To know definition of uterovaginal prolapse To know predisposing factors To know symptoms of prolapse To know differential diagnosis of genital prolapse
In the majority of adult women, when standing, the uterus is anteverted, the fundus directed forwards, and anteflexed, the body of the uterus bent forward on the cervix.
Aprolapse is ahernia &is aprotrusion of pelvic organ or structures beyond its normal anatomical bounderies.The pelvis is devided into three compartments, Antrior :contain urethra&bladder Middle :contain utrerine or vault descent&enterocele Posterior :contain rectum
Acystocele occurs when the bladder descends through pubocervical fascia Urethrocele occurs because of loss of support by the pubocervical fascia&posterior pubourethral ligaments Descend of uterus&cervix occur when the lateral cervical ligaments become weakened
Vault prolapse occurs following hysterectomy due to inadequate support by lateral cervical ligaments Rectocele represent increased hiatus between left&right portions of levator ani muscle
It is estimated that prolapse affect 12-30% of multiparous &2% of nulliparous women
Three degrees of prolapse are described&the lowest or most dependant portion of the prolapse is assessed whilst the patient is straining 1st degree descent within vagina 2nd degree descent to the introitus 3rd degree:descent outside introitus which is termed procidentia&is usually accompanied by cystourethrocele&rectoceleThe connective tissue,levator ani&intact nerve supply are vital for the maintenance of position of the pelvic structures&are influenced by pregnancy,child birth&aging. Congenital weakness of the pelvic floor may occur with bladder extrophy. Altered collagen metabolism Congenital shortness of the vagina&deep uterovesical pouch.
Race :adecrease in prevalence of prolapse among black women may be due to to better connective tissue or lumber lordosis that encourage divertion of abdominal forces towards abdominal wall rather than pelvic diaphragm Acquired factors include: 1-Child-birth which lead to denervation&mechanical injury of the pelvic floor.
2-Rise in intra-abdominal pressure associated with chronic obstructive airway disease,smoking,constipation&ascitis. 3-Lack of vitamin c &corticosteroid therapy. 4-Surgery as burch colposuspension 5-loss of supporting hormones as in menopause
Symptoms of prolapse depends on the type&site of prolapse. Discomfort is usually caused by abnormal tention on nerves of the tissues that stretched. Feeling of alump in the vagina which usually worse towards the end of the day&relieved by lying down.
Cystocele may lead to dragging discomfort&urinary symptoms: . The commonest urinary symptom is stress incontinance if there is descent of urethrovesical junction. Voiding difficulty can occur if large cystocele is present&bladder neck is normal in position so the woman has to reduce the mass digitally in order to pass urine with incomplete emptying of bladder which may lead to overflow incontinance.
Alarge cystocele may lead to increased frequency due to persistant residual urine or recurrent urinary tract infection because of stasis. Urgency&frequency are found in association with cystocele which may developed as self induced habit to keep the bladder empty.
Uterine descent cause low backache,protrusion of cervix&blood stained discharge. Enterocele&vault prolapse may produce vague symptoms of discomfort,rarely dehiscence of the vault with acute abdomen&small bowel may be seen at the vulva. Rectocele gives rise to symptoms of backache,lump&incomplete bowel emptying.
The patient is examined in lithotomy or left lateral position with sims speculum.Stress incontenance is demonstrated when the bladder is full&the patient is asked to cough or bear down.Anterior wall descent or uterine descent will be demonstrated by retracting the posterior vaginal wall.
Enterocele &rectocele can be demonstrated by using the speculum to retract the anterior vaginal wall. If the cervix protrude outside the vagina,it may be ulcerated&hypertrophied. Full pelvic examination should be performed to exclude pelvic mass that may cause the prolapse.
Anterior vaginal wall cyst Urethral diverticulum Large uterine polyp Metastasis from uterine tumour
Mid-stream urine specimen sent for culture&sensitivity prior to further investigations. Stress incontinance should be evaluated ,if urinary frequency is present urinary diary is completed with morning acid-fast bacilli.
Anterior vaginal wall can be imaged with perineal ultrasound. Vaginal endosonography ,flouroscopy&MRI can be used.
Shortening of the second stage of delivery&reducing traumatic labour,decrease use of forceps may result in fewer women developing prolapse. Women should avoid smoking ,constipation&heavy work. The benefit of episiotomy &HRT at menopause have not been substantiated.
Prior to specific treatment attempts should be made to correct obesity,chronic cough or constipation . If the prolapse is ulcerated aseven day course of local estrogen should be administrated.
Before safe anesthesia&surgery ,prolapse was managed by avariety of pessaries of different shapes&sizes.But nowadays the indications of pessary treatment are: During&after pregnancy awaiting involution of tissues. As therapeutic test to confirm benefit of surgery.
When the patient has not completed her child-bearing. When she is medically unfit. If the patient wish conservative treatment. While awaiting surgery.
Pessaries are the most popular form of conservative treatment ,made of silicon –rubber or inert plastic.They are inserted into vagina &need replacement at intervals of three months to one year.The most common pessary is ring-shaped of variable sizes.Shelf pessaries are also used in women who cannot retain ring pessary.
Vaginal ulceration Infection Incarciration leading to vaginal discharge&bleeding when pessary has been forgotten ¬ changed.
The aim of surgical repair is to restore anatomy&function.There are vaginal&abdominal operations designed to correct prolapse.Majority of operations are performed through the vagina&the abdominal route is reserved for recurrence or more complex prolapse.
1-Anterior repair or colporrhaphy is the commonest performed surgical procedure used to correct cystocele or cystourethrocele &stress incontinence.An anterior vaginal wall incision is made &the fascial defect allowing the bladder to herniate through is identified&closed.With the bladder position restored any redundent vaginal epithelium is exised&incision is closed.
Can correct very effectively cystocele&stress incontinence,the lateral vaginal fornices are approximated&sutured to ipsilateral iliopectineal ligaments
Posterior colporraphy or posterior repair is the commonest procedure performed.Aposterior vaginal wall incision is made&the fascial defect allowing the rectum to herniate through is identified&closed.with the rectal position restored any redundant vaginal epithelium is excised&the incision closed.
The surgical principles are similar to anterior&posterior repair but the peritoneal sac containing small bowel is excised,the pouch of Douglas is closed by approximating the peritoneum &uterosacral ligaments./
If the woman does not wish to conserve her uterus for fertility then vaginal hysterectomy with adequate support of the vault to the uterosacral ligaments. If uterine conservation is required then the Manchester operation is performed,which involves partial amputation of cervix&approximation of the cardinal ligaments.
Sacrocolpopexy is performed by attaching the vaginal vault to the sacrum using amesh&the pouch of Douglas is closed.