Types, pathogenesis and treatment of genital prolapse

1. GENITAL PROLAPSE
-dr.jason zachariah

2.  Anatomy-supports of uterus and vagina
 What is prolapse?
 Aetiology
 Classification
 Symptoms
 Signs
 Differential diagnosis
 Complications
 Prophylaxis

3. DE LANCEY- 3 LEVEL SUPPORT
 Level I- Uterosacral and cardinal ligaments-
support the uterus and vaginal vault
 Level II- Pelvic fascia and paracolpos-
connects vagina to the white line on lateral
pelvic wall through arcus tendinous
 Level III- Levator ani- supports lower one
third of vagina

9. WHAT IS PROLAPSE?
• Genital prolapse is the downward descent of
the uterus and /or the vagina towards or
through the introitus .
• The bladder , urethra , rectum and bowel
may be secondarily involved

10. AETIOLOGY
1.Atonicity and asthenia after menopause
2.Child birth
 Birth injury, excessive stretching of pelvic floor
muscles and ligaments.
 Peripheral nerve injury -pudendal nerve
 Ventouse extraction-before cx is fully dilated
 Prolonged bearing down in second stage of
labor and Crede’s method
 Delivery at home, by untrained dais
 Big baby
 Rapid succession of pregnancies

11. 3. Nulliparous
 Spina bifida
 Congenital weakness of pelvic floor muscles
4. Raised intra-abdominal pressure
 Chronic bronchitis
 abdominal tumors
 ascites
 obesity

12. 5. Surgeries
 Abdominoperineal excision of rectum
 Radical vulvectomy
 Operations for stress incontinence
6. Predisposition
 Smoking, chronic cough, constipation

13. CLASSIFICATION
Anterior vaginal wall
 Upper 2/3rd- Cystocele
 Lower 1/3rd- Urethrocele
Posterior vaginal wall
 Upper 1/3rd- Enterocele(pouch of Douglas
hernia)
 Lower 2/3rd-Rectocele
cystourethrocele

14. CLASSIFICATION
Uterine descent
 1st degree- Descent of cervix into the vagina
 2nd degree- Descent of cervix up to the
introitus
 3rd degree- Descent of cervix outside the
introitus
 Procidentia- All of the uterus outside the
introitus

16. CYSTOCELE

17. ENTEROCELE

18. RECTOCELE

19. UTERINE PROLAPSE

20. 1ST AND 2ND DEGREE PROLAPSE

21. 3RD DEGREE PROLAPSE

22. SYMPTOMS
1. Mass coming down p/v (sensation of swelling or
fullness in the vagina)
2. Backache
3. Urinary symptoms:
 Difficulty in passing urine
 Incomplete evacuation-frequency
 Urgency and frequency (cystitis?)
 Painful micturition-infection
 Stress incontinence
 Retention of urine

23. 4.Vaginal discharge- friction, decubitus ulcer
5. Coital difficulties
6. Rectal symptoms-constipation

24. DECUBITUS ULCER
 It is atrophic ulcer, found at the dependent
part of the prolapsed mass lying outside the
introitus
 Surface keratinasation- cracks- infection-
sloughing –ulceration
 Impaired venous drainage, trauma due to
friction
 Reduction of prolapse and daily packing for 2
weeks

25. SIGNS
 When you ask the patient to cough it raises the
intra-abdomial pressure leading to:
Bulge in anterior vaginal wall in case of cystocele.
Bulging of the anterior and lower 1/3rd of vagina in
case of cystourethocele,
Bulging of the posterior vaginal wall in case o f
rectocele and enterocele.
Stress incontinence
 Pinch Test:

26.  Cough impulse in uterine prolapse leads to
the expulsion of the mass PV.
 In case of first degree prolapse
examination is made by introducing
speculum and one may see the cervical
descent below the level of ischial spines.

27. DIFFERENTIAL DIAGNOSIS
 Vulval cyst
 Cyst of anterior vaginal wall
 Urethral diverticula
 Congenital elongation of cervix
 Cervical fibroid polyp
 Chronic inversion
 Rectal prolapse

28. COMPLICATIONS
 Kinking of ureter with resulting renal
damage- procidentia, enterocele
 UTI leading to upper renal tract infection and
renal damage
 Cancer of vagina-decubitus ulcer

29. PROPHYLAXIS
 Antenatal physiotherapy,relaxation exercises
 Proper management of second stage of labour
a)Generous episiotomy
b)Low forceps delivery
c)Suturing of perenieal tear
 Post natal exercises
 Early postnatal ambulation
 Provision of adequate rest for first 6 months
after delivery
 Reasonable interval between pregnancies
 Prophylactic hormone replacement therapy