33.genital Prolapse.pdf.pdf

Genital prolapse

Prepared by: Dr. Gehanath Baral MBBS,DGO,MD Senior Consultant Gynecologist & Obstetrician: Government of Nepal Visiting Professor: CTGU, China

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Definition Genital prolapse: • Descent of vaginal wall and/or the uterus from the normal position due to loss of support from pelvic floor. 1. Cyctocele =Ant.wall, upper 2/3rd 2. Urethrocele =Ant.wall, lower 1/3rd 3. Rectocele =Post.wall, lower 2/3rd 4. Enterocele =Post.wall, upper 1/3rd 5. Uterine prolapse =Descent below the level of ischial spine. 6. Vault prolapse =Enterocele after hysterectomy

Genital displacement: • Change of position of uterus beyond its normal limits. 1. Fixed retroversion 2. Acute inversion 3. Chronic inversion 2

Uterine prolapse

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Cystocele/ Urethrocele

4

Rectocele/ Enterocele

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Aetiology 1.

Birth injury 1. Overstretching of ligaments and fascia 2. Subinvolution of supporting structures

2.

Congenital weakness

3.

Atonicity at menopause

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Risk factors

• Malnutrition • Increased intra-abdominal pressure • Downward traction by polyp or vaginal wall

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Uterine supports1

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Uterine supports2

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Uterine supports3

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Degree of uterine prolapse

• 1st =Descent up to the vaginal introitus • 2nd =Partial descent outside vagina (uterine fundus still inside) • 3rd =Complete descent outside vagina

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Degree of uterine prolapse

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Diagnosis: Clinical 1.

Something coming down from vagina

2.

Symptoms from traction: Backache

3.

Pressure symptoms: •

Urinary:1. 2. 3. 4.

•

4.

Incomplete voiding Retention Stress incontinence Infection

Bowel:-Difficulty passing stool

Trophic :- Decubitus ulcer, Vaginitis, Cervicitis 13

UVProlapse

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O/E: 1. Inspection

1. Ask pt to strain, squat or cough.

2. Palpation

2. Feel ischial spine

3. Per speculum

3. Palpate fundus of uterus if you can get above it or not.

4. Per rectal

4. Test on full bladder for stress incontinence. 15

D/D:

• Fibroid polyp

• Cx polyp or growth

• Cx elongation

• Vulval cyst

• Chronic inversion

• Vaginal cyst

• Rectal prolapse

• Urethral diverticulum

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Prevention 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Optimum wt. gain during pregnancy Proper management of 2nd stage Episiotomy Not to allow to prolong labor Proper management of 3rd stage Repair perineal tear Early postnatal ambulation Adequate rest postpartum Perineal exercise Birth spacing and decrease multiparity HRT in menopause 17

Management: 1.General • • • •

Nutrition HRT Safe delivery Treat complication: • Infection • Decubitus ulcer

2.Pessary • • • •

Decubitus ulcers Early pregnancy Puerperium Unfit/Unwilling for surgery 3.Surgery

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Surgery

1.

Vaginal hysterectomy + PFR

2.

PFR= Ant. + post. repair

3.

Fothergill’s repair=Cx shortening + Ant./Post.repair

4.

Anterior colporrhaphy

5.

Posterior colpoperineorrhaphy

1. Le Fort operation= Apposition of vaginal wall

2. Repair of vault prolapse: 1. Colpopexy 2. Cervicopexy 3. Le fort operation

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Enterocele Repair1

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Enterocele Repair2

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Steps of Fothergill’s repair 1. D & C Incision all around the Cx Anterior vaginal flaps made Urinary bladder pushed up Posterior vaginal flap made 2. Amputation of cervix

3. Plication of Mackenrodt’s ligament in front of Cx New Cx made with vaginal flaps 4. Anterior colporrhaphy

5. Posterior colpoperineorrhaphy Keep indwelling catheter Keep vaginal pack 22

Fothergill’s repair1

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Fothergill’s repair2

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Fothergill’s repair3

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Fothergill’s repair4

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Vaginal hysterectomy + PFR

1. 2. 3. 4.

Hysterectomy

Anterior colporrhaphy

Posterior colpoperineorrhaphy

Keep indwelling catheter & vaginal pack

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Vaginal hysterectomy: 1. 2. 3. 4. 5. 6. 7.

Incision on the vaginal wall just over the Cx Elevate vaginal wall flaps Push up urinary bladder Apply clamps on either side: Clamp, cut & ligate Mackenrodt’s ligament Clamp, cut & ligate uterine vessels Clamp, cut & ligate uterine cornual structures: 1. 2. 3. 4.

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Parametrium Round ligament Fallopian tube Ovarian ligament

Remove uterus 28

Anterior colporrhaphy after hysterectomy 1.

Close pelvic peritoneum

2.

Apply purse string suture beneath the bladder

3.

Tie two cornual structures together

4.

Tie two Mackenrodt’s ligaments together

5.

Trim redundant anterior vaginal flap

6.

Suture to close anterior vaginal flaps 29

Vaginal hysterectomy:1

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Vaginal hysterectomy:2

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Vaginal hysterectomy:3

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Vaginal hysterectomy:4

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Vaginal hysterectomy:5

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Vaginal hysterectomy:6

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Vaginal hysterectomy:7

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Vaginal hysterectomy:8

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Anterior colporrhaphy for cystocele without hysterectomy 1.

Incision on the vaginal wall just over the Cx

2.

Elevate vaginal wall flaps

3.

Push up urinary bladder

4.

Apply purse string suture beneath the bladder

5.

Trim redundant anterior vaginal flap

6.

Suture to close anterior vaginal flaps

7.

Keep indwelling catheter & vaginal pack 38

Anterior colporrhaphy1

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Anterior colporrhaphy2

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Anterior colporrhaphy3

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Anterior colporrhaphy4

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Posterior colpoperineorrhaphy 1.

Horizontal incision over the fourchete

2.

Elevate posterior vaginal flap and trim it

3.

Appose levator ani muscles together with 2-3 delayed absorbable interrupted sutures

4.

Suture to close anterior vaginal flaps

5.

Suture skin as in episiotomy repair 43

Posterior colpoperineorrhaphy1

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Posterior colpoperineorrhaphy2

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Posterior colpoperineorrhaphy3

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Complication of PFR/Vag.Hyst. Prolapse: 1. Obstructive uropathy 2. Bowel obstruction 3. Persistent infection with infective uropathy 4. Decubitus ulcer may change into cancer 5. Poor quality of life 6. Need of surgical intervention

Surgery: 1. Bleeding 2. Injury to: 1. Bladder (VVF) 2. Ureter 3. Rectum(RVF)

3. 4. 5. 6.

Infection Urinary retention Dyspareunia Vault prolapse 47

Complication of Fothergill’s repair

1. Bleeding 2. Injury to: 1. Bladder (VVF) 2. Ureter 3. Rectum(RVF)

3. Infection 4. Urinary retention 5. Dyspareunia

1. Cx stenosis • • •

Infertility Hematometra Cx dystocia

2. Cx incompetence • •

Recurrent abortion Preterm delivery

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