Management Of Genital ProlapseManagement Of Genital Prolapse

Associate Professor Semyatov S.M.Department of Obstetrics and Gynecology

with course PerinatologyPeoples’ Friendship University of Russia, Moscow

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.

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

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.

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.

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

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, Puerperium & Lactation• When Operation is Unsafe due to Extreme

Senility/Debility and Diseases• Preoperatively • For therapeutic test

HOW TO TREAT ? • SURGICAL TREATMENT: -

RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.

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.

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 patient’s 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

VAGINAL OPERATIONS FOR PROLAPSE

• Anterior colporrhaphy

• Posterior colporrhapry- High / Low

• Enterocele repair

• Perineorrhaphy

• Amputation of cervix

• Paravaginal repair

• Hysterectomy with or without Colporrhaphy / Perineorrhaphy

VAGINAL OPERATIONS FOR PROLAPSE

• Manchester/ Fothergill’s operation & Shirodkar’s modification

• Uterus/Cervix suspension/fixation

• Vaginal vault suspension/fixation

• Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse

• Vaginectomy ?

• Colpocleisis ?

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

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

Perineorrhaphy• Not an Operation for prolapse, but Indicated

only for associated old 2nd degree perineal tear

• Performed along with posterior 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

Vaginal Hysterectomy with/without Vaginal repair

• Indicated when uterus needs removal, in old age & in total prolapse.

• Patient’s 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.

Amputation of cervix• Not for Prolapse.Indicated only for cervical

elongation (Uterocervical length >12.5 Cm )• To be done only as a part of Fothergill’s

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

Fothergill’s 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 Meconrodt’s 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

Fothergill’s operation• Not useful if ligaments are weak & Uterus is of

normal size. Purandare’s 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

ABDOMINAL OPERATIONS FOR PROLAPSE

• Sling operations

• Closure or repair of enterocele

• Sacrocolpopexy

• Anterior Colpopexy

• Colposuspension

• Paravaginal repair

Abdominal Sling operations• Indicated when the ligaments are extremely weak as

in nullipara & 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.

Abdominal Sling operations• It is a major abdominal operation & Synthetic

material is costly & not widely available in India.

• Types-.– Shirodkar’s posterior sling.– Purandare’s anterior cervicopexy.– Khanna’s sling.– Virkud’s composite sling.

Shirodkar’s sling• Tape is fixed to the post. Aspect of isthmus &

sacral promontory

• Anatomically most correct but difficult to perform

• Risks of complication

Purandare’s cervicopexy• Tape is anchored to the ant.aspect of isthmus

and ant. abd. Wall

• Easy to perform

• Dynamic support

Virkud’s 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

Khanna’s 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

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.

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

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.

Vault / Colposuspension

• Vault is fixed to the abdominal wall by a facial strip or merseline tape

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

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

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

Laparoscopic Vault suspension/ Culdoplasty)

• Can be done with VH / LAVH / LH / TLH

• Corrects mild laxity

• Prevents vault prolapse

Laparoscopic Pelvic Reconstruction

With VH / LAVH / LH / TLH • An alternative to Ward-Mayo’s 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

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

Laparoscopic Enterocele repair • Rectovaginal space is opened, sac excised

and purse string suture given

• Uterosacral ligament sutured

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

Time has come for Laparoscopic Surgery for Prolapse

So move with the times. Practice laparoscopy.

This is the Surgery of the future today.