Genital Prolapse

dr.Bambang Widjanarko, obstetrics & gynecologist

UTEROVAGINAL PROLAPSE : descent of some of the pelvic organ.  PELVIC ORGAN: 

 Urethra  Bladder  Uterus  Small bowell  Rectum

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Multifactorial MAIN PREDISPOSING FACTOR :     

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Childbirth Menopause Congenital Suprapubic surgery for urinary incontinence Genetics

Obesity – chronic cough and constipation INTRA-ABDOMINAL TISSUE

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Trauma of the pelvic floor Loss of tissue support to the pelvic organ  Vaginal delivery  Multiparity

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DISRUPT THE FASCIA

Prolonged Labor ( prolonged 2nd stage) – large baby and perineal trauma Direct damage to the FASCIA and NEUROMUSCULAR tissue Of the pelvic floor

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ESTROGEN DEFICIENCY: Influence of COLLAGEN FORMATION

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LOSS OF CONNECTIVE TISSUE STRENGTH

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Neurological deficiency Congenital weakness Anatomical variants

ORIGINAL POSITION OF ORGAN

PROLAPSE

SYMPTOMS Urinary symptoms of discomfort – dragging – feeling of a “lump” and coital problem

ANTERIOR

URETHROCELE CYSTOCELE

CENTRAL

SERVIK / UTERUS Bleeding and Discharge from 1ST , 2ND and 3RD degree ulceration in association with PROCIDENTIA procidentia

POSTERIOR

RECTOCELE ENTEROCELE

Bowel symptoms Feeling incomplete evacuation

Urethrocele : descent of the part of the anterior wall which is fused to the urethrae  3 – 4 cm anterior wall distal vagina, superior to the urethral meatus  Urethrocele and Cystocele are often considered together ( cystourethrocele ) 

cystocele

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Cervix occupies the proximal third of the vagina UTERINE PROLAPSE:  1st degree : descent of the uterus and cervix within

vagina ; the cervix does not reach the introitus  2nd degree : descent of the cervix to the level of the introitus  3rd degree : the cervix and uterus protrude out of the vagina 

PROCIDENTIA : cervix and vagina outside the introitus.

1st degree uterine prolapse

2nd degree uterine prolapse

3rd degree uterine prolapse

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Weakening of the tissue that lies between the vagina and rectum ( rectovaginal fascia )

ENTEROCELE is the only type of vaginal prolapse which is truly a HERNIA  It has a sac – neck and contents  SAC : protrusion of the peritoneum of the pouch of Douglass  May contain SMALL BOWEL or OMENTUM 

Prolapse may be asymptomatic and detected when patients present for a cervical smear  Symptoms usually non-specific 

STRETCH EFFECT On TISSUE - Uncomfortable dragging feeling or backache that improves when lying down. - ‘Something coming down’. - Coital difficulties ( sometimes ).

Urinary symptoms ( it involves bladder and urethra )  Over 50% stress incontinence : cysto urethrocele  Other urinary symptoms : 

 Frequency and urgency  Incomplete emptying of the bladder  Retained urine

UTI

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Examination : part of general gynaecological examination Suspicion :  Obesity – mobility and general well being  Dyspnoea – cough and abnormal chest sign

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Abdominal examination: pelvic mass may be pushing the pelvic organ Inspection :  atrophic changes of the vulva  Prolapsus seen at the introitus  Urinary leakage

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Bimanual examination : degree of uterine descent Examination in the left lateral or ‘Sims Position” be helpful Sometime be necessary to examine the patient in standing position

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Conservative Treatment  Patient does not want or is not fit enough for surgery  Pelvic floor exercise are not effective when prolapse is well

established  Pessaries are commonly used  Atrofi of the lower genital tract in association with prolapse : oestrogen cream topically 

SURGERY  Most procedure are performed through the vagina  Attention should be given to preserving the calibre of the

vagina if the women wishes to remain sexually active

Stress incontinence may need to be investigated prior to surgery  Principle : 

 Midline incision through anterior vaginal skin  Reflect underlying bladder of the vaginal mucosa  Lateral supporting suture are placed into fascia in

order to elevate the bladder and bladder neck  The remaining redundant vaginal skin that has been ’ballooning’ down are excised  Vagina skin is the sutured closed

ANTERIOR COLPORRHAPY and BLADDER BUTRESS The anterior vaginal wall is opened in the midline and the bladder buttres by sutures achored in the fascia either side of the bladder neck

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Principles similar to anterior repair  Incision posterior vaginal wall  Rectum separated from vagina  Supporting sutures are placed laterally to reduce

prolapse  The lax vaginal skin is the excised  Incision clossed

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This operation can combined with a repair of the perineal body to support the perineum Particular care must be taken not to narrow vagina and cause problem with dyspareunia

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The posterior wall is opened in the midline to expose the rectum:

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The posterior wall is closed after reducing the prolapse:

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Complete eversion of the vagina following a hysterectomy

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The surgical option :  Sacrocolpopexy  Sacrospinous fixation

Suturing the vaginal vault to the body of sacrum either directly or indirectly  The procedure is performed through an abdominal incision or laparoscopically 

Suture the top of vaginal vault to the sacrospinous ligament.  Procedure is performed through the vagina.  Complication : damage of sciatic nerve and pudendal vessels 