Genital Prolapse

بسم الله الرحمن الرحيمبسم الله الرحمن الرحيم

International University of International University of AfricaAfrica

Faculty of Medicine Faculty of Medicine and Health Sciencesand Health Sciences

Genital Genital prolapse prolapse

Presented by:Presented by:

Dr. Alwaleed M.AlfakiDr. Alwaleed M.Alfaki

Gya. & Obs.Gya. & Obs.www.doctor.sdwww.doctor.sd

Genital ProlapseGenital Prolapse - -Genital prolapse is a herniaGenital prolapse is a hernia

--It is defined as a protrusion of a pelvic organ or It is defined as a protrusion of a pelvic organ or structure beyond its normal anatomical structure beyond its normal anatomical

boundariesboundaries . .

TypesTypes-: -:

11..Uterine prolapseUterine prolapse 22..Vaginal prolapseVaginal prolapse

33..Vault prolapseVault prolapse

www.doctor.sdwww.doctor.sd

Uterine prolapseUterine prolapse-: -:

- Descent of the uterus & the cervix .Descent of the uterus & the cervix .- Usually due to weakness of the cervical Usually due to weakness of the cervical

ligament.ligament.- 3degrees of uterine descent are recognized .3degrees of uterine descent are recognized .

a) a) First degree :-First degree :-Slight descent of the uterus but the cervix remain Slight descent of the uterus but the cervix remain

with in the vagina .with in the vagina .


b) Second degreeb) Second degree-:-: The cervix projects through the vulva on starting The cervix projects through the vulva on starting

or standingor standing. .

c) Third degree (procidentia)c) Third degree (procidentia)

The entire uterus prolapse out side the vulvaThe entire uterus prolapse out side the vulva. .

The whole vagina or at least the whole of its The whole vagina or at least the whole of its anterior wall is invertedanterior wall is inverted. .

22 . .Vaginal prolapseVaginal prolapse-: -: Divided to anterior wall prolapse & posterior wall Divided to anterior wall prolapse & posterior wall

prolapseprolapse. .


i) Anterior wall prolapse i) Anterior wall prolapse a) Cystocele :-a) Cystocele :-

- the bladder base descends with the upper 2/3 of - the bladder base descends with the upper 2/3 of the anterior vaginal wall .the anterior vaginal wall .

- It represents a weakness in the investing fascia .It represents a weakness in the investing fascia .

b) Urethrocele :-b) Urethrocele :- - The urethra descends with the lower third of the The urethra descends with the lower third of the

anterior vaginal wall. anterior vaginal wall. - Usually due to loss of support by the pubo Usually due to loss of support by the pubo

cervical fascia & more important the posterior cervical fascia & more important the posterior pubourethral ligament .pubourethral ligament .


ii) Posterior vaginal wall ii) Posterior vaginal wall prolapseprolapse- It can affect the upper or lower vagina .It can affect the upper or lower vagina .- It represents increased hiatus between the left It represents increased hiatus between the left

& right portion of the levator ani muscle .& right portion of the levator ani muscle .

a) Enterocele :-a) Enterocele :- due to upper posterior wall prolapse & Usually due to upper posterior wall prolapse & Usually

associated with herniation of pouch of douglas associated with herniation of pouch of douglas & its content (bowel & omentum) .& its content (bowel & omentum) .


b) Rectoceleb) Rectocele-: -:

prolapse of the rectum through the lower prolapse of the rectum through the lower posterior vaginal wallposterior vaginal wall. .

c) Vault prolapsec) Vault prolapse-: -: prolapse of the vaginal vault after prolapse of the vaginal vault after

hysterectomy (inversion of the vagina)hysterectomy (inversion of the vagina) . .


AetiologyAetiology-:-:

It is due to failure of one or more of the supports It is due to failure of one or more of the supports of the uterus & vagina . of the uterus & vagina .

Predisposing factors :-Predisposing factors :-1) Congenital weakness of uterine & vaginal 1) Congenital weakness of uterine & vaginal

supports .supports .- Operates in both nulliparous & multiparous Operates in both nulliparous & multiparous

prolapse .prolapse .- Nulliparous prolapse is very rare & usually Nulliparous prolapse is very rare & usually

associated with spina bifida (detects in associated with spina bifida (detects in innervation) innervation)


2. Injury sustained during child birth repeaetd 2. Injury sustained during child birth repeaetd delivery leads to over stretching and delivery leads to over stretching and denervation of the supporting tissue .denervation of the supporting tissue .

