Genital Prolapse N Stress Incont

Genital Prolapse - Dr. Khisa WW Introduction • Genital Prolapse is the descent of the vaginal wall and /or uterus whenever there is a defect in the pelvic organ support e.g. bladder, uterus, rectum, and urethra.

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It is common in the parous women.

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It signifies weakness in the pelvic organ support.

The Uterine support • Normally is anteverted and anteflexed in position whilst the cervix is at the level of the ischial spines.

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It is kept in this position and level by 3 supports

Upper supports 1. Endopelvic fascia covering the uterus 2. Round ligaments 3. Broad ligament Note: These are weak supports Middle support 1. Transverse-cervical (mackenrodt’s) ligaments 2. Uterosacral ligaments 3. Pubocervical fascia or ligaments These form the cardinal support of the uterus; if weak the uterus descends into the vaginal canal. Lower support 1. Endopelvic fascia 2. Pelvic floor These provide indirect supports to the uterus. Etiology of Prolapse Factors causing weakness of the structures supporting the organs in position leads to prolapse. These include • Predisposing factors • Aggravating factors Predisposing factors Can be acquired or congenital Acquired 1. Vaginal delivery with consequent injury to the supporting structures rare in cesarean delivery. 2. Prolonged distension of the perineum with avoidance or delay in giving episiotomies. 3. Improper repair of the perineal injuries. 4. Resumption of physical activities prematurely before tissues have regained their tone. 5. Persistent distended bladder on the perineum in puerperium 6. Premature bearing down before full dilatation of the cervix. 7. Repeated or frequent childbirths. 8. Use of forceps or vacuum extraction before cervix is fully dilated.

Congenital congenital weakness of the supporting structures. Aggravating factors where supports are already weakened 1. Postmenopausal atrophy 2. Chronic constipation /coughing 3. Fibroids or polyp 4. Malnutrition 5. Obesity Types Broadly it can be: • Vaginal • Uterine Vaginal Prolapse • Anterior-Cystocele due laxity of pubo- cervical fascia leading to heniation of the bladder. • Posterior-Rectocele-laxity of posterior vaginal wall rectum heniates through the wall. • Vault Prolapse -Especially after hysterectomy. Uterine Prolapse • Usually is accompanied by Cystocele or Rectocele however may occur alone –as in congenital cases. • Classification 1. 1st degree –The uterus descends down from its normal position halfway to the hymen. 2. 2nd degree –The uterus protrudes outside the vaginal introitus however the body of uterus remains inside the vagina. 3. 3rd degree– Also called procidentia- uterine body descends to lie outside the introitus. Staging: POP-Q • New classification • Uses objective measurements from fixed anatomic points- hymen easily seen consistently. • Plane at the level of hymen is described as zero. Anything in front is measured as positive and behind as negative. • A stage is assigned according to the most severe portion of the Prolapse. 1. 2. 3. 4.

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Stage 0: No Prolapse is demonstrated. Stage-1-Most distal portion of Prolapse > 1cm above the level of the hymen. Stage –2 –Most distal portion of Prolapse< 1cm proximal or distal to the plane of hymen. Stage –3 –Most distal portion of Prolapse is > 1 cm below the hymen but protrudes no further than 2 cm less than the TVL. Stage –5- complete version of the total length of the lower genital tract is demonstrated.

COMPLICATIONS OF THE PROLAPSE

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Trophic ulcers on the vaginal mucosa decubiters ulcers. Blood stained vaginal discharge due to congestion Cervical elongation Bladder o -Incomplete emptying o -Cystitis o -Hydronephrosis o -Pyelitis/ Pyelonephritis Cancer on the ulcer-rare

Clinical Features Symptoms • Feeling of something coming down per vaginal when moving about. • Discomfort on walking. • Backache or dragging pain in the pelvis. • In presence of Cystocele –Urinary symptoms – e. g difficult in passing urine, urgency or frequency dysuria, stress incontinence

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Rectocele - Difficulty in passing stool.

Signs • Inspection and digital or speculum examination of the vagina anteriorly and posterior, rectal and recto-vaginal. • Dorsal position o Standing /squatting. o Valsalva maneuver o EUA o Assess other associated Prolapse. o Evaluate etiological aspects of the Prolapse. o Bladder should be full for examination Investigation • Good clinical history and examination is more than sufficient. • U/S –Assess uterine masses, kidneys, uterus, bladder • IVU-Visualize bladder, kidneys, congenital anomalies • Urine for cystitis • CT-scan –For urethral obstruction, kidney stones • MRI-invaluable Differential diagnosis • Gartner’s cyst (Cystocele) o Metal catheter o Retention cyst o Remnants of wolfian duct o Loss of rugosity o Vaginal mucosa tense and shiney o Not reduce able o No cough impulse • Chronic inversion of the uterus • Fibroid or polyp • Congenital elongation of cervix Prevention

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Good and effective antenatal care –nutrition, physiotherapy, hygiene. • Adequate intrapartum care. o Prevent premature bearing down or application of forceps or vacuum. o Avoid prolonged second stage o Timely episiotomy o Accurate repair of perineal injuries • Adequate postnatal care o Especially pelvic floor exercises o FP-adequate spacing of childbirth o Avoid steroids exercises prematurely at least 6 months after delivery. Treatment Conservative measures • Improve nutrition • Kegel’s exercises • Pessaries –smith Hodge pessary useful in pregnancy or while waiting for operation. • Estrogen- in menopause Surgery • Cystocele- anterior colporrhapy • Rectocele- colpoperineorrhaphy • Vault Prolapse – P.F.R • Uterine Prolapse- Manchester operation or repair (conservation) • -TVH+ PFR Complications • VVF • RVF • Recurrence of Prolapse • Hemorrhage • Urinary retention • Sepsis Stress incontinence • GSI- commonest form of urinary in continence after acquired summary incontinence as in VVF. • Increase in intra abdominal pressure leads to urine loss. Due to abdominal pressure transmission to the bladder than the urethra. • Other form include –Detrusor instability and overflow incontinence, diverticulum and U.T.I Management >Non-surgical therapy plays a role in management and include: • Behaviour change/dietary change • Bladder training- measure void volume and decrease to only 1000ml fluid intake per day • Reduce caffeine /alcohol ingestion – diuretics • Bladder training –decrease frequency by 50% • Reduce tobacco use; weight loss and improved care for chronic diseases- reduce pelvic floor pressure.

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Kegels exercise – strengthen levator ani/ urogenital sphincter muscles; Restore anatomy of proximal urethra and pelvic floor. >Drugs – Estrogen replacement. >Mechanical – Smith Hodge pessary >Surgery • Anterior colporrhaply • Sling procedures • tvt /tot