Genital prolapse

1. Prof. Aboubakr Elnashar
Benha University Hospital
Aboubakr Elnashar

2. Genital support
I. Cervical ligaments (Main uterine support)
1. Cardinal: from supravaginal cervix & vaginal vault to
lateral pelvic wall
2. Uterosacral: to 3rd piece of the sacrum.
3. Pubocervical, pubourethral, puborectal ligaments: to
back of s. pubis
II. Pelvic floor muscles:
Mainly levator ani, iliococcygeus
III. Anteveresion of the uterus:
Longitudinal axis of the uterus is perpendicular to that of
the vagina Aboubakr Elnashar

3. a horizontal vaginal axis: The vaginal lies in a nearly
horizontal axis when the woman is standing. Hence
any intra-abdominal downward force will appose the
vagina on the pelvic floor muscles preventing
descent. This is aided by fascial and ligamentous
support around the vagina which hold it in place. This
support is divided into three levels:
a. upper vagina (vault) is supported by uterosacral and cardinal
ligaments,
b. middle vagina is supported by levator ani muscles via fascial
attachments to the arcus tendineus (“white line”), and
c. lower vagina (introitus) is supported by urogenital diaphragm
via pubourethral and pubocervical ligaments and posteriorly to
the perineal body.
Aboubakr Elnashar

4. Aboubakr Elnashar

5. Diagram showing the normal horizontal axis of vagina and
three levels of support for the vagina10 and anatomy of
pelvic floor10
Aboubakr Elnashar

6. Aboubakr Elnashar

7. Aboubakr Elnashar

8. DEFINITION
 Prolapse: from the Latin prolapsus, a slipping
forth
falling or slipping out of place of a part or viscus.
 Pelvic organ prolapse:
descent of the pelvic organs into the vagina, often
accompanied by urinary, bowel, sexual, or local
pelvic symptoms.
pelvic relaxation due to a disorder of pelvic
support structures that is, the endopelvic fascia
downward decent of uterus &/or vagina
 Procidentia: from Latin procidere - to fall
Procidentia: third degree uterine prolapse.Aboubakr Elnashar

9. Incidence
Difficult to determine {many women do not seek
medical advice}.
half of parous women lose pelvic floor support,
resulting in some degree of prolapse, and that of
these women 10­20% seek medical care.
The chance of a woman having a prolapse
increases with age. Therefore, the incidence of
prolapse will rise as life expectancy increases.
Aboubakr Elnashar

10. Causes and contributing factors
Congenital: nulliparous (virginal)
Bladder exstrophy
Collagen defects (type IV Ehlers­Danlos syndrome,
Marfan syndrome)
Race (white people have a higher risk)
Anatomy (congenitally short vagina)
Childbirth
Sucessive vaginal deliveries
Straining during 1st stage of labor
Forceps before full cevical dilatation
Prolonged 2nd stage of labor
•Trauma
Denervation
Aboubakr Elnashar

11. Raised intra­abdominal pressure
Chronic obstructive airway disease
Straining, constipation, heavy lifting
Post menopause
Oestrogen deficiency: atrophy of cervical ligaments
Iatrogenic
Pelvic surgery (hysterectomy, colposuspension,
sacrospinous fixation)
Aboubakr Elnashar

12. TYPES
 Vaginal
Anterior:
Cystocele: upper part containing
base of the bladder
Urethrocele: lower part containing
urethtera
Posterior:
Enterocele: upper part containing
peritoneum of D.P & loops of
intestine
Rectocele: lower part containing
aterior rectal wall
Vault: prolapse of upper vagina
after hysterectomy
 Uterine:
First degree: external
os below ischial
spines but not
outside the vulva
Second degree:
cervix but not the
whole uterus
protrudes from the
vulva
Third degree:
complete
procidentia: whole
protrudes from the
vulvaAboubakr Elnashar

