Prolapse

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Genital prolapse Mohamed Salama Gad

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Cystocele —Bulging of the bladder into the vagina. Cystourethrocele —Bulging of the bladder neck into the vagina. Enterocele —Bulging of the intestine into the upper part of the vagina. Kegel exercises —Pelvic muscle exercises that strengthen bladder and bowel control. Pessary —A device inserted into the vagina to support sagging organs. Rectocele —Bulging of the rectum into the vaginal wall. Uterine prolapse —Bulging of the uterus into the vagina. Vaginal prolapse —Bulging of the top of the vagina into the lower vagina or outside the opening of the vagina .

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Prolapse and Pelvic Relaxation

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Surgical Photo Gallery Prolapsed Uterus Prolapsed

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Genital prolapse has many similarities to hernias. They are both due to weakness of the supporting tissues. Genital prolapse is due to weakness of the pelvic floor. The pelvic floor is composed of muscles, collagen, connective tissue and fascia. A weakness of these supporting tissues allows the tissues and organs surrounding the vagina to herniate into the vagina resulting in prolapse

Definition:

Definition Prolapse is downward decent of the uterus and/or vagina Procidentia is extreme degree of genital prolapse it is Latin word means to fall Pelvic organ prolapse is a state of pelvic relaxation due to a disorder of pelvic support Genital prolapse is not a disease but rather a disabling condition Recurrent prolapse

Introduction:

Introduction In erect posture the genital system of the female is hanging in the hiatus of the pelvis and carrying above it the weight of the abdominal viscera which is accentuated by bearing and efforts What protects from genital prolapse is -the pelvic valve, -pelvic fascia –AVF position of uterus, -pelvic floor muscles.

Erect posture ::

Erect posture : Lumbar lordosis Curved sacrum Strong pelvic floor Unfortunately enough: The pelvic floor in the female is weakened by the vaginal aperture. Both urinary and anal incontinence are more common in females than males.

Pelvic valve:

Pelvic valve The upper half of the vagina is bent backward to rest on the rectum and levator plate Deficient pelvic valve

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Parietal fascia Obturator fascia Superior fascia of pelvic diaphragm Superior fascia of urogenital diaphragm Visceral fascia (Endopelvic) Cardinal ligaments Pubocervical fascia Rectovaginal fascia (Denonvillier) Pelvic fascia , Delancey (1992)

Evidence in favor of supporting function of cervical ligaments:

Evidence in favor of supporting function of cervical ligaments When these ligaments are weakened by repeated childbirth the woman is prone to genital prolapse We cannot remove the uterus surgically except when these ligaments are cut When these ligament are infiltrated by malignant growth the uterus gets fixed in its place

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The levator ani muscle 1- Back of the Pubis Pubococcygeus Pubovisceralis 2- White line (ATFP) Iliococcygeus 3- Ischial spine Ischiococcygeus Levator ani contracts simultaneously with thigh adductors and reciprocally with abdominal wall muscles Cough and sneeze are different from labor and defecation

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Urogenital diaphragm Braces the vagina and urethra (PUL) Provides the stage for sexual quartet Stabilizes the perineal body

AETIOLOGY What Causes Pelvic Support Problems? :

AETIOLOGY What Causes Pelvic Support Problems? There are two primary causes of pelvic support problems. The first is damage to pelvic support systems caused by pregnancy, labor and vaginal childbirth. The second cause is hormonal changes at menopause Other factors include obesity, smoking, chronic constipation, and repeated heavy lifting or strenuous exercise. AETIOLOGY OF RGP

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Intrapartum Injury Levator ani muscle Muscle tears Connective tissue Breakage Stretching Pudendal nerve Denervation Loss of muscle tone Shy-Drager synd. Chronic denervation Tabes dosalis Menopause and aging Connective tissue failure GENITAL PROLAPSE Childbirth is the major cause of pelvic floor damage Good midwifery is preventive gynecology

Childbirth is the main contributor to pelvic relaxation:

Childbirth is the main contributor to pelvic relaxation First labor Unattended delivery Forceps operation Outlet contraction Macrosomia Face to pubis delivery Hidden damage can follow uncomplicated vaginal delivery

Perineal laceration and vaginal prolapse:

Perineal laceration and vaginal prolapse

Urogenital hiatus Pelvic floor aperture:

Urogenital hiatus Pelvic floor aperture Normal Short levator plate Levator plate Sagging levator plate

Loss of lumbar lordosis, appears to be a significant risk factor in the development of pelvic organ prolapse. :

Loss of lumbar lordosis, appears to be a significant risk factor in the development of pelvic organ prolapse. Am J Obstet Gynecol 2000 (Dec);   183(6):   1381–4

Manifestations of genital prolapse:

Manifestations of genital prolapse Pelvic pressure Pelvic pain Pelvic floor dysfunction Urinary and rectal troubles Mass protruding from the vulva Complications Trophic ulceration UTI Incarceration Cervical elongation The patient should be examined in both lithotomy and standing positions At rest and during straining

Clinical evaluation in genital prolapse:

Clinical evaluation in genital prolapse History Personal: age, parity, need for children Symptoms: related to organ descend, related to organ dysfunction, related to complications, how far the patient is embraced. Obstetric history: Menstrual: Past history: Sexual history: Every parous woman should be questioned about her pelvic floor function and dysfunction.

