Utero-Vaginal Prolapse

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Utero-Vaginal Prolapse
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Background

• The pelvis encloses organs that primarily
  function in storage, distension and evacuation.
  The pelvic viscera must maintain their normal
  anatomic relationships within this cavity so that
  these physiological functions can be sustained.

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Background
The uterus is normally anteverted,
anteflexed Version is the angle between the
longitudinal axis of cervix, and that of the
vagina Flexion is the angle between the
longitudinal axis of the uterus, and that of the
cervix
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Genital Prolapse

• Genital prolapse is the descent of one or more of
  the genital organ (urethra, bladder, uterus,
  rectum or Pouch of Douglas or rectouterine pouch)
  through the fasciomuscular pelvic floor below
  their normal level
• Vaginal prolapse can occur without uterine
  prolapse but the uterus cannot descend without
  carrying the vagina with it.

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Supports of the uterus

• DeLancey in 1994 defined three levels of vaginal
  support, reviving the importance of the
  connective tissue structures and giving a working
  basis for the present day understanding of the
  anatomy and surgical treatment.

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Three level of Supports of Uterus

• Level I The cardinal uterosacral ligament
  complex
• Level II The pubo- cervical and recto-vaginal
  fascia
• Level III The pubo-urethral ligaments anteriorly
  the perineal body posteriorly

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Anterior vaginal wall prolapse

• Prolapse of the upper part of the anterior
  vaginal wall with the base of the bladder is
  called cystocele
• Prolapse of the lower part of the anterior
  vaginal wall with the urethra is called
  urethrocele.
• Complete anterior vaginal wall prolapse is called
  cysto-urethrocele.

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Anterior vaginal wall prolapse

• Weakness in the
• Supports of the bladder neck
• Urethero vesical junction
• Proximal urethra
• Caused by
• Weakness of pubocervical fascia and pubourethral
  ligaments

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Middle compartment defect

• Enterocele and eversion of vagina
• Enterocele (Herniation of POD)

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Posterior compartment defect

• Rectocele
• Perineal body descent

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Uterine descent

• Utero-vaginal (the uterus descends first followed
  by the vagina) This usually occurs in cases of
  virginal and nulliparous prolapse due to
  congenital weakness of the cervical ligaments.
• Vagino-uterine (the vagina descends first
  followed by the uterus)This usually occurs in
  cases of prolapse resulting from obstetric
  trauma.

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Degree of uterine descent

• 1st degree The cervix desends below its normal
  Ievel on straining but does not protrude from the
  vulva (The extemal os of the cervix is at the
  level of the ischial spines)
• 2nd degree The cervix reaches upto the vulva on
  straining
• 3rd degree The cervix protrudes from the vulva
  on straining
• Procidentia- whole of the uterus is prolapsed
  outside the vulva and the vaginal wall becomes
  most completely inverted over it. Enterocele is
  usually present

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Vault prolapse

• Descent of the vaginal vault, where the top of
  the vagina descends )or inversion of the vagina)
  after hysterectomy

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Pelvic organ prolapse quantitative (POPQ) exam

• In 1996, by the ICS
• POPQ system describes the location and severity
  of prolapse using segments of the vaginal wall
  and external genitalia, rather than the terms
  cystocele, rectocele, and enterocele

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Aetiology

• Erect posture causes increased stress on muscles,
  nerves and connective tissue
• Acute and chronic trauma of vaginal delivery
• Aging
• Estrogen deprivation
• Intrinsic collagen abnormalities
• Debilitation
• Iatrogenic

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Precipitating factors

• ? intra abdominal pressure
• ? weight of the uterus
• Traction of the uterus by vaginal prolapse or by
  a large cervical polyp
• Obesity(40--75)
• Smoking
• Pulmonary disease (chronic coughing)
• Constipation (chronic straining)
• Recreational or occupational activities(frequent
  or heavy lifting)

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Symptoms of Prolapse

• Pelvic floor disorders become symptomatic through
  either of two mechanisms
• 1. Mechanical difficulties produced by the
  actual prolapse,
• 2. Bladder or bowel dysfunction, disrupting
  either storage or emptying.

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Clinical presentation

• Before actual prolapse. the patient feels a
  sensation of weakness in the perineum.
  particularly towards the end of the day
• Later the patient notices a mass which appears on
  straining. and disappears when she lies down
• Urinary symptoms are common and trouble some even
  with slight prolapse
• a) Urgency and frequency by day
• b) Stress incontinence
• c) Inability to micturate unless the anterior
  vaginal wall is pushed upwards by the patient's
  fingers
• d) Frequency when cystitis develops

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• Rectal symptoms are not so marked. The patient
  always feels heaviness in the rectum and a
  constant desire to defaecate. Piles develop from
  straining.
• Backache, congestive dysmenorrhoea and
  menorrhagia are common.
• Leucorrhoea is caused by the congestion and
  associated by chronic cervicitis.
• Associated decubitus ulcer may result in
  discharge which may be purulent or blood stained

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Diagnostic approach

• Beginning with a careful inspection of the vulva
  and vagina to identify erosions, ulcerations, or
  other lesions
• The extent of prolapse should be systematically
  assessed
• Suspicious lesions should be biopsied

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Examination

• Local examination
• Per speculum examination
• Per vaginal/ Bimanual examination
• Bonneys stress test
• Evaluation of tone of pelvic muscles
• Recto vaginal examination
• Position of patient for examination
• - standing straining
• - dorsal lithotomy