13. Aboubakr Elnashar

14. Aboubakr Elnashar

15. Aboubakr Elnashar

16. Cystourethrocele is the most
common type of prolapse, followed
by
uterine descent and then
rectocele.
Urethroceles are rare.
Aboubakr Elnashar

17. Aboubakr Elnashar

18. Aboubakr Elnashar

19. Aboubakr Elnashar

20. Vault prolapse
Aboubakr Elnashar

21. Aboubakr Elnashar

22. Pelvic Organ Prolapse Quantification (POPQ).
Diagram of reference points used in POPQ
measurements. Aa is the distance of 3 cm from
the anterior vaginal wall to the hymen.
Aboubakr Elnashar

23. Line and grid representation of
measurements obtained using POPQ.
Aboubakr Elnashar

24. The vagina
• Thickend wall: oedma
& congesion
• Keratinization:
exposure
• Trophic ulcer:
congestion, friction,
menopausal atrophy
The cervix
1. Hypertophy: congestion,
chronic cervicitis
2. Trophic ulcers
3. Elongation of supravaginal
cervix: in vagino uterine
prolapse: vagina descend: pulls
the cervix: supravaginal part
attached to the stronger upper
part of the cardinal ligament
resists
Pathological changes
Aboubakr Elnashar

25. Symptoms
often asymptomatic & clinical examination may not
necessarily correlate with symptoms.
Symptoms are often related to the site and type
Symptoms common to all types of prolapse are a feeling
of dragging, or a lump in the vagina, or something
coming down.
1. Urinary symptoms
Stress incontinence
Frequency (diurnal and nocturnal)
Urgency and urge incontinence
Hesitancy
Poor or prolonged urinary stream
Feeling of incomplete emptying
Manual reduction to start or complete emptying
Positional changes to start or complete emptyingAboubakr Elnashar

26. 2. Bowel symptoms
Difficulty in defecation
Incontinence of flatus, liquid stool, or solid stool
Urgency of defecation
Digitation or splinting of vagina, perineum, or anus to
complete defecation
Feeling of incomplete evacuation
Rectal protrusion during or after defecation (rectal
prolapse)
Aboubakr Elnashar

27. 3. Sexual symptoms
Inability to have or infrequent coitus
Dyspareunia
Lack of satisfaction or orgasm
Incontinence during sexual activity
Aboubakr Elnashar

28. 4. local symptoms
a. Feeling of pressure or heaviness in the vagina
b. Pain in the vagina or perineum
c. Sensation or awareness of protrusion from the
vagina
d. Low back pain, which is eased with lying down
e. Abdominal pressure or pain
f. Blood stained and purulent discharge
Aboubakr Elnashar

29. Signs
I. General:
1. Exclude anaemia
2. Chest: chronic bonchitis
II. Abdominal:
1. Renal angle: hydronephrosis or tenderness
2. Nulliparous prolapse: Spina bifida,
visceroptosis, hernia
Aboubakr Elnashar

30. III. Pelvic:
• Inspection & digital palpation:
a. Old perineal tear
b. Prolapsed structures: type of prolapse, degree
of uterine prolapse, changes in vagina &
cervix.
c. Stress incotinence
d. Tone of levator ani: 2 fingers in the vagina &
the thumb on the perineum while the patient is
asked to contract the muscles
e. Enterocele: impulse on cough & gurgling
sensation
Aboubakr Elnashar

31. 2. Bimanual Examination
Size & position of uterus & adenxa
3. Speculum Examination:
Cervical lesion
4. Sounding:
Detect supravaginal elongation of the cervix
5. P.R.:
In enterocele the rectum is not forming part of the
prolapse
Position: left lateral or standing position—with a Sims'
speculum, inserting it along the posterior vaginal
wall to assess the anterior wall and vault and vice versa.
Uterine descent can be assessed by traction with a
single toothed vulsellum.
Aboubakr Elnashar

