Genital Prolapse

1. Genital Prolapse

2. UTREUS

4. Aetiology of prolapse • Predisposing • Acquired • Congenital • Aggravating Acquired • Vaginal delivery (injury to the supporting structures)

5. Cont.. • Overstretching of the Mackenrodt’s and uterosacral ligaments • Premature bear down • Application of forceps or ventose • Fundus pressure • Preciptate labour

6. Cont.. 2. Overstretching of the endopelvic fascial sheath of the vagina • Based on two factors Degree of distension of birth canal. Duration of such distension.

7. Cont.. 3. Overstretching of the perineum Prolonged station of the head. Avoidance or delay in episiotomy. Imperfect repair of the perineal injuries

8. Cont.. 4. Subinvolution of the supporting structures. Noticeable in : • Ill-nourished and asthenic women • Early resumption of activities • Repeated childbirth. • Persistent overfilling of the bladder stretching of the pubo-cervical fascia

9. cont inadequate involution Congenital. Congenital weakness of the supporting structures is responsible for nulliparous prolapse or prolapse following an easy vaginal delivery.

10. cont • Aggravating factors. Postmenopausal atrophy Increased intra-abdominal pressure Increased weight of the uterus ( fibroid/ myohyperplas Traction by the anterior vaginal wall/Cervical polyp. Undernutrition.

11. Clinical types • Genital prolapse is broadly grouped into: Vaginal prolapse Uterine prolapse. Vaginal prolapse - Anterior wall • Cystocele • Urethrocele • Posterior wall Relaxed perineum Rectocele

12. Cont.. Vault prolapse. - Enterocele. Uterine prolapse Two types uterovaginal congenital

13. Cont… • Uterovaginal The commonest type Cystocele occurs first followed by traction effect on the cervix causing retroversion of the uterus. • Congenital Usually no cystocele The uterus herniates down along with inverted upper vagina.

14. Degrees of uterine prolapse • 1st degree : The uterus descends down from its normal position, the external os still remains inside the vagina. • 2nd degree: The external os protrudes outside the vaginal introitus, the uterine body still remains inside the vagina. • 3rd degree: The uterine body descends to lie outside the introitus.

15. Morbid changes • Vaginal mucosa: Mucosa becomes stretched. If exposed to air- thickened and dry there may be pigmentation. • Decubitus ulcer: A trophic ulcer found at the dependent part of the prolapsed mass lying outside the introitus. There is initial surface keratinisation cracks infection sloughing ulceration.

16. Cont.. • Cervix: Vaginal part- chronic congestion leads to hyperplasia and hypertrophy of the fibro-muscular-glandular components. Supravaginal part- elongated due to the strain imposed by the pull of the cardinal ligaments to keep the cervix in position. • Urinary system Bladder: incomplete emptying of the bladder. Incomplete evacuation favours cystitis.

17. Cont.. • Uterus: carries downwards along with elongated Mackenrodt’s ligament, mechanically obstructed by the hiatus of the pelvic floor. Compressed even by the uterine arteries at their crossing. results- hydroureteric changes.

18. Cont.. • Incarceration Infection of the paravaginal and cervical tissues makes the entire prolapsed mass oedematous and congested. result – irreducible mass. • Peritonitis. Peritoneal infections may occur through the posterior vaginal wall. Pelvic peritonitis produces adhesions between the gut of the enterocele obstruction.

19. Cont.. • Carcinoma; rarely develops on decubitus ulcer. Symptoms: • Feeling of something coming down per vaginam • Backache/ dragging pain in the pelvis. • Urinary symptoms • Bowel symptoms. • Excessive white or blood stained discharge

20. diagnosis

21. Clinical examination and diagnosis • A composite examination- inspection, vaginal,rectal , recto-vaginal or even under anaesthesia may required. • A negative finding on inspection in dorsal postion should be reconfirmed by asking the patient to strain on squatting position. • Prolapse of one organ is usually associated with prolapse of the adjacent organs. • Aetiological aspect of prolapse should be evaluated.

22. cystocele • Bulge of varying degree of the anterior vaginal wall which increases when the patient is asked to strain. • Seen on inspection. • The mucosa over the bulge has got transverse rugosities. • The bulge has got impulse on coughing , with diffuse margins and is reducible.

23. Cysto-urethrocele • The bulging of the anterior vaginal wall involves the lower third also. • Urine escape out through the urethral meatus when patient is asked to cough- stress incontinence. • To elicit the test the bladder should be full. Relaxed perineum The lower part of the posterior vaginal wall is visible with or without straining.

24. Treatment • Preventive • Conservative • Surgery Preventive: • Effective antenatal care:- Nutritional supplement Antenatal hygiene Physiotherapy with relaxation exercises.

25. Cont.. • Adequate intranatal care: To prevent premature bearing down efforts To prevent premature application of forceps before the cervix is fully dilated. To avoid prolonged second stage. To avoid too much fundal pushing in an attempt to expel the placenta. To perform timely and adequate episiotomy To repair any perineal injuries immediately and accurately.

26. Cont.. • Adequate postnatal care: To prevent undue distension of the bladder To encourage early ambulance. To encourage pelvic floor exercises. • General measures: To avoid strnuous activities for at least 6 months following delivery. To avoid future pregnancy too soon. • Conservative: Genital prolapse is a sort of hernia

27. Cont.. There is practically no scope of conservatie treatment. This includes: • Assurance • Improvement of nutritional status • Pelvic floor exercises in an attempt to strengthen the muscles. Pessary treatment Ring pesssary used, is not the treatment of prolapse.

28. Cont.. • Early pregnancy: Should be placed inside upto 18 weeks when the uterus becomes sufficiently enlarged to sit on the brim of the pelvis. • Puerperium: to facilitate involution. • Patients absolutely unfit for surgery, • Patients unwillingness for operation • While waiting for operation.

29. Cont… • Surgery: Surgery is the corrective treatment of symptomatic prolapse unless there is sufficient reason to withhold it. Surgical correction is to be withheld in asymptomatic prolapse detected accidententally. Young age with future reproductive potentialities is no bar for surgery in symptomatic cases. Meticulous examination, if necessary under anaesthesia is necessary to establish the correct diagnosis of the organ prolpased so that effective and appropriate repair can be carried out with reasonable success. There is no uniform procedure to correct all types prolapse.

30. Types of operation • Anterior colporrhaphy • Colpoperineorrhaphy • Repair of enterocele • Pelvic floor repair. • Vaginal hysterectomy with PFR. • Repair of vault prolapse • Le fort operation • Cervicopexy

31. complications • operative • Haemorrhage • Trauma. Post operative Urinary retention Haemorrhage Sepsis

32. Cont… • Complications of vaginal hysterectomy with PFR Immediate : Vault cellulitis Pelvic abscess Thrombophlebitis Pulmonary embolism Late: Vault prolapse

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