Management Of Uterovaginal Prolapse

MANAGEMENT OF UTEROVAGINAL PROLAPSE BY DR DENNIS ALLAGOA

MANAGEMENT PREVENTION EXPECTANT SURGICAL

PREVENTION SPECIFIC MEASURES -correct obesity -treat chronic cough -prevent premature bearing down during delivery - Avoid credes’ manoevre during delivery of baby and placenta. -repair of genital tract lacerations and incisions -Avoid forceful instrumental delivery technique.

Prevention cont Avoid constipation in the puerperium Encourage postnatal exercise(Kegel’s exercises) Prevention of post hysterectomy vault prolapse by apposition of the cardinal and uterosacral ligament to the vaginal vault. Family planning.

Expectant management Physiotheraphy involving the pelvic floor muscles. -kegel’s exercises -Faradism -TENS (Trans-cutaneous Electric Nerve Stimulation) Applications of pessaries to the vaginal vault. Oestrogen replacement.

Indications for expectant management  Physiotherapy -prolapse discovered within six months of delivery -minor degree of prolapse  Pessaries -Therapeutic test to determine if symptoms are really due to prolapse. -Prolapse discovered during pregnancy, puerperium and throughout the period of lactation. -Patients not fit for surgery. -Those who refuse surgery -Presence of decubitus ulcers to promote their healing before surgery while awaiting surgery -When family size is not complete NOTE: Pessaries come in varieties: Ring, Stem, Hodge, Shelf, Gehrung,gellhorn, Doughnut and inflatable pessaries.

Complications of pessaries Impaction of pessaries Ulceration of vaginal wall Stress incontinence Infection Carcinoma of vaginal wall (rarely)

Oestrogen replacement therapy Postmenopausal women Healing of decubitus ulcer Mild degree of prolapse

SURGICAL MANAGEMENT PREOPERATIVE CARE -Correction of anaemia and nutritional deficiencies. -Treatment of UTI, vaginitis and cervicitis -Treatment of decubitus ulcers via -packing with acriflavine, normal saline and estrogen creams. -pessary insertion,ulcer heals in 23wks - Avoid smoking

Pre –operations cont Investigations -Full blood count and ESR -cervical smear for PAP Test -urinalysis and urine culture -vaginal and cervical cultures -blood urea and electrolytes -cystometry and cystoscopy when urinary symptoms are overt. -Electrocardiography with patient> 40yrs -Chest X ray > 40 years or preexisting cardio respiratory disease.

TYPES OF SURGERY Pelvic floor repair - anterior colporrhaphy -posterior colpoperineorrhapy - combination of above - enterocelectomy: Halban/ Moschowitz approach Manchester or fothergill’s operation -examination under anaesthesia and dilatation and curettage - Anterior colporrhaphy -posterior colpoperineorrhapy -amputation of the cervix -shortening of the transverse cervical ligament

Operations cont. Vaginal hysterectomy, pelvic floor repair + shortening of the cardinal ligament and obliterating the pouch of Douglas by using the McCall’s culdoplasty Vaginal colpocleisis: Le forte’s and complete colpocleisis. Post hysterectomy vaginal vault prolapse -vaginal approach - uterosacral ligament suspension: plication of the uterosacral ligament,McCall’s ,mayo’s ;modified McCall’s culdoplasty. - sacrospinous fixation - iliococcygeal fixation ( prespinous colpopexy)

Operations cont Abdominal approach. Uterosacral suspension Sacrocolpopexy Laparoscopic approach Uterosacral suspension Sacrocolpopexy

Post operative care Continous catherisation: 2-5days foley’s or suprapubic -if foley’s catheter is used it should be secured firmly to the thigh to avoid pulling on the bladder neck. -after removal of catheter if residual urine is less than 50mls then reinsert the catheter. -Culture urine at the removal of catheter.

Postoperative care Vaginal pack -A pack soaked in antiseptic solution to be removed after 24 hours -Pack is useful in securing haemostasis and prevention of adhesions. ANTIBIOTICS -used until removal of catheter.

Complications of the procedures Haemorrhage Urinary retension Urinary incontinence Vault infection Thromboembolic phenomenon Dyspareunia Apareunia Constipation Recurrent Prolapse Mesh erosion Vaginal stenosis Subfertility Premature/precipitate labour and cervical dystocia

Followup visits The patient is seen at followup clinic at Six weeks; then at three monthly intervals for a minimum of three years.

CONCLUSION Measures to reduce difficult deliveries, grandmultiparity, post operative morbidity and mortality, as well as provision of basic maternity services and empowerment of women must be continually advocated.

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