Staging and Management of Genital Prolapse

1. Staging and Management of Genital Prolapse

2. Dr. V.P.Paily MD; FRCOG Professor Jubilee Mission Medical College, Thrissur, Kerala. Consultant, Mother Hosp and Raji Nursing Home , Thrissur, Kerala

3. Prolapse • Very common problem. • Confusion regarding assessing degree / stage

6. Conventional Staging • Cervix is the main point.

7. Conventional staging • Difference between British and American System.

8. Baden Walker Halfway System

10. Prolapse quantification • Pelvic organ prolapse quantification(POP-Q) • Recommended by ICS, society of Gyn.Surgeons &Amer. Urogyn. Surgeons

11. Pelvic organ prolapse • Quantification • POP Q

12. Quantification • Vault, Cx or Posterior fornix • Anterior & Posterior walls • Introitus • Perineal body • Length of vagina

13. Quantification • Anterior (a) -- Point A & B • Posterior (p) -- Point A & B • Point C -- Lips of Cervix • Point D -- Post.fornix

14. Quantification • Length of vagina • Diameter of introitus • Perineal body

15. POP- Q

16. Quantification

18. POP-Q Drawbacks • Appears complicated • Doesn’t include lateral prolapse.

19. Comprehensive pattern required incorporating defects at various levels & compartments

20. Look for defects At 3 levels Upper Middle Lower

21. Look for defects At two compartments • Anterior • Posterior

22. Compartmental approach Level 1 • Descent of cervix • Descent of vault • Enterocele

23. Compartmental Approach Level 2 • Anterior segment – cystocele • Posterior segment – rectocele • Lateral detachment

24. Compartmental Approach Level 2 • High rectocele can extend up to post fornix and has to be differentiated from enterocele.

25. Compartmental Approach Level 2 • Midline defects are due to tear or weakness of fascial envelope – pubo vesico cervical fascia and rectovaginal fascia ( Denonvilliers).

26. Compartmental Approach Level 3 • Anteriorly – Urethrocele • Posteriorly – Detached perineal body

27. Compartmental Approach Level 3 • Detached Perineal body • Reattach to recto vaginal fascia

28. Practical approach to Level 3 defects • Common complaint Sound of air being sucked in

30. Compartmental Approach Lateral detachment • Reattach to Arcus Tendineus • Fascia pelvis or Arcus Tendineus • Fascia Rectovaginalis

32. Compartmental Approach Anterior Lateral detachment • Richardson’ s operation • Transvaginal • Transabdominal • Endoscopic

33. Compartmental Approach Posterior Lateral detachment • Reattach to Arcus tendineus fascia rectovaginalis

34. Symptomatology Record symptoms related to • Anatomical descent • Urinary function • Sexual function • Reproductive need • GI symptoms • Air suction

37. Management • Restore anatomy by correcting the defect.

39. Special Situations

40. Nulliparous prolapse

42. Older age with weak tissues

43. Mesh for Repair • Concept borrowed from Hernia repair • Special mesh being developed. (Gyne mesh) • We have tried prolene mesh.

44. Conclusions • Detailed record of defects • Detailed record of symptoms • Individualised surgery

45. Thank you