Uterovaginal Prolapse

Uterovaginal Prolapse : Aetiology : Clinical Presentation : : Diagnosis : Mangement :

The physician should look upon the patient as a besieged city and try to rescue him with every means that art and science place at his command.  Alexander of Tralles

In this presentation… • • • • • •

Review of applied anatomy Definitions – What is a Prolapse? Types of Prolapse Classification of Prolapse Signs and Symptoms, Examination, Differential diagnosis, Investigation of UV Prolapse Management of an UV Prolapse

Review of Applied Anatomy

Uterine fundus Sacrum

Cervix

Vagina

A schematic, simplified sagittal view of the female pelvic structures

The Vagina • A fibromuscular canal, 7-9 cm long, extending from the uterus to the vulva. • Four-walled structure with a vault superiorly into which projects the cervix. • The vaginal vault is divided into four fornices by the cervix. • Relations: Anteriorly: base of the bladder and urethra Laterally: the levator ani, visceral pelvic fascia and ureters Posteriorly (inferior to superior): the anal canal, rectum and rectouterine pouch. • Highly elastic structure, capable of distension during delivery of the fetus. • Support to the upper part of the vagina is provided by the cardinal (transverse cervical) and uterosacral ligaments.

Supports of Pelvic Floor •

Peritoneum: not contributory

•

Pelvic fascia

•

Pelvic floor fascia (fascia over pelvic floor muscles) - Endopelvic fascia: main support - Lateral cervical (transverse cervical, cardinal or Mackenrodt) ligament: lateral aspect of cervix and upper vagina to pelvic side walls - Uterosacral ligament: back of uterus to front of sacrum - Pubocervical ligament (fascia): anterior aspect of cervix to back of body of pubis - Posterior Pubourethral Ligament: post. inf. of symphysis pubis to ant. of middle ⅓ of urethra & bladder

• Pelvic Floor muscles - Levator ani muscle (pelvic diaphragm): Pubococcygeus, Iliococcygeus, Puborectalis - Coccygeal muscle - Urogenital diaphragm: superficial and deep transverse perineal muscles

Definition

Pelvic organ prolapse: A hernia of one or more pelvic organs (uterus, vaginal apex, bladder, rectum) and its associated vaginal segment from its normal location.

(ref: Neeraj Kohli, MD, Donald Peter Goldstein, MD.An overview of the clinical manifestations, diagnosis, and classification of pelvic organ prolapse.)

 

Types and Classification

A vaginal prolapse can be of the following types: Anterior Vaginal wall prolapse • Urethrocele: urethral descent • Cystocele: bladder descent • Cystourethrocele: descent of bladder and urethra

Posterior Vaginal wall prolapse • Rectocele: rectal descent • Enterocele: small bowel descent

Apical vaginal prolapse • Uterovaginal: uterine descent with inversion of vaginal apex • Vault: post hysterectomy inversion of vaginal apex These may occur singly or even in combinations in a patient.

Uterine prolapse

Vaginal Vault Prolapse

Rectal prolapse (Rectocele)

Bladder prolapse (Cystocele)

Enterocele

Classification Systems There are two systems of classification for pelvic prolapse: • Baden Walker (1968) and Beecham (1980) • Pelvic Organ Prolapse Quantification (1996) Baden Walker and Beecham system: • Conventional • Three degrees of prolapse are described and the lowest or most dependent portion of the prolapse is assessed whilst the patient lying in the left lateral position and is straining. 1st degree: cervix within vagina 2nd degree: cervix at introitus 3rd degree: descent outside the introitus, at the vulva (procidentia)

Pelvic Organ Prolapse Quantification (1996) • Devised by International Continence Society in 1996 • Hymen is the fixed reference point • provides standardized means for documenting, comparing, and communicating clinical findings with proven interobserver and intraobserver reliability • Necessary to specify condition of examination and position of patient • Approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10. Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International

POP-Q Stage

Description

• 0

No descent of pelvic structures during straining

• I • II

The leading surface of the prolapse does not descend bellow 1 cm above the hymenal ring

• III

The leading edge of the prolapse extends from 1 cm above the hymen to 1 cm through the hymenal ring

• IV

The prolapse extends more than 1 cm beyond the hymenal ring, but there is not complete vaginal eversion The vagina is completely everted

Prevalence

Estimated prevalence of UV Prolapse: • 12-30% of multiparous women • 2% of nulliparous women • Less among Blacks compared with Caucasians • More common among elderly/postmenopausal women

Aetiology

Congential: - seen in nulliparous women (accounting for 2% of prevalence) - inherent defect in supports, strong familial incidence - Eg: Ehlers-Danlos syndrome, congenital shortness of vagina, deep uterovesical/uterorectal pouches

Acquired: •

Childbirth - mechanical and nerve damage during vaginal delivery - parity associated with increasing prolapse, rare in nulliparous - seven times mores common in women with seven or more children - rare during pregnancy itself

•

Raised Intra-abdominal Pressure: - added strain on pelvic floor, especially in susceptibles - eg: chronic cough, constipation, tumors - very rarely chronic ascites1 or pregancy may be

•

Ageing

•

Menopause

•

Surgery - post hysterectomy (approx. 1% cases) - other surgical procedures such as colposuspension

Clinical Presentation

History (nonspecific symptoms) Lump in vagina or protruding out of it

Local discomfort

Renal failure (rare)

Nonspecific symptoms Dyspareunia Or Apareunia

backache Bleeding Or infection

History (specific symtoms) Urinary frequency

Urinary urgency

UTI Cystourethrocele

Stress Incontinence

Voiding difficulty

History (specific symtoms) Incomplete bowel emptying

Rectocele

Digitation (to empty bowel)

Also ask about… • COAD • Parity • Mode of deliveries

Physical Examination

General examination: • State of health, anemia, chest and cardiovascular examination, abdominal examination

Vaginal/Speculum examination: Examine the patient in the left lateral position while she is straining, using a Sims’ speculum. • Prolapse may be obvious • Ulceration and atrophy may be apparent A vaginal pelvic examination should be performed to rule out a pelvic mass.

