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Management Of Genital Prolapse

9 June, 2012. Management of Genital Prolapse - Prof.S.N.Panda. 2. DEFINITION. Prolapse/Procidentia is downward decent of uterus

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Management Of Genital Prolapse

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    1. Management Of Genital Prolapse Prof. Surendra Nath Panda, M.S. Department of Obstetrics and Gynecology M.K.C.G.Medical College Brahmapur, Orissa, India

    2. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 2 DEFINITION Prolapse/Procidentia is downward decent of uterus &/or vagina (Procidentia is from Latin procidere - to fall) It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia It is not a disease but a disabling condition

    3. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 3 CAUSE WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA Precipitating / Exaggerating / Unmasking Causes - INCREASED INTRA ABDOMINAL PRESSURE Chronic cough Chronic Constipation Heavy Wt.Lifting / domestic Work Obesity, Ascitis WEAKNESS OF THE SUPPORTS & MUSCLES Chronic ill health, malnutrition dysentery, anemia Inadequate rest during pureperium Menopause

    4. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 4 TYPES OF PROLAPSE Vaginal Anterior cystocele & urethrocele Posterior - Enterocele & Rectocele Vault Prolapse - a special term applied to the prolapse of upper vagina Uterine/Utero-vaginal- Acquired or Congenital. First degree. Second degree &. Third degree-(total Prolapse / complete procidentia). However Procidentia is often used only to denote third degree uterine prolapse.

    5. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 5 EFFECTS OF PROLAPSE NO SYMPTOM- mild & moderate prolapse. Discomfort & disability. Sexual Dysfunction. URINARY- Frequency, Dysuria, Stress incontinence, infection. Incomplete emptying of rectum. Discharge. Backache. Ulceration & Infection.

    6. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 6 WHEN TO TREAT ? Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse ) Interferes with the normal activity of the woman The patient seeks treatment

    7. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 7 HOW TO TREAT ? NON-SURGICAL Methods: -Limited Role PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium). HORMONE REPLACEMENT, both systemic and local. PESSARY TREATMENT for temporary relief During Pregnancy, Pureperium & Lactation When Operation is Unsafe due to Extreme Senility/Debility and Diseases Preoperatively For therapeutic test

    8. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 8 HOW TO TREAT ? SURGICAL TREATMENT: -RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.

    9. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 9 SURGICAL TREATMENT It is the definitive & curative treatment of Prolapse. It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first. Pre operative pessary/tampoon & or Hormone treatment should be given as indicated. Meticulous and through examination under anaesthesia should be done before deciding the surgery.

    10. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 10 SURGICAL TREATMENT Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patients requirement. Absolute haemostasis is mandatory.Diathermy should be liberally used. Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable. Catheter for more than 48 hrs should be exceptional. Strict antibiotic prophylaxis is essential

    11. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 11 VAGINAL OPERATIONS FOR PROLAPSE Anterior colporrhaphy Posterior colporrhapry- High / Low Enterocele repair Perineorrhaphy Amputation of cervix Paravaginal repair Hysterectomy with or without Colporrhaphy / Perineorrhaphy

    12. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 12 VAGINAL OPERATIONS FOR PROLAPSE Manchester/ Fothergills operation & Shirodkars modification Uterus/Cervix suspension/fixation Vaginal vault suspension/fixation Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse Vaginectomy ? Colpocleisis ?

    13. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 13 Anterior colporrhaphy & Urethroplasty For correction of Cystocele & Urethrocele Incision- Midline / Inv.T / Elliptical Excision of vagina according to the size & site of laxity Avoid shortening &/or narrowing of vagina Closure with interrupted sutures

    14. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 14 Posterior colporrhaphy & Enterocele repair For correction of Enterocele & Rectocele Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures. Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential Excision of vagina should be tailor made Perineorrhapy to be done only if perineal body is torn

    15. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 15 Perineorrhaphy Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear Performed along with post. colporrhaphy Aim-Reconstruction of the Perineal body and reduction of gaping introitus. Can cause Dyspareunea Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles

    16. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 16 Vaginal Hysterectomy with/without Vaginal repair Indicated when uterus needs removal, in old age & in total prolapse. Patients consent is mandatory knowing that there are alternatives to hysterectomy. Usually combined with Ant. & Posterior colporrhaphy. Perineorrhaphy is not mandatory but case specific. Vault suspension is an essential step. If sexual function is not needed narrowing of vaginal canal should be done.