32. D.D
Cystocele
1. Gartner cyst:
anterolateral in
vagina,
incomperessible,
catheter: normal
uretheral direction
2. Uretheral
diverticulum:
pressure on the
mass, urine from
external meatus
Rectocele
1. Dermoid cyst:
incompressible,
PR: rectum not
mass
2. Enterocele: arises
from upper part of
the posterior
vaginal wall,
gurgling & impulse
on cough, PR:
rectum not part of
mass, PR+PV: on
straining the
rectum is pushed
back
2nd & 3rd uterine
prolapse
1. Congenital
elongation of
portio-vaginalis:
vaginal vault is at
its normal level,
deep fornices
2. Fibroid polyp,
Chronic
inversion: absent
external os
Aboubakr Elnashar

33. WHEN TO TREAT ?
 Should be treated only when it is symptomatic
(Be certain symptoms are due to Prolapse )
 Interferes with the normal activity of the woman
 The patient seeks treatment
Aboubakr Elnashar

34. HOW TO TREAT ?
 NON-SURGICAL Methods: -Limited Role
 PELVIC FLOOR REHABILITATION (pelvic muscle
exercises, galvanic stimulation, physiotherapy,
rest in the purperium).
 HORMONE REPLACEMENT, both systemic and
local.
 PESSARY TREATMENT for temporary relief
 During Pregnancy, Pureperium & Lactation
 When Operation is Unsafe due to Extreme
Senility/Debility and Diseases
 Preoperatively
 For therapeutic test
Aboubakr Elnashar

35.  SURGICAL TREATMENT: -
RECONSTRUCTIVE SURGERY is invariably needed
and has to be a COMBINATION OF PROCEDURES
to correct the multiple defects.
 It is the definitive & curative treatment of Prolapse.
 It is a cold operation. So complete investigation
should be done & all existing diseases & disorders
should be treated first
 Pre operative pessary/tampoon & or Hormone
treatment should be given as indicated.
 Meticulous and through examination under
anaesthesia should be done before deciding the
surgery.
Aboubakr Elnashar

36.  Depending on the type & extent of Prolapse, surgery
should be tailor made not only to rectify the defect
but also to suit the individual patient’s requirement.
 Absolute haemostasis is mandatory.Diathermy
should be liberally used.
 Vaginal suturing should be with interrupted stitches.
Synthetic absorbable fine sutures are preferable.
 Catheter for more than 48 hrs should be exceptional.
 Strict antibiotic prophylaxis is essential
Aboubakr Elnashar

37. VAGINAL OPERATIONS FOR
PROLAPSE
 Anterior colporrhaphy
 Posterior colporrhapry- High / Low
 Enterocele repair
 Perineorrhaphy
 Amputation of cervix
 Paravaginal repair
 Hysterectomy with or without
Colporrhaphy / Perineorrhaphy
Aboubakr Elnashar

38. VAGINAL OPERATIONS FOR
PROLAPSE
 Manchester/ Fothergill’s operation &
Shirodkar’s modification
 Uterus/Cervix suspension/fixation
 Vaginal vault suspension/fixation
 Retro-rectal levatorplasty and post. anal
repair for associated rectal prolapse
 Vaginectomy ?
 Colpocleisis ?
Aboubakr Elnashar

39. Anterior colporrhaphy &
Urethroplasty
 For correction of Cystocele & Urethrocele
 Incision- Midline / Inv.T / Elliptical
 Excision of vagina according to the size &
site of laxity
 Avoid shortening &/or narrowing of vagina
 Closure with interrupted sutures
Aboubakr Elnashar

40. Posterior colporrhaphy &
Enterocele repair
 For correction of Enterocele & Rectocele
 Enterocele repair can be done either by vaginal or
abdominal route depending on the associated
procedures.
 Approximation of uterosacral ligaments for
enterocele & prerectal fasciae and levator for
rectocele with interrupted sutures is essential
 Excision of vagina should be tailor made
 Perineorrhapy to be done only if perineal body is torn
Aboubakr Elnashar

41. 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.
 Can cause Dyspareunea
 Essential steps - Excision of the scar tissue &