3. Atrophy of the supporting tissue at the 3. Atrophy of the supporting tissue at the menopause due to defficency of oestrogen.menopause due to defficency of oestrogen.

Activating orprecipitating factors :-Activating orprecipitating factors :-If aweakness is present the circumstanles likely If aweakness is present the circumstanles likely

to precipitate the onset of prolapse one .to precipitate the onset of prolapse one .* Increase intra-abdominal press caused by * Increase intra-abdominal press caused by

chronic cough Ascites , straining at chronic cough Ascites , straining at stool ,lifting heavy weights .stool ,lifting heavy weights .

*Traction of the uterus by large cervical polyps. *Traction of the uterus by large cervical polyps. www.doctor.sdwww.doctor.sd

PresentationPresentation-:-:Symptoms:- Symptoms:- Dragging discomfort and a feeling of some Dragging discomfort and a feeling of some

thing coming down . The swelling may be the thing coming down . The swelling may be the cervix , cystocele or rectocele or all the three . cervix , cystocele or rectocele or all the three . Also a feeling of bearing down sensation . Also a feeling of bearing down sensation .

A cystocele or cystourethrocele can also presents A cystocele or cystourethrocele can also presents with urinary symptoms such as stress in with urinary symptoms such as stress in continence , urgency & frequency , & continence , urgency & frequency , & difficulty in emptying the bladder difficulty in emptying the bladder necessitating digital pressure . necessitating digital pressure .


In severe utro-vaginal prolapse the urethra may In severe utro-vaginal prolapse the urethra may becomes so acutely angled that retention of becomes so acutely angled that retention of urine results .urine results .

Rectocele can also presents with backache & Rectocele can also presents with backache & difficulty in emptying the rectum (the bowel difficulty in emptying the rectum (the bowel evacuated by helding back the rectocele evacuated by helding back the rectocele digitally) .digitally) .

Uterine descend also can presents with backache Uterine descend also can presents with backache which is relived by lying down & by blood which is relived by lying down & by blood stained vaginal discharge when there is a stained vaginal discharge when there is a decubital ulceration . decubital ulceration .


ExaminationExamination-: -: * *Examination is best carried out with the patient Examination is best carried out with the patient

in the left lateral position or sims position using in the left lateral position or sims position using sims speculumsims speculum . .

* *The presence , type & extent of prolapse & The presence , type & extent of prolapse & presence of stress incontinence if any can presence of stress incontinence if any can usually be determined by asking the patient to usually be determined by asking the patient to

bear down or to cough during examinationbear down or to cough during examination. .

**If there is doubt the patient should be asked to If there is doubt the patient should be asked to stand or walk for some time before stand or walk for some time before

examinationexamination . . www.doctor.sdwww.doctor.sd

* *Occasionally it is necessary to test for uterine Occasionally it is necessary to test for uterine descent by pulling the cervix with volsellumdescent by pulling the cervix with volsellum. .

Hazards of prolapseHazards of prolapse-: -:

Provided that there is no urinaryProvided that there is no urinary tract obstruction tract obstruction or infection prolapse carries no risk to life. or infection prolapse carries no risk to life.

PreventionPrevention-:-:

- -Avoidance of obesity & cigaretteAvoidance of obesity & cigarette smokingsmoking. .

--Appropriate use of hormone replacement therapyAppropriate use of hormone replacement therapy . .--Encourage postnatal pelvic floor exerciseEncourage postnatal pelvic floor exercise. . --Avoid long second stage of labour by doing Avoid long second stage of labour by doing

Episiotomy .with low forceps ,ventouse when Episiotomy .with low forceps ,ventouse when neededneeded www.doctor.sdwww.doctor.sd

Treatment:-Treatment:-1/Pessary treatment1/Pessary treatment-:-:

- -Ring pessaries are made of inert plastic , are of Ring pessaries are made of inert plastic , are of different size , can be left in place for up to one different size , can be left in place for up to one yearyear..

- -Shelf pessaries are helpful in severe utrovaginal Shelf pessaries are helpful in severe utrovaginal prolapseprolapse. .