Rectal examination: To differentiate rectocele from enterocele, if present.

Differential Diagnosis

• • • • • • •

Cervical polyp Large Endometrial polyp Pedunculated myoma Cervical cancer Metastasis of uterine cancer Urethral diverticulum Vaginal wall cyst

Investigations

Baseline: • • • • • • •

FBC UCE FBS Blood group, X-match Urine microscopy (MCS) CXR ECG

Additional: • • • •

Ultrasonography Computed tomography (CT) MRI Cystoscopy

Complications

•Keratinization of vagina •Hypertrophy of the cervix •Decubitus ulcers – ischaemic changes •Recurrent UTI •Acute urinary retention •Hydorureters / Hydronephrosis •Renal failure •Incarceration of the prolapse •Malignant change: rare

Mangement

Management options • Prevention • Medical • Surgical

Prevention • Correct obesity, chronic cough, constipation • Avoid Crede’s maneuver during delivery of baby and placenta • Shorten second stage of delivery • Avoid forceful instrumental delivery technique • Prevention of post hysterectomy vault prolapse by apposition of the cardinal and uterosacral ligament to the vaginal vault • Family planning

Medical Physiotherapy: Minor prolapse or prolapse developing within six months of delivery.

Use of pessaries: - Therapeutic test - Prolapse discovered during pregnancy, puerperium and throughout the period of lactation - Patients not fit for surgery - Those who refuse surgery - Promote healing of decubitus ulcers before surgery - When family size is not complete Complications of pessaries: impaction, ulceration of

Various types of pessaries

Surgery • • • •

Definitive treatment Aim is to restore anatomy and function Who opts for surgery?1 Many types of surgical procedures, depending on type and degree of prolapse

•

Preoperative preparation: - Correct anemia and nutritional deficiencies - Treatment of UTIs, vaginitis, cervicitis - treatment of decubitus ulcers - Written, informed consent - Arrange and X-match blood - Investigations for anesthesia fitness (baseline, cervical smear, ECG and CXR in patient over forty and/or with relevant symptoms) - NPO at least 24 hr before surgery - Clean and shave the surgical part - Pre-medication - IV fluids started on morning of surgery - Prophylactic IV antibiotics - Catheterize patient and shift to operation theatre

1 Conservative versus surgical management of prolapse: what dictates patient choice? (Int Urogynecol J Pelvic Floor Dysfunct. 2009 Oct;20(10):1157-61. Epub 2009 Jun 19)

•

Anterior Colporraphy: most common procedure for cystourethrocele

•

Posterior Colporraphy: most common procedure for rectocele

•

Enterocele: Pouch of Douglas is closed surgically after resecting peritoneal sac containing small bowel

•

Uterovaginal prolapse: - Manchester repair - Sacrohysteropexy - Vaginal hysterectomy: if patient does not wish to retain the uterus - Vaginal colpocleisis In case of post-hysterectomy vaginal vault prolapse: - Sacrocolpopexy - Uterosacral ligament suspension

Post operative care – – – – – – –

Receiving notes NPO till gut sounds are audible I/O charting Remove vaginal pack after 24 hours Retain Foley’s for 2-5 days IV antibiotics Analgesics

Complications of Surgery • • • • • • • • • • • • • •

Anesthesia complications Hemorrhage Urinary retention Urinary incontinence Vault infection Thromboembolic phenomenon Dyspareunia Apareunia Constipation Recurrent Prolapse Mesh erosion Vaginal stenosis Subfertility Premature/precipitate labour and cervical dystocia

References • • • •

• • •

• •

• •

POP-Q staging system: http://edu.ipuls.se/Utbildningskatalogen/CourseFiles/POPQ__.ppt Massive uterovaginal prolapse in a young nulligravida with ascites: a case report. J Reprod Med. 2007 Aug;52(8):727-9 Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10. Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 1996; 175:1467 Conservative versus surgical management of prolapse: what dictates patient choice? (Int Urogynecol J Pelvic Floor Dysfunct. 2009 Oct;20(10):1157-61. Epub 2009 Jun 19) http://www.pdfcoke.com/doc/6587132/Uterovaginal-Prolapse Vaginal reconstructive surgery for severe pelvic organ prolapses: a 'uterinesparing' technique using polypropylene prostheses (Eur J Obstet Gynecol Reprod Biol. 2008 Aug;139(2):245-51. Epub 2008 Mar 5) http://www.pdfcoke.com/doc/6586665/Management-of-Uterovaginal-Prolapse Sacrohysteropexy with prolene-1 for the management of uterovaginal prolapse Pak Armed Forces Med J Dec 2005;55(4):314-7. Uterovaginal Prolapse: Epidemiological and Biochemical Parameters Mother & Child Dec 1999;37(4):147-152. The relationship of vaginal prolapse severity to symptoms and quality of life.

Thank You