Clinical Types of Genital Prolapse:

Uterine descend I o descend in the vagina II o descend outside vagina III o Procidentia Vaginal prolapse Anterior wall Urethrocele Cystocele Posterior wall Enterocele Rectocele Vault prolapse Clinical Types of Genital Prolapse Utero-vaginal (poor suspension) Vagino-uterine (poor support)

Vaginal wall prolapse:

Vaginal wall prolapse

Pelvic organ prolapse Quantification system (POPQ):

Pelvic organ prolapse Quantification system (POPQ) Six points in cm above the hymen (negative number) or below the hymen (positive number) Aa, Ba, C, and D, Bp, Ap

Normal support with no genital prolapse:

Normal support with no genital prolapse -3 Aa -3 Ba -8 C 2 Gh 3 Pb 10 TVL -3 Ap -3 Bp -10 D A B C Genital hiatus Perineal body Total vaginal length A B D

Grading and staging of genital prolapse:

Grading and staging of genital prolapse Grade Grading system (Beecham 1980) Stage POPQ (AUGS 1996) 0 No prolapse 0 No prolapse 1 Descent in the vagina 1 < -1 cm II Descent to the introitus II > -1cm III Descent past the introitus III > +1 cm IV Procidentia IV > +[TVL-2] cm

Non-surgical treatment:

Non-surgical treatment Prophylactic treatment Physiotherapy Hormonal treatment Pessary treatment

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Prophylactic treatment Proper selection for vaginal delivery Proper conduct of labor Effective pudendal block Timely episiotomy when indicated Prophylactic outlet forceps (DeLee) Vaginal PGE2

Cesarean Delivery and Pelvic Organ Prolapse :

Cesarean Delivery and Pelvic Organ Prolapse Cesarean delivery during active labor does not protect women from developing pelvic organ prolapse related to childbirth. (Level of Evidence: 1b) Obstet Gynecol November 2002;100(5 pt 1):981-6.

Different types of pessaries to suit various genital defects:

Different types of pessaries to suit various genital defects During pregnancy Surgically unfit patient In preparation for surgery Pessary test

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قُلْ اللَّهُمَّ مَالِكَ الْمُلْكِ تُؤْتِي الْمُلْكَ مَنْ تَشَاءُ وَتَنْزِعُ الْمُلْكَ مِمَّنْ تَشَاءُ وَتُعِزُّ مَنْ تَشَاءُ وَتُذِلُّ مَنْ تَشَاءُ بِيَدِكَ الْخَيْرُ إِنَّكَ عَلَى كُلِّ شَيْءٍ قَدِيرٌ (26)

Surgical treatment , to avoid recurrence:

Surgical treatment , to avoid recurrence Depends on the type & extent of Prolapse Surgery should be tailored to suit patient’s need. Perfect control of bleeding. Diathermy should be liberally used. Vaginal suturing should be interrupted. Synthetic absorbable fine sutures are preferable. In recurrent cases use mesh. Catheter for more than 48 hrs is rarely needed. Strict antibiotic prophylaxis is essential

Basics of surgical treatment of genital prolapse :

Basics of surgical treatment of genital prolapse Hysterectomy DOES NOT need to be performed when treating pelvic organ prolapse Utero-vaginal (poor suspension) Vagino-uterine (poor support)

Anterior Colporrhaphy :

Anterior Colporrhaphy Exposure of the vesical fascia Repair of the vesical fascia Closure of the vaginal skin

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Anterior Vaginal Repair ( colporrhaphy )

Posterior Colporrhaphy :

Posterior Colporrhaphy Exposure of the damaged fascia Repair of pre-rectal fascia and perineal muscles Closure of the vaginal skin

Perineorrhaphy:

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. Essential steps - Excision of the scar tissue - Approximation of levator ani - Superficial perineal muscles

Vaginal Hysterectomy with Vaginal repair (Ward-Mayo’s operation):

Vaginal Hysterectomy with Vaginal repair ( Ward- Mayo’s operation) 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 colporrhaphy. Perineorrhaphy is recommended Vault suspension is an essential step. If sexual function is not needed narrowing of vaginal canal should be done.