- -The two main complication of pessaries are The two main complication of pessaries are vaginal ulceration & incarceration leading to vaginal ulceration & incarceration leading to

discharge & bleedingdischarge & bleeding . .


- -Indication of pessaries treatment areIndication of pessaries treatment are-:-: During & after pregnancy awaiting involution During & after pregnancy awaiting involution

of tissues .of tissues . As a therapeutic test to confirm that surgery As a therapeutic test to confirm that surgery

might help .might help . When the patient is medically unfit or refuses When the patient is medically unfit or refuses

surgery .surgery . for relief of symptom while the patient is for relief of symptom while the patient is

awaiting surgery .awaiting surgery .


Surgical Treatment:-Surgical Treatment:- prolapse is not life threating condition but surgery prolapse is not life threating condition but surgery

has its mortality & morbidity .has its mortality & morbidity .

a) Anterior repair (anterior colporrhaphy):-a) Anterior repair (anterior colporrhaphy):-- Correct cystocele or cystourethrocele .Correct cystocele or cystourethrocele .- The vaginal skin is divided in the midline , the The vaginal skin is divided in the midline , the

bladder is reflected upwards & the pubocervical bladder is reflected upwards & the pubocervical fascia on either side inforced with interrupted fascia on either side inforced with interrupted stutures , redundant vaginal skin is excised & stutures , redundant vaginal skin is excised & vaginal skin is closed .vaginal skin is closed .

- Postoperative urinary retention is common . Postoperative urinary retention is common . www.doctor.sdwww.doctor.sd

b) b) Posterior repair(colpo-perineorrhaphyPosterior repair(colpo-perineorrhaphy

- Correct rectocele Correct rectocele - A vertical posterior vaginal wall incision A vertical posterior vaginal wall incision

is used to descet the posterior vaginal is used to descet the posterior vaginal wall from the rectum , the edges of the wall from the rectum , the edges of the levator ani muscles are sutured together levator ani muscles are sutured together in the midline & the posterior vaginal in the midline & the posterior vaginal skin is closed . skin is closed .


c) Vaginal hysterectomy with repairc) Vaginal hysterectomy with repair-:-:

- It is now the standard operation for utro-It is now the standard operation for utro-vaginal prolapse .vaginal prolapse .

- It is also the operation of choice when an It is also the operation of choice when an enterocele present .enterocele present .

- Best well when there is procidentia .Best well when there is procidentia .

d) Manchester (fothergill) repair :-d) Manchester (fothergill) repair :-

- Appropriate for the small number of women - Appropriate for the small number of women with severe utro-vaginal prolapse who wish to with severe utro-vaginal prolapse who wish to have further children .have further children .


- - It combines shortening of the transverse It combines shortening of the transverse cervicalcervical ligament with amputation of the ligament with amputation of the cervix & anterior colporraphy .cervix & anterior colporraphy .

-full amputation of the cervix may not be -full amputation of the cervix may not be necessary in less severe cases .necessary in less severe cases .

-Caesarean section is necessary in any -Caesarean section is necessary in any subsequent pregnancy . subsequent pregnancy .

e) Leefort operation e) Leefort operation


Support of the uterusSupport of the uterus-:-:

The uterus is held in position of The uterus is held in position of anteflection and anteversion by its wieght anteflection and anteversion by its wieght , by the round ligaments which hold the , by the round ligaments which hold the fundus forwards and the uteroscaral fundus forwards and the uteroscaral ligaments which keep the supra vaginal ligaments which keep the supra vaginal cervix far back in the pelvis while the cervix far back in the pelvis while the transverse cervical ligament prevent its transverse cervical ligament prevent its descent . descent .


Support of the Support of the vaginavagina

In its upper part it is supported by the lower In its upper part it is supported by the lower components of the transverse cervical components of the transverse cervical ligament which fuse with its fascial sheath .ligament which fuse with its fascial sheath .

- Below this it is held by the fibres of the levator - Below this it is held by the fibres of the levator ani which are inserted into its side walls by the ani which are inserted into its side walls by the urogenital diaphram and by the perineal urogenital diaphram and by the perineal muscle . muscle .


Date post:	12-Nov-2014
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Genital Prolapse

Health & Medicine