Management Of Prolapseby: Siti Nur HamizahPreventiveConservative Surgery
Preventive General measures Antenatal &intranatal care Postnatal care * Avoid strenuous * Encourage early activities, chr.* To avoid injury to cough, constipationthe supporting ambulation & heavy weightstructures during * Encourage pelvic liftingtime of vaginal floor exercise by * Avoid futuredelivery eithersspontaneous or squeezing the pelvic pregnancy too sooninstrumental floor muscles in the & too many by puerperium contraceptive practise
Conservative: Pessary treatment Limitations It is never curative and only be palliative It can cause vaginitis Pessary needs to be changed every 3 months The wearing of pessary is not comfortable to some women and may cause dyspareunia If the vaginal orifice is very patulous, the pessary is often not retained. A forgotten pessary can be the cause of ulcer, rarely carcinoma of vagina and a vesicovaginal fistula A pessary does not cure urinary stress incontinence
Indications: A young woman planning a pregnancy During early pregnancy Puerperium Temporary use while clearing infection and decubitus ulcer A woman unfit for surgery In case a woman refuses for surgery Ring pessary is made of soft plastic polyvinyl chloride & available in different sizes.
Surgery Type of surgery offered to the patient with prolapse depends on the age of patient, her desire to retain the uterus either for reproductive or menstrual function, her menstrual history, general condition as well as the degree of uterine prolapse and uterine abnormality Aim: Relieve symptoms Restore anatomy Restore sexual function
Type of prolapse and the commonsurgical repair procedures
Anterior Colporrhaphy To correct cystocele & urethrocele. Principles: to excise a portion of the relaxed ant. Vaginal wall, to mobilise the bladder and push it upwards after cutting the vesicocervical ligament. The bladder is then permanently supported by plicating the endopelvic fascia under the bladder neck in the midline. Preliminaries: ↓ GA/ EA Pt in lithotomy position Vulva and vagina are to be swabbed with antiseptic solution Perineum to be draped with sterile towel and legs with leggings Bladder is to be emptied by metal catheter Vaginal examination is done to assess the type and degree of prolapse.
Perineorrhaphy/ Colpoperineorrhaphy Designed to repair the prolapse of post.vaginal wall. its uses and extent of repair are employed in: Relaxed perineum – the operation is extended to repair the torn perineal body. Rectocele – correct rectocele by tightening the pararectal fascia Enterocele – high perineorrhaphy is to be done right upto the cervicovaginal junction along with correction of enterocele. Lax vagina over the rectocele is excised, and rectovaginal fascia repaired after reducing the rectocele. Approximation of medial fibres of levetor ani helps to restore the calibre of hiatus urogenitalis, restore perineal body & provide adequate perineum separating the hiatus urogenitalis from the anal canal Commonly combined with ant.corrporaphy, or vaginal hysterectomy requiring PFR, & as part of Fothergill’s repair
Fothergill’s repair/ Manchester operation Combines an ant.colporrhaphy with amputation of cervix, sutures the cut ends of the Mackenrodt ligaments in front of the cervix, covers the raw area on the amputated cervix with vaginal mucosa and follows it up with colpoperineorraphy. Preserves menstrual and childbearing functions Fertility reduced because of the amputation of the cervix causing loss of cervical mucus. Suitable for women under 40 who are desirous of retaining their menstrual and reproductive function. Cervical amputation may lead to incompetent cervical os, habitual abortions or preterm deliveries. Excessive fibrosis → cervical stenosis and dystocia during labour Rarely cause haematometra. Recurrence may occur following vaginal delivery
Shirodkar’s procedure Modified Fothergill’s operation Ant. Colporraphy performed, attachment of Mackenrodt ligaments to cervix on each side is exposed. Vaginal incision is then extended posteriorly round the cervix. POD is opened, uterosacral ligaments identified and divided close to the cervix. The stumps of these ligaments are crossed and stiched together in front of cervix. High closure of the peritoneum of POD is carried out. Cervix is not amputated, rest of operation similar to Fothergill’s operation
Vaginal hysterectomy with PFR Women more than 40 yrs Have completed her family No longer keen on retaining her childbearing & menstrual functions Steps: Circular insicion over cervix, below bladder sulcus & vagina mucosa dissected off the cervix all around. POD identified post & peritoneum incised Bladder pushed upwards until uterovesical peritoneum is visible & incised Mackenrodt & uterosacral ligament are clamped, cut & pedicles transfixed Uterine vessels are identified, clamped,cut & ligated Upper portion of broad ligament holding uterus contains round & ovarian ligament & fallopian tube identified, clamped, cut & pedicle transfixed. Uterus removed
Peritoneal cavity is closed with purse-string suture Ant. Colporraphy & post colpoperineorraphy is performed as required. Vaginal is packed with betadine pack for 24 hrs Cathetherize for 48 hrs. Complications: Hemorrhage Sepsis Anaesthesia risks UTI Rarely trauma to bladderand rectum. Vault prolapse as late sequela Dyspareunia caused by short vagina
Le Fort’s repair Reserved for the very elderly menopausal ptwith advanced prolapse or for those considered unfit for any major surgical procedure. Pap smear & pelvic sonography to r/o pelvic pathology prior to procedure Procedure can be performed under sedation & LA or EA. Flaps of vagina from ant & post vaginal walls are excised, the raw areas apposed with catgut sutures Wide area of adhesion is created in the midline prevents uterus from prolapsing, small tunnels on either side permitting drainage of discharge. Operation limits marital function, not to be advised to women with active married life. Contraindicated in menstruating woman,a woman with diseased cervix and uterus.
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. Operation in common practise: Abdominocervicopexy Shirodkar’s abdominal sling operation Khanna’s abdominal sling operation
Vault prolapse Delayed complication of both abdominal and vaginal hysterectomy when supporting structure become weak and deficient. Also a result of failure to identify and repair an enterocele during hysterectomy. Treatment: Right transvaginal sacrospinous colpopexy Transabdominal sacral colpopexy Colpocleisis Le forte Laparoscopic colpopexy Abdominoperineal surgery Ring pessary.