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Pelvic organ prolapse – Management

This document discusses the management of pelvic organ prolapse including conservative management with pelvic floor exercises and pessaries as well as surgical management. Surgical procedures are described to repair prolapse in the anterior compartment, posterior compartment, middle compartment, and for enterocele repair. Procedures are also summarized for vault prolapse, hysterectomy, and repair in nulliparous patients. Complications of treatment methods are also outlined.

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Pelvic Organ Prolapse – Management
Complications 1. Kinking of ureter 2. UTI 3. Ca vagina
Mx of decubitus ulcer 1. Smear for cytology 2. Colposcopy and directed biopsy 3. Reduction of prolapse 4. Oestrogen cream - if postmenopausal
Conservative management 1. Mild degrees of prolapse 2. Unfit for surgery or unwilling for surgery 3. Childbearing not complete 4. In pregnancy 5. Awaiting for surgery
1. Pelvic floor muscle training  Kegel’s exercises 2. Life style measures • Lose weight, avoid weight lifting • Stop smoking • Treat c/c cough & constipation 3. Vaginal Pessaries
Vaginal Pessaries  Indications – 1. Unfit / unwilling for surgery 2. Awaiting for surgery 3. Pregnancy 4. Lactation 5. For decubitus ulcer to heal
1. Support pessaries  Smith – Hodge pessary or Ring pessary  Stage I & II 2. Space filling pessaries  Gelhorn and Cube pessaries  Advanced stages  More support
Complications 1. Vaginal discharge 2. Vaginal irritation 3. Erode vaginal ------ fistula 4. Ca vagina
Surgical Management
 Anterior Compartment  Posterior compartment  Middle compartment  Enterocele  Nulliparous prolapse
 Reconstructive  Obliterative Le Fort’s Colpocleisis
Anterior Compartment 1. Anterior cystocele  Midline defect 2. Paravaginal defect / lateral cystocele  Detachment from arcus tendinus fascia
Anterior Colporrhaphy  Plication of pubo-vesico-cervical fascia  Inverted T shaped incision  Hzntal – bladder sulcus  Vertical - to just below ext urethral meatus  Cut vesicocervical ligament, push bladder up  Bladder buttressing  Site specific repair – pubocervical fascia to arcus tendineus
Paravaginal repair 1. Abdominal 2. Vaginal 3. Laparoscopic  Approximating vagina and arcus tendinus fascia pelvis
Posterior Compartment 1. Posterior colporrhaphy 2. Site specific repair 3. Perineorrhaphy
Posterior Coplorrhaphy  Plication of rectovaginal fascia  Pair of allis forceps – either side, at lower labium minora  3rd forceps – on post vaginal wall midline, above bulge  Horizontal incision – dissect vaginal mucosa from prerectal fascia  Vertical incision – to apex  Approximate prerectal fascia in midline
 Anterior plication of pubococcygeus also  Perineorrhaphy  Repair of perineal body
Middle compartment  Uterine prolapse  Vault prolapse  Enterocele
Vaginal Hysterectomy  Ward Mayo repair  Uerovaginal prolapse – childbearing complete
Anterior colporrhaphy , push up bladder Extend cervical incision posterior - open POD Uterus delivery anteriorly
 1st clamp – Uterosacral & Cardinal lig  2nd clamp – Uterine vessels  3rd clamp – round ligament, f.tube, ovarian lig  Enterocoele correction  Close peritoneum – Purse string suture
Vaginal vault prolapse  Vaginal Approach 1. Sacrospinous colpopexy - vaginal vault to sacrospinous ligament 2. McCalls Culdoplasty - approximation of uterosacral lig ; vaginal vault to uterosacral ligament 3. Iliococcygeus Colpopexy - vaginal vault to iliococcygeus 4. Uterosacral lig suspension - vaginal vault to uterosacral lig
 Abdominal Approach – 1. Abdominal Sacrocolpopexy – vaginal vault to anterior sacral ligament 2. Abdominal uterosacral suspension – vaginal vault to utero sacral ligamants  Laparoscopic – 1. Laparoscopic Sacrocolpopexy – vaginal vault to anterior sacral lig
Sacrospinous Colpopexy  In Procidentia & Vault prolapse  Vault of Vagina to sacrospinous ligament
Abdominal Sacrocolpopexy  Y shaped mesh  Long arm – anterior longitudinal ligament  Short arms – ant & post vagina  In Nullipara – Sacro hysteropexy  Uterocervical jn – ant long. ligament
Le Fort’s Colpocleisis  Obliterative procedure  In elderly women unfit for repair operation  Remove vaginal epi suture ant & post walls  Laterally tunnels  Disdav- vaginal intercourse not possible
Manchester / Fothergill’s operation  In women completed family , but wish to retain uterus  In lesser degrees of UV prolapse, with supravaginal elongation of pelvis  Prior dilatation of cervix
Anterior colporrhaphy Isolate & ligate cardinal ligament Amputation of cervix Suture cardinal lig to front of cervix – Fothergills’s stitch Reforming lips of cervix – Sturmdorf sutures
 Shirodkar’s extended –  Cervical amputation avoided  Uterosacral ligaments – as slings – infront of cervix
Enterocoele  Vaginal – 1. McCall’s Culdoplasty  Open cul de sac – dissect high – excise  Approximate uterosacral lig – to vaginal vault
Abdominal 1. Vaginal vault ----- Uterosacral ligament 2. Halban procedure –  AP sutures b/w post vagina & peritoneum over rectosigmoid 3. Moscowitz procedure  Concentric sutures – uterosacrals & peritoneum..
Nulliparous prolapse 1. Abdominal Sacrohysteropexy – uterocervical jn to anterior longitudinal ligament 2. Purandare’s sling operation – cervix to anterior abdominal wall (fascia) 3. Shirodkar’s sling procedure – cervix to anterior long ligament 4. Khanna’s posterior sling – cervix to ASIS
Associated Stress Incontinence  Vaginal – Tension Free Vaginal tape  Polypropylene mesh kept under midurethra  Abdominal – Burch’s colposuspension  At level of bladder neck ---- ileopectineal lig / cooper’s ligament
Pelvic organ prolapse – Management