Utero-Vaginal prolapse pdf - All Lectures

Utero-Vaginal Prolapse

SENIOR CONSULTANT

ASSIATANT PROFESSIOR

ISRAA HASHIM ABID ALKAREEM

FIOG.DOG.DHPE.

Background

• The pelvis encloses organs that primarily

function in storage, distension and evacuation.
The pelvic viscera must maintain their normal
anatomic relationships within this cavity so
that these physiological functions can be
sustained.

Background

The uterus is normally

anteverted,

anteflexed

Version:

is the angle between the

longitudinal axis of cervix, and that of the
vagina

Flexion:

is the angle between the

longitudinal axis of the uterus, and that of
the cervix

Genital Prolapse

• Genital prolapse

is the descent of one or more

of the genital organ (urethra, bladder, uterus,
rectum or Pouch of Douglas or rectouterine
pouch) through the fasciomuscular pelvic floor
below their normal level

• Vaginal prolapse

can occur without uterine

prolapse but the uterus cannot descend
without carrying the vagina with it.

Supports of the uterus

• DeLancey in 1994 defined three levels of

vaginal support, reviving the importance of
the connective tissue structures and giving a
working basis for the present day
understanding of the anatomy and surgical
treatment.

Three level of Supports of Uterus

• Level I: The cardinal uterosacral ligament

complex

• Level II: The pubo- cervical and recto-vaginal

fascia

• Level III: The pubo-urethral ligaments

anteriorly & the perineal body posteriorly

Anterior vaginal wall prolapse

• Prolapse of the upper part of the anterior

vaginal wall with the base of the bladder is
called

cystocele

• Prolapse of the lower part of the anterior

vaginal wall with the urethra is called

urethrocele.

• Complete anterior vaginal wall prolapse is

called

cysto-urethrocele.

Anterior vaginal wall prolapse

• Weakness in the

– Supports of the bladder neck
– Urethero vesical junction
– Proximal urethra

• Caused by

– Weakness of pubocervical fascia and

pubourethral ligaments

Middle compartment defect

• Enterocele and eversion of vagina

• Enterocele (Herniation of POD)

Posterior compartment defect

• Rectocele

• Perineal body descent

Uterine descent

• Utero-vaginal

(the uterus descends first

followed by the vagina): This usually occurs in
cases of virginal and nulliparous prolapse due
to congenital weakness of the cervical
ligaments.

• Vagino-uterine

(the vagina descends first

followed by the uterus):This usually occurs in
cases of prolapse resulting from obstetric
trauma.

Degree of uterine descent

• 1st degree:

The cervix desends below its

normal Ievel on straining but does not protrude

from the vulva (The extemal os of the cervix is

at the level of the ischial spines)

• 2nd degree

: The cervix reaches upto the vulva

on straining

• 3rd degree

: The cervix protrudes from the vulva

on straining

• Procidentia-

whole of the uterus is prolapsed

outside the vulva and the vaginal wall becomes

most completely inverted over it. Enterocele is

usually present

Vault prolapse

• Descent of the vaginal vault, where the top of

the vagina descends )or inversion of the
vagina) after hysterectomy

Pelvic organ prolapse quantitative

(POPQ) exam

• In 1996, by the ICS
• POPQ system describes the location and

severity of prolapse using segments of the
vaginal wall and external genitalia, rather than
the terms cystocele, rectocele, and enterocele

Aetiology

• Erect posture causes increased stress on muscles, nerves and

connective tissue

• Acute and chronic trauma of vaginal delivery
• Aging
• Estrogen deprivation
• Intrinsic collagen abnormalities
• Debilitation
• Iatrogenic

Precipitating factors

▪ ↑ intra abdominal pressure
▪ ↑ weight of the uterus
▪ Traction of the uterus by vaginal prolapse or by a large

cervical polyp

▪ Obesity(40%--75%)
▪ Smoking
▪ Pulmonary disease (chronic coughing)
▪ Constipation (chronic straining)
▪ Recreational or occupational activities

(frequent or heavy lifting)

Symptoms of Prolapse

• Pelvic floor disorders become symptomatic

through either of two mechanisms:

1. Mechanical difficulties produced by the

actual prolapse,

2. Bladder or bowel dysfunction, disrupting

either storage or emptying.

Clinical presentation

• Before actual prolapse. the patient

feels a sensation

of weakness in the perineum

. particularly towards

the end of the day

• Later the patient

notices a mass

which appears on

straining. and disappears when she lies down

• Urinary symptoms

are common and trouble some

even with slight prolapse:

Urgency and frequency by day

Stress incontinence

Inability to micturate

unless the anterior vaginal

wall is pushed upwards by the patient's fingers

Frequency

when

cystitis

develops

• Rectal symptoms

are not so marked. The patient always

feels heaviness in the rectum and a constant desire to
defaecate. Piles develop from straining.