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Diagnostic approach

• The maximal extent of prolapse is demonstrated
  with a standing straining examination when the
  bladder is empty
• Pelvic muscle function should be assessed after
  the bimanual examination ? palpate the pelvic
  muscles a few centimeters inside the hymen, along
  pelvic sidewalls at the 4 8 oclock
• Resting tone voluntary contraction of the anal
  sphincters should be assessed during rectovaginal
  examination

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Evaluation of pelvic floor tone

• Place 1 or 2 fingers in the vagina and instruct
  the patient to contract her pelvic floor muscles
  (i.e., the levator ani muscles). Then gauge her
  ability to contract these muscles, as well as the
  strength, symmetry, and duration of the
  contraction.
• The strength of the contraction can be
  subjectively graded with a modified Oxford scale
  (0 no contraction, 1 flicker, 2 weak, 3
  moderate, 4 good, 5 strong).

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Bladder evaluation

• For all patients with prolapse following
  information should be obtained
• Screening for urinary tract infection
• Postvoid residual urine volume
• Presence or absence of bladder sensation
• Bonneys stress test performed following
  reduction of prolapse
• If test positive incontinence surgery should be
  performed at the time of prolapse surgery

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Testing for Integrity of anal sphincter

• Should be assessed for resting tone and voluntary
  squeeze and sensation around the vulva with the
  bulbo-cavernous reflex and crude sensory testing
  for evidence of pudendal neuropathy

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Prevention

• During labour puerperium
• Avoid premature bearing down
• Avoid long second stage
• Repairs all tears incisions accurately in layers
• Use delayed absorbable suture
• Do not express the uterus when attempting to
  deliver placenta
• Encourage pelvic floor exercise
• Avoid puerperal constipation-decreases bearing
  down

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Prevention

• At hysterectomy
• Vault suspension with uterosacral and cardinal
  ligaments
• Obliteration of deep cul-de sac by Moschowitz
  sutures
• Sacropexy in high risk situations like collagen
  disorders
• Increase acceptability of estrogen replacement
  therapy

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Treatment

• Physiotherapy
• Kegels pelvic floor exercise
• Kegels perineometer
• Influence only the voluntary muscles
• No action to the fascial supporting system
• Vaginal cones of increasing weight .

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Associated decubitus ulcer

• To relieve congestion, the prolapse can be
  reposited in the vagina with the help of tompoons
  ar pessary and this helps in healing of the ulcer
• Hygroscopic agents like acriflavin-glycerine can
  help reduce the congestion further

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Pessary

• During pregnancy
• Immediately after pregnancy, during lactation
• When future childbearing is intended in near
  future
• Refusal to operation by patient
• As a therapeutic test
• To promote healing in a decubital ulcer

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Pessary in situ
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Complications of pessary

• Constipation
• Urinary incontinance
• B.vaginitis, ulceration of vaginal wall
• Cervicitis
• Carcinoma of vaginal wall
• Impaction of pessary
• Strangulation of prolapsed tissue

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Principles of Management

• Physical examination must not be used in
  isolation to develop treatment strategy.
• Any decision for surgical intervention should
  take account of how prolapse is affecting
  lifestyle.

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Aim of pelvic reconstructive surgery

• To restore anatomy, maintain or restore visceral
  function, and maintain or restore normal sexual
  function

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Uterine descent- surgeries

• Vaginal hysterectomy
• Sling surgeries
• Shirodkar
• Khannas
• Purandares
• Fothergills surgery

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Vault prolapse

• Separation of the rectovaginal fascia from
  pubocervical fascia.
• In post hysterectomy patients it is important to
  reattach the rectovaginal fascia to the
  pubocervical fascia and to provide good support
  to the vaginal apex by reattaching the vaginal
  cuff to the uterosacral cardinal ligament complex.

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Surgery for prolapsed vaginal vault

• Vaginal surgery
• Decreased operative time
• Decreased incidence of adhesion formation
• Quicker recovery time
• Abdominal surgery.
• Failed previous vaginal approach
• Have foreshortened vagina
• Young patients with advanced prolapse
• With other co existing conditions
• Obliterative procedures

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Vaginal surgery

• Mc Call culdoplasty
• Internal
• external
• Sacrospinous ligament fixation
• High uterosacral ligament suspension with
  fascial reconstruction
• Iliococcygeus fascia suspension

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Abdominal repairs

• Abdominal sacral colpopexy
• High uterosacral ligament suspension
• Laparoscopic approach

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Obliterative procedures

• Le forte partial colpocleisis
• Colpectomy and colpocleisis

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Diagnosis of Stress Incontinence with Pelvic
Organ Prolapse

• Loss of urine during coughing, sneezing, laughing
  or lifting something heavy
• These activities cause an increase in "belly
  pressure ? forces the urine out of the bladder
• Stress incontinence occurs almost exclusively in
  women thought to be due to "pelvic (vaginal)
  relaxation" from childbirth or aging

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Treatment of Stress Incontinence with Pelvic
Organ Prolapse

• Conservative therapy
• - Pelvic floor exercises
• - Urinary meatel occlusion devices
• - Collagen injections
•  Urinary incontinence surgery
• - Ant repair Kellys plication
• - Pubo-vaginal sling procedure
• - TVT sling procedure
• - Burch Urethropexy    

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