Sie sind auf Seite 1von 20

GENITAL PROLAPSE

Dr. Fayez Jallad 2009-2010

GENITAL PROLAPSE
Definition
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

Incidence :
Genital prolapse occurred in about 10-30% of multiparous women and in 2% of nulliparous women .

Types
1. Uterine prolapse: 3 degrees of uterine prolapse First degree : is the descent of the cervix within the vagina . Second degree :is the descent of the cervix through the introitus . Third degree (Procidentia ): is the descent of the cervix and the whole uterus through the introitus.

Types
2. Vaginal prolapse: mild , moderate or severe
vaginal prolapse
Cystocele : is the prolapse of the upper 2/3 of the anterior vaginal wall and the bladder. Urethrocele: is the prolapse of the lowest 1/3 of the anterior vaginal wall and the urethra . Rectocele : is the prolapse of the posterior vaginal wall and the rectum. Enterocele : is a true hernia of the pouch of Douglas through the posterior vaginal fornix - which may contain bowel or omentum. Vault prolapse : is an inversion of the vaginal apex which occur after abdominal or vaginal hysterectomy.

Pelvic support
1. Uterus: is supported by the following ligaments .
I. Transverse,Cardinal or Mackenrodts cervical ligaments. II.Uterosacral ligaments III.Pubocervical ligaments
N.B: The followings dont give support to the uterus, ie broad ligaments, round ligaments and the levator ani muscles.

2. Vagina is supported by the pelvic floor muscles


( the levator ani muscles mainlyand the superficial and deep transverse perineal muscles) and by the pelvic floor fascia.

Etiology
Prolapse is due to weakening of and damage to the supporting structures of the pelvic organs which may occur as a result of : 1. Childbirth :
Childbirth is the most important risk factor in the development of prolapse .

Factors which increase risk of trauma and denervation to the pelvic support include:
increasing parity, prolonged labour , bearing down before full cervical dilatation and difficult

instrumental deliveries.

Etiology
2. Chronic elevation in intra-abdominal pressure:
Factors which increase the intra-abdominal pressure include obesity, smoking chronic cough ,chronic constipation ,heavy lifting at work , abdominal masses and ascites .

3. Menopause :which leads to weakness of the pelvic support


due to the reduction in the amount of collagen and weakness of the connective tissue

4. Pelvic surgery :

Vault prolapse which may occur after abdominal or vaginal hysterectomy Rectocele and enterocele which may occur after colposuspension

Etiology
5. Congenital prolapse , due to congenital reduction in
the amount of collagen and weakness of connective tissue of the pelvic support Is responsible for the occurrence of prolapse in 2% of nulliparous women .

6.

Racial variation .
Prolapse is common in Caucasian women , less common in Asians , and rare in Blacks . This racial variation is explained by the variation in the amount of collagen and connective tissue in the pelvic support . ie greater in Blacks and lesser in Caucasian

Diagnosis :
A. History
1. Symptoms: which depends on the site , type & on the degree of the
prolapse
A feeling of something coming down below or a lump within the vagina or protruding from the introitus, is almost always present in all types of prolapse which is worse at the end of the day , increased on standing and coughing, and relieved by lying down. Other symptoms , depends on the organ which has prolapsed into the vagina . In case of uterine prolapse: Low backache, which is central, worse at the end of the day , increased on standing and relieved by lying down. In case of cystocele : Urinary symptoms such as stress incontinence, frequency , reccurent UTI , urgency , incomplete emptying of the bladder and the patient may has to reduce the cystocele digitally in order to be able to empty her bladder

Diagnosis :
In case of rectocele : Constipation , incomplete rectal evacuation and the patient may has to reduce the rectocele digitally to be able to empty her rectum. In case of procidentia : Ulceration, blood stained or purulent vaginal discharge.

Coital problems such as uncomfortable or difficult intercourse occur in

uterine and vaginal prolapse

Diagnosis :
B. Examination (signs)
Inspection of the vulva with cough and straining demonstrate severe prolapse and may demonstrate stress incontinence ( provided the bladder is full) Speculum examination either in dorsal position using Bivalve speculum or in left lateral position using Sims speculum . Rectal examination, to differentiate between rectocele (finger goes through it) from enterocele ( finger goes high up) .