• Backache, congestive dysmenorrhoea and menorrhagia

are common.

• Leucorrhoea

is caused by the congestion and associated

by chronic cervicitis.

• Associated

decubitus ulcer

may result in discharge which

may be purulent or blood stained

Diagnostic approach

• Beginning with a careful inspection of the

vulva and vagina to identify erosions,
ulcerations, or other lesions

• The extent of prolapse should be

systematically assessed

• Suspicious lesions should be biopsied

Examination

• Local examination
• Per speculum examination
• Per vaginal/ Bimanual examination
• Bonney’s stress test
• Evaluation of tone of pelvic muscles
• Recto vaginal examination
• Position of patient for examination

- standing & straining
- dorsal lithotomy

Diagnostic approach

• The maximal extent of prolapse is demonstrated with

standing straining examination

when the bladder is

empty

• Pelvic muscle function should be assessed after the

bimanual examination

→ palpate the pelvic muscles a

few centimeters inside the hymen, along pelvic
sidewalls at the 4 & 8 o’clock

• Resting tone & voluntary contraction of the anal

sphincters should be assessed during

rectovaginal

examination

Evaluation of pelvic floor tone

• Place 1 or 2 fingers in the vagina and instruct the

patient to contract her pelvic floor muscles (i.e., the
levator ani muscles). Then gauge her ability to contract
these muscles, as well as the strength, symmetry, and
duration of the contraction.

• The strength of the contraction can be subjectively

graded with a modified Oxford scale (0 = no
contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 =
good, 5 = strong).

Bladder evaluation

• For all patients with prolapse following information

should be obtained

– Screening for urinary tract infection
– Postvoid residual urine volume
– Presence or absence of bladder sensation

• Bonney’s stress test performed following reduction

of prolapse

• If test positive incontinence surgery should be

performed at the time of prolapse surgery

Testing for Integrity of anal sphincter

• Should be assessed for resting tone and

voluntary squeeze and sensation around the
vulva with the bulbo-cavernous reflex and
crude sensory testing for evidence of
pudendal neuropathy

Prevention

• During labour &puerperium

– Avoid premature bearing down
– Avoid long second stage
– Repairs all tears &incisions accurately in layers
– Use delayed absorbable suture
– Do not express the uterus when attempting to

deliver placenta

– Encourage pelvic floor exercise
– Avoid puerperal constipation-decreases bearing

down

Prevention

• At hysterectomy

– Vault suspension with uterosacral and cardinal

ligaments

– Obliteration of deep cul-de –sac by Moschowitz

sutures

– Sacropexy in high risk situations like collagen

disorders

– Increase acceptability of estrogen replacement

therapy

Treatment

• Physiotherapy

– Kegel’s pelvic floor exercise

• Kegel’s perineometer
• Influence only the voluntary muscles
• No action to the fascial supporting system

– Vaginal cones of increasing weight .

Associated decubitus ulcer

• To relieve congestion, the prolapse can be

reposited in the vagina with the help of
tompoons ar pessary and this helps in healing
of the ulcer

• Hygroscopic agents like acriflavin-glycerine

can help reduce the congestion further

Pessary

• During pregnancy
• Immediately after pregnancy, during lactation
• When future childbearing is intended in near

future

• Refusal to operation by patient
• As a therapeutic test
• To promote healing in a decubital ulcer

Pessary in situ

Complications of pessary

• Constipation
• Urinary incontinance
• B.vaginitis, ulceration of vaginal wall
• Cervicitis
• Carcinoma of vaginal wall
• Impaction of pessary
• Strangulation of prolapsed tissue

Principles of Management

• Physical examination must not be used in

isolation to develop treatment strategy.

• Any decision for surgical intervention

should take account of how prolapse is
affecting lifestyle.

Aim of pelvic reconstructive surgery

• To restore anatomy, maintain or restore

visceral function, and maintain or restore
normal sexual function

Uterine descent- surgeries

• Vaginal hysterectomy
• Sling surgeries

– Shirodkar
– Khanna’s
– Purandares

• Fothergill’s surgery

Vault prolapse

• Separation of the rectovaginal fascia from

pubocervical fascia.

• In post hysterectomy patients it is important

to reattach the rectovaginal fascia to the
pubocervical fascia and to provide good
support to the vaginal apex by reattaching the
vaginal cuff to the uterosacral cardinal
ligament complex.