Manchester-Fothergill operation:

Manchester-Fothergill operation It is an alternative to hysterectomy in women who desire to preserve fertility. The procedure involves dissecting the bladder off the cervix, which is then amputated. The cardinal ligaments are sewn to the anterior cervical stump and the vaginal cuff is sewn over the cervical stump so as to create a new os. Sturmdorff sutures are used to reconstruct the cervix portio. T he operation is performed in conjunction with an anterior and posterior vaginal repair

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Posterior Vaginal Repair and Perineoplasty

Abdominal Halban Culdoplasty for enterocele:

Abdominal Halban Culdoplasty for enterocele

Culdoplasty during abdominal hysterectomy:

Culdoplasty during abdominal hysterectomy Halban Culdoplasty McCall Culdoplasty

Vaginal Halban-type closure :

Vaginal Halban-type closure

Transabdominal sacral colpopexy:

Transabdominal sacral colpopexy The procedure involves attaching the vagina to the sacrum using a retroperitoneal bridge of Mersilene mesh, which reestablishes the horizontal vaginal axis.

Surgical approach to sacrospinous ligament:

Surgical approach to sacrospinous ligament

Transvaginal sacrospinous colpopexy :

Transvaginal sacrospinous colpopexy The inferior gluteal vessels and nerves are superior to the ligament The lumbosacral plexus lies on the piriformis muscle just above the ligament The pudendal vessels and nerves and the sciatic nerve lie posterior to the ligament

Pulley and safety stitches:

Pulley and safety stitches

Retropubic paravaginal repair :

Retropubic paravaginal repair

Abdominal Sling operations:

Abdominal Sling operations It is a major abdominal operation Types- Shirodkar’s sling to sacral promontory Purandare’s sling to abdominal Wall Khanna’s sling to anterior superior iliac spine Virkud’s composite sling Right side to sacral promontory Left side to abdominal wall All types of sling operations can be performed by laparoscopy

LeFort’s partial colpocleisis:

LeFort’s partial colpocleisis The LeFort procedure refers to the excision of rectangular strips of vaginal epithelium from the anterior and posterior vaginal walls. The exposed fascial and muscular layers are closed, while leaving a narrow epithelial tunnel along each lateral vaginal wall. This operation is indicated in uterine descend in an old patient disinterested in sex

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Vault prolapse

Vault prolapse:

Vault prolapse Enterocele Cystocele Uterine descend Stump prolapse Proper vault prolapse

Enterocele:

Enterocele Enterocele is a herniation of Douglas pouch down into the rectovaginal septum It may present as a bulging in the upper posterior vaginal wall or anterior rectal wall (sliding hernia) Extremely large enterocele may present as a bulging on both sides of the perineum (saddle hernia)

Types of enterocele:

Types of enterocele Congenital (deep cul-de-sac) Traction (associated with genital prolapse) Pulsion (due to excess abdominal pressure) Iatrogenic Following colposuspension Following hysterectomy

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Enterocele

Vault support after hysterectomy :

Vault support after hysterectomy Uterosacral ligaments Pubocervical fascia Rectovaginal fascia

Enterocele protruding into the RVS between the vagina and rectum:

Enterocele protruding into the RVS between the vagina and rectum

Vault prolapse with enterocele:

Vault prolapse with enterocele

Symptoms of enterocele:

Symptoms of enterocele Pelvic or vaginal pressure Dyspareunia Backache Increasing discomfort with standing Decreased discomfort upon lying down

Manifestations of enterocele:

Manifestations of enterocele A mass seen bulging behind the cervix The mass felt on rectovaginal examination Within the sac a loop of gut may be felt Rectal finger cannot enter the pouch Association with genital prolapse It may follow hysterectomy Enterocele behind well suspended vault Vault prolapse dragging enterocele out Complete vaginal eversion

Predisposing factors:

Predisposing factors Obesity Chronic coughing Chronic constipation Heavy lifting Estrogen deficiency

Differential diagnosis:

Differential diagnosis Rectocele Enterocele Bulging Upper vagina Lower vagina Relation Away from cervix Behind the cervix Content Empty Loop of gut PR Enter pouch Cannot Bowel Constipation Rare

Emergency measures Complications of Enterocele:

Emergency measures Complications of Enterocele Incarceration of the prolapsed mass Rupture of enterocele Eviceration of the content Gut gangrene

Non-surgical treatment:

Non-surgical treatment Improving the general condition Control Chronic cough Chronic constipation Obesity Pessary treatment? Pack Antiseptic Estrogen

Abdominal repair :

Abdominal repair Moschowitz culdoplasty Purse string sutures Halban culdoplasty Sagittal sutures Presacral suspension Paravaginal repair

Vaginal repair :

Vaginal repair Ligation of enterocele sac McCall transverse culdoplasty Right sacrospinous colpopexy (Zweifel) Paravaginal repair (White) Le Fort’s Colpocleisis