genital prolapse

1. Genital Prolapse
Dr. Isameldin Elamin MD DOWH MBBS
Assistant professor
Obstetrics & Gynaecology Department

2. Definition
 A prolapse is a protrusion of an organ or
structure beyond its normal confines.
 Prevalence of 41–50 per cent of women
over the age of 40 years.
 The annual incidence of surgery for
POP
is within the range of 15–49 cases
per 10 000 women years.

3. Pathophysiology Of Prolapse
 The uterus and vagina are supported
by:
o Ligaments and fascia, from the pelvic side
walls.
o Levator Ani muscles.
o Posterior angulation of the vagina.

4. Pathophysiology of prolapse…CONT.
 Important ligaments and fascia:
o The uterosacral–cardinal complex.
o The pubocervical fascia.
o The rectovaginal fascia.
 Damage to any of these mechanisms
will contribute to prolapse.

5. Aetiology of prolapse
 The maintenance of position need
intact:
o Connective tissue.
o Levator ani muscles.
o Nerve supply.
 All are affected by:
o Pregnancy and childbirth.
o Ageing.

6. Aetiology of prolapse…CONT.
 Types:
o Congenital.
o Acquired.
 The main factor in both types is connective
tissue defects.
 Why congenital type? Because:
o Prolapse can occurs in nulliparous
women.(2%).
o Genital prolapse is rare in afro-caribbean
women.

7. Aetiology of prolapse…CONT.
 Causes of a acquired type:
o Vaginal delivery.
 Due to the damage of the nerve, levator ani and
fascia.
o More parity.
o Pregnancy.
 Due to progesterone and relaxin.
o Increase in intra-abdominal pressure.
 (E.g. Chronic cough or constipation).

8. Aetiology of prolapse…CONT.
 Ageing due to:
o Loss of collagen.
o Weakness of fascia and connective tissue.
o Oestrogen deficiency in post-menopause.
 Postoperative.
o Poor vaginal vault support at the time of
hysterectomy.
 Gynaecological surgery:
o such as colposuspension.

9. Classification
 Anterior vaginal wall prolapse:
o Urethrocele:
 Urethral descent,
o Cystocele:
 Bladder descent .
o Cystourethrocele:
 Descent of bladder and urethra.

10. Classification ..CONT.
 Posterior vaginal wall prolapse:
o Rectocele: rectal descent.
o Enterocele: small bowel descent.
 Apical vaginal prolapse:
o Uterovaginal: uterine descent with
inversion of vaginal apex.
 Vault prolapse:
o post-hysterectomy inversion of vaginal
apex.

13. Grading
 Three degrees of prolapse:
o 1st: descent within the vagina
o 2nd: descent to the introitus
o 3rd: descent outside the introitus.
 Procidentia:
o Third-degree uterine prolapse.

15. Clinical features
 History:
o Enquire about aetiological factors.
o Ask about symptoms:
o Non-specific symptoms:
 Lump.
 Local discomfort.
 Backache.
 Bleeding/infection.
 Dyspareunia or apareunia.
 Renal failure.

16. Clinical features…CONT.
 Specific symptoms:
 Cystourethrocele:
o Urinary frequency and urgency.
o Voiding difficulty.
o Urinary tract infection.
o Stress incontinence.
 Rectocele:
o Incomplete bowel emptying.
o Passive anal incontinence.

17. Clinical features…CONT.
 Abdominal examination for:
o Organomegaly or abdominopelvic mass.
 Vaginal examination:
o Examine the patient in the dorsal position.
o Look for:
 Prolapse
 Ulceration.
 Atrophy.

18. Clinical features…CONT.
 Vaginal pelvic examination for:
o Pelvic mass.
o Assess vaginal walls.
o Assess cervical descent.
o Put patient in left lateral position.
o Ask him to strain.
Use a Sims speculum.
 Do rectal and vaginal examination to
differentiate rectocele from enterocele

19. Differential diagnosis:
 For anterior wall prolapse:
o Dermoid vaginal cyst.
o Urethral diverticulum.
 For uterovaginal prolapse:
o Large uterine polyp.

20. Prevention
 Shortening the second stage of delivery.
 Reduce traumatic delivery.

21. Investigations
 No essential investigations.
 If urinary symptoms:
o Urine microscopy.
o Cystometry and cystoscopy.
 If renal failure suspected:
o Serum urea and creatinine .
o Renal ultrasound.
 In obstructed defaecation:
o MR proctography.

22. Treatment
 Treatment depends on:
o The patient’s wishes.
o Fitness of patient.
o Coital function.
o Prior treatment.
 Correct obesity.
 Treat chronic cough.
 Treat constipation.
 If ulcerated :
o give topical oestrogen, biopsy, then pessary.

23. Treatment…CONT.
 Uterovaginal prolapse:
 If no symptoms:
o Observation or conservative.
 If mild symptoms
o Pelvic floor physiotherapy
 Conservative therapy is by:
o Silicon rubber-based ring pessaries.
o Shelf pessaries are rarely used.

25. Treatment….CONT.
 Complication of pessaries :
o Vaginal ulceration.
 Indications for pessary treatment are:
o Patient’s wish.
o As a therapeutic test.
o Childbearing not complete.
o Medically unfit.
o During and after pregnancy (awaiting involution).
o While awaiting surgery.

26. Surgical teartment
 The aim is to restore anatomy and
function.
 Types of operations:
o Vaginal.
o Abdominal.
 Coital function is determinant factor to
choose the type and operation.

27. Surgical teartment …CONT.
 Cystourethrocele:
o Anterior repair (colporrhaphy) is the most
commonly performed surgical procedure.
o Should be avoided if there is concurrent
stress incontinence.
 Procedure:
o Incision made.
o Defect identified and closed.
o Redundant tissue removed.

28. Surgical teartment …CONT.
 Rectocele:
o Procedure is posterior repair
(colporrhaphy).
 Enterocele:
o Peritoneal sac excised.
o Pouch of Douglas is closed.

29. Surgical teartment …CONT.
 Uterovaginal prolapse:
 Uterine preserving surgery when:
o Woman wishes to preserve her uterus.
o Woman wants further children.
 Options uterine preserving surgery are:
o Hysterosacropexy:
 A mesh between the cervix and the anterior
longitudinal ligament on the sacrum.

30. Surgical teartment …CONT.
 The manchester repair:
o Amputating the cervix and using the
uterosacral cardinal ligament complex to
support the uterus.
 Complications:
o Cervical stenosis.
o Cervical incompetence.

31. Surgical teartment …CONT.
 Le fort colpocleisis:
o Partial closure of the vagina used when:
 Patient unfit .
 Patient not sexually active.
 Total mesh procedure using an
introducer device.

32. Procedures involving hysterectomy
 Vaginal hysterectomy.
 Total abdominal hysterectomy and
sacrocolpopexy.
 Subtotal abdominal hysterectomy and
sacrocervicopexy.

33. Treatment of Vault Prolapse
 Sacrocolpopexy.
 Sacrospinous ligament fixation.

35. Further reading
 http://www.uptodate.com.
 Gynaecology by ten teachers 19 editions.
 Essential of obstetrics and gynaecology.
Hacker & Moore, fifth edition

36. THANK YOU