Diagnosis :
C.Differential diagnosis :
Anterior vaginal wall prolapse to be differentiated from congenital Gartners cyst, inclusion dermoid cyst & urethral diverticulum Uterine prolapse- to be differentiated from large cervical or endometrial polyp & chronic uterine inversion. MSU for analysis and culture . Renal ultrasound and IVU in cases of procidentia and severe cystocele to exclude hydroureter & hydronephrosis which may occur as a result of kinking of the ureters Cystometry in cases of incontinence , in order to exclude urge incontinence

D.Investigations :

Prevention
Genital prolapse is a preventable disease
1. Prevention and limiting injury to pelvic support during childbirth by : Avoiding of: prolonged labour , bearing down before full cervical dilatation and difficult instrumental delivery Encouragment of postnatal pelvic floor exercises . Family planning and smaller family size . 2. Avoiding and treating factors which increase the intraabdominal pressure such as obesity , smoking, chronic cough and chronic constipation 3. Prevention of postmenopausal atrophy of pelvic support by balanced diet, exercise, calcium & by the increased use of HRT.

Treatment
Treatment :
Methods : - Pessaries .
- Surgical treatment .

Choice of method - depends on the followings:


Age, fitness and wish of the paitent
Parity and wish for further pregnancy.

General measures :
Treatment of urinary tract infection. Avoiding and treating factors which increase the intra-abdominal pressure such as smoking, obesity, chronic cough and chronic constipation . Use of HRT in menopausal patients . Reducing the procidentia and treatment of ulceration with oestrogen cream. The ulcer will usually heal within 7 days .

Treatment
Pessaries :
Indications :
Patient unfit for surgery . Patient refuses surgery . During pregnancy and after delivery . During waiting time for surgery. As a therapeutic test to confirm that surgery may help .

Types :
Ring pessary commonly used pessary. Shelf pessary rarely used

Side effects:
Vaginal infection and discharge Vaginal ulceration and bleeding

Precautions - to minimize side effects:


Use of silicon pessary - rubber pessary should not be used. Change the pessary yearly - or earlier if infection or ulceration occurred . Use of vaginal ostrogen cream in menopausal patients .

Treatment
Surgical treatment : which is the definitive treatment of prolapse 1. Preoperative assessment and preparation of the patient:
Choice of operation depends on : 1. Type of prolapse 2. Age and parity of the patient The aims of surgery are : to correct the prolapse , maintain continence and preserve coital function. Success of the surgery depends on: 1. Preoperative preparation of the patient such as reduce weight in obese, stop smoking and treatment of chronic cough .
N.B : The gynaecologist cant do his part unless the patient fullfils her

2.

Postoperative care

Treatment
2. Operations : A. Uterine prolapse operations : i. Vaginal hysterectomy is the preferred operation in uterine prolapse
Indicated in young patients who complete the family and in menopausal patients .

ii. Manchester ( Fothergill ) operation.


Indicated in young patients who not complete the family. Consisted of :
1. Partial amputation of the cervix 2. Shortening of the transverse cervical ligaments and suturing them to the front of cervical stump. 3. Anterior and posterior repair.

iii. Sacrohysteropexy
Indicated in patients who complete the family and wish to conserve the uterus

Treatment
2. Operations : B. Vaginal prolapse operations : i. Anterior repair ie anterior colporrhaphy - in Cystocele and Urethrocele. ii. Posterior repair ie posterior colpoperineorrhaphy - in Rectocele iii. Resection of enterocele sac - in Enterocele iv. Abdominal sacrocolpopexy - in Vault prolapse C. Le-Forts operation :
Rarely indicated in elderly and frail patients who are unfit for vaginal hysterectomy or pelvic floor repair . Rectangular strips of vaginal epithelium are removed from the anterior and posterior vaginal walls in order to obtain a partial closure of the vagina .

Treatment
3. . Postoperative care : Immediate postoperative care :
Vaginal pack which to be removed within 24 hours. Foleys catheter ,which to be removed after 1- 2 days Prophylactic antibiotics : Metronidazole and cephalosporin

Instructions after discharge - to minimize recurrence


Avoiding intercourse for 6 weeks . Gradual return to normal activities over 2 months . Avoiding smoking ,obesity ,constipation and lifting of heavy objects Elective C.S. in the subsequent pregnancy.

Recurrent prolapse
Recurrence occur in about 20-25% Even with expert surgery and good postoperative care, recurrence can occur, especially in the presence of obesity, smoking and constipation .

Das könnte Ihnen auch gefallen