    17. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 17 Amputation of cervix Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm ) To be done only as a part of Fothergills repair/sling operations. Adequate cervical dilatation - a prerequisite Bladder displacement is a must Excision of cervix should not exceed 2 cm Likely to affect reproductive life Long-term complications are real risks

    18. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 18 Fothergills operation It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required. It is a combination of, Amp. of Cx., Fixation of the Meconrodts ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must. Post. Colporrhaphy to be performed only if Ent/Rectocele is present Perineorrhaphy is usually not required

    19. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 19 Fothergills operation Not useful if ligaments are weak & Uterus is of normal size. Purandares modification may help. Technically difficult operation, requiring high degree of surgical skill. Threat of short-term complications. Real possibilities of long term complications. Recurrence/Failure. Sling operations are better alternatives HAS A BLEAK FUTURE

    20. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 20 ABDOMINAL OPERATIONS FOR PROLAPSE Sling operations Closure or repair of enterocele Sacrocolpopexy Anterior Colpopexy Colposuspension Paravaginal repair

    21. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 21 Abdominal Sling operations Indicated when the ligaments are extremely weak as in nulipara & young women. Preserves reproductive function. Principle-With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis. Amp.of Cx should also be done if Utereocervical length >12.5cm. Cystocele/Rectocele repair if needed can be done vaginally before or after. Enterocele repair can also be done abdominally.

    22. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 22 Abdominal Sling operations It is a major abdominal operation & Synthetic material is costly & not widely available in India. Types-. Shirodkars posterior sling. Purandares anterior cervicopexy. Khannas sling. Virkuds composite sling.

    23. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 23 Shirodkars sling Tape is fixed to the post. Aspect of isthmus & sacral promontory Anatomically most correct but difficult to perform Risks of complication

    24. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 24 Purandares cervicopexy Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall Easy to perform Dynamic support

    25. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 25 Virkuds composite sling operation Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side Utrosacral ligament is plicated Technically easy

    26. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 26 Khannas sling operation Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine Easier to perform and safer But tape is superficial Risk of infection

    27. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 27 Abdominal Colpopexy / Colposuspension Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy. Major abdominal operation & technically difficult. Sexual function is preserved. Methods-. Sacrocolpopexy. Ant.Colpopexy. Colposuspension.

    28. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 28 Sacrocolpopexy Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum Enterocele repair can be done if required

    29. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 29 Ant.Colpopexy Corrects ant. vag laxity & stress inc. Useful at abdominal hysterectomy / for vault prolapse. Extra peritoneal supra pubic approach if done alone. Enterocele repair if required. Vagina stitched to the ileo-pectineal ligaments.

    30. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 30 Vault / Colposuspension Vault is fixed to the abdominal wall by a facial strip or merseline tape

    31. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 31 LAPAROSCOPIC SURGERY PROLAPSE Advantages of M I S-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar Can all types of prolapse be treated?- Yes. Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery However extended period of rest is essential Expertise is needed Presently cannot be widely practised This is the surgery of the future today

    32. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 32 LAPAROSCOPIC SURGERY PROLAPSE PROCEDURES:- Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair VH / LAVH / LH / TLH + Colposuspension VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction Rectocele repair & levatorplasty Enterocele repair with suturing of uterosacral ligaments Colpopexy- Ant / Post

    33. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 33 Laparoscopic Cervicopexy/sling Operations All types of sling operations can be better performed by laparoscopy Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair) Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy

    34. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 34 Laparoscopic Vault suspension/ Culdoplasty) Can be done with VH / LAVH / LH / TLH Corrects mild laxity Prevents vault prolapse

    35. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 35 Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH An alternative to Ward-Mayos operation Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension Lap. levator plication if needed Enterocele repair and suturing of uterosacral ligaments if needed Retro pubic Colposuspension (Bruch) if required

    36. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 36 Laparoscopic Rectocele repair & Levatoroplasty Rectovaginal space is opened & rectum dissected Interrupted sutures given in the levator in the midline Enterocele repair done if indicated Vaginal vault suspension done

    37. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 37 Laparoscopic Enterocele repair Rectovaginal space is opened, sac excised and purse string suture given Uterosacral ligament sutured

    38. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 38 Laparoscopic Post Colpopexy / Sacrocolpopexy Indicated for vault prolapse Enterocele if present is first repaired Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the Rt.para rectal space

    39. 9 June, 2012 Management of Genital Prolapse - Prof.S.N.Panda 39 Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today.

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