lifting.
• Presence of abdominal tumors e.g fibroid & ovarian cysts.
• High impact exercises
• Age/Menopause
• Obesity
• Smoking
• Multiparity
• Congenital Weakness-rare, due to deficiency in collagen metabolism
• Injury to pelvic floor muscles
• Iatrogenic/Pelvic surgery- Hysterectomy
15. AETIOPATHOGENESIS
1-Congenital weakness of the pelvic supports is associated with- short vagina, spina
bifida & deep utero-vaginal & utero-sacral pouches
It leads to the appearance of prolapse at an early age, the so-called “nulliparous” or
even “virginal” prolapse.
2-Acquired weakness of pelvic supports;
• This is assoc with direct injury to pelvic musculature and fasciae as well as partial
denervation of pelvic floor muscles
16. AETIOPATHOGENESIS-contd
Acquired weakness of the cervical ligaments and pelvic
connective tissue
A) Obstetric childbirth trauma:
• Straining during the first stage of labour.
• Wrong forceps application before full cervical dilatation.
• Prolongation of the 2nd stage of labour leads to pressure & stretching
of levator ani
• Rapid succession of pregnancies; before involution of the pelvic
structures.
• unsutured or badly repaired perineal tear
B) Postmenopausal atrophy:
• Oestrogen deficiency & ageing may lead to loss of collagen and
weakness in CT & fascia, particularly in patients predisposed to by
obstetric trauma.
34. CLINICAL FEATURES OF PROLAPSE
Symptomatic or asymptomatic:
Exaggerated by effort and straining, and disappear by lying down & reduction
1. Sensation of pelvic heaviness
2. Backache; especially in uterine prolapse, due to stretch on uterosacral ligaments
3. A mass filling the vagina or protruding from the vulva; on straining or squatting, and disappears by
lying down on the back.
4. Urinary symptoms:
– Frequency of micturition by day due to mechanical irritation of the trigone.
– Stress (urodynamic) Incontinence.
– Inability to complete the act of micturition unless the anterior vaginal wall is pushed upwards and supported
by the finger.-
– Features of UTI
– Acute urinary retention mostly in 1st trimester
5 .Bowel symptoms; heaviness in the rectum and a constant desire to defecate.
6. Decubitus ulcer.
8. Vaginal discharge
9. Dyspareunia
10. others- cough
35. DIFFERENTIAL DIAGNOSIS OF
PROLAPSE
• VAGINAL CYST
• CERVICAL POLYP
• ELONGATION OF THE CERVIX
• Tumors of the urethra/Bladder
• Large urethral Diverticulum
• Skene’s and Bartholin’s gland cysts/abscess
36. MANAGEMENT
• History- (age, risk factors and complications)
• Physical examination-
• Examine in either the Sims position[left lateral] or dorsal
position-
• Use a speculum to depress post vaginal wall to view
anterior wall and vice versa.
• Urinary stress incontinence also tested for.
• Rectal examination to differentiate between rectocele and
enterocele.
• Rectovaginal examination
• She can stand/squart and then cough/strain
37. Investigations in a case of prolapse
1. Urine analysis, microscopy, culture and sensitivity in cases with
urinary symptoms.
2. Urodynamic studies in cases associated with stress incontinence.
3. IVU and cystography to delineate course of ureters and detect
vesical pouch
4. Pelvic and abdominal US if suspected pelvic or pelviabdominal
swellings.
5. Routine preoperative Investigations; blood chemistry, CBC, kidney
and liver function tests.
6. Wound swab mcs
7. Others depend on history and finding- CXR in elderly,
38. TREATMENT OF PROLAPSE
• The choice of treatment for genital prolapse
depends on several factors including
1. The type and degree of prolapse
2. Her desire to preserve coital function.
3. Her desire to preserve fertility.
4. The patient’s acceptance for surgical treatment.
5. Her level of fitness for a surgical approach.
Treatment options is divided into
a)Conservative
b)Surgical
39. CONSERVATIVE METHOD OF
TREATMENT
• While treating underlying conditions
• Life style modification
• Pelvic floor physiotherapy
• Estrogen replacement therapy
• Vaginal pessary
40. Pessary treatment of prolapse
• Indications of pessary treatment
1. Temporary measure to allow for treatment of
underlying conditions e.g.Promote healing of
decubital ulcers prior to surgery
2. Patients who refuse surgery
3. During pregnancy
4. Medically unfit patients, as very old age,
morbid obesity, cerebrovascular accidents, etc.
5. Therapeutic test to confirm that presenting
symptoms are due to prolapse
42. CARE OF PESSARY
• The patient should be shown how to withdraw the
pessary if it becomes displaced.
• Inform her not to use contraceptive diaphragm while
vaginal pessary is in place
• Tell her to report any discomfort – (bleeding,
disturbance in defecation or urinary function)
immediately.
• The patient should be examined 1-2weeks after
insertion, a repeat exam can be done in 4 weeks after
which visits should be 3-6month interval.
• The pessary should be maintained with an acidic gel.
43. COMPLICATIONS OF PESSARIES
• 1-Ulceration of vaginal vault.
• 2-Impaction of pessary.
• 3-Constipation.
• 4-Stress incontinence when large type is used.
• 5- Fistula
• 6-Carcinoma of the vaginal wall in neglected
cases.
7-Dyspareunia
44. OESTROGEN REPLACEMENT THERAPY
• Important in postmenopausal women with
atrophy of vaginal wall.
• Mild degrees of prolapse may improve
remarkably.
• Oestrogen helps improve quality of vaginal
mucosa and improves blood flow.
45. Surgical treatment for genital prolapse
• Indications for Surgery
a) Failed conservative treatment
b)Severe degree of Prolapse
c) Patient who has completed her family size
and doesn't desire to preserve fertility
• Surgical treatment is divided into:
a) Conservative surgical methods
b) Radical method
c)Others- mgt of Vault prolapse
46. Conservative surgical methods
• 1-Pelvic floor repair
– Anterior colpo-perineorrhaphy.
– Posterior colpo-perineorrhaphy.
– Combination of ant & post types.
2-Manchester Fothergill operation.
3-Sacrohysteropexy and sacrospinous fixation
4-Vaginal colpocleisis – complete or incomplete.
-Le Forts operation/complete-postmenopausal
& surgically poor risk pxs.
47. Radical Surgery for Treatment of
Prolapse
Vaginal hysterectomy & pelvic floor repair: in
older women when future pregnancy is not con-
templated, or after menopause.
It can be Abdominal, Vaginal or Laparoscopic Hysterectomy
• Other surgical method include: Vaginal Vault Prolapse repair
– Abdominal approach (abdominal sacro-colpopexy)
– Vaginal approach (sacrospinous ligament fixation)
48. Complications of Surgical Treatment
• Anaesthetic complication
• Haemorrhage
• Damage to surrounding structures
• Wound breakdown
• Recurrence
• Vault Prolapse
• Cervical stenosis/Incompetence
• Preterm Labour
• miscarriage = FROM CERVICALAMPUTATION
• Cervical dystocia
• Precipitate labour
• Dyspareunia
49. Prevention of prolapse
- Family planning/Child spacing to avoid
repeated child birth
- Proper selection of patients for instrumental
delivery
- Weight reduction/prevention of Obesity
- Stop smoking
- Partographic management of labour
- good repair of episiotomy and perineal tears
after labour
- Avoid constipation in pueperium.
-Encourage postnatal exercises
55. Sacrospinous Ligament Suspension
• Sacrospinous ligament
fixation entails attachment of
the vaginal apex to the
sacrospinous ligament, the
tendinous component of the
coccygeus muscle
56. All references & acknowledgements are
in accompanying resource materials
56
Sacrocolpopexy and paravaginal repair
for total pelvic floor prolapse
When the uterus prolapses, it carries the vagina along with it but the vaginal wall can prolapse without the uterus. Ie the vagina can prolapse independent of the uterus.
Pelvic muscles are in state of tonic contraction.
If vagina axis were to be vertical as in fig b, a slight increase in IAB will tend to cause vagina eversion.
NB; Essence of the level support: Level one support results in vaginal vault or uterine prolapse, level 11 support failure results in development of cystocoele/ rectocoele while level 111 support failure results in prolapse of bladder neck.
Overstretching and subsequent damage to the ligaments following attempt to bear down in first stage of labour.
It can be symptomatic or asymptomatic, most symptoms are posture dependent, Exaggerated by effort and straining, and disappear by lying down & reduction .
Life style modification may include advice on diet, weight loss in obese patients, increase fiber content in food, laxatives and modification of drug regimen including laxatives.
A) The Ring pessary: , The shelf pessary: , cup and stem” pessary: , determination of appropriate size is based on trial and error, optimal time interval for changing of pessary has also not been defined., careful examination at every 6 months is advisable and topical estrogen may reduce ulceration.
This anterior wall repair and plication of pubocervical fasciae was described by kelly in 1913 and it has become the treatment of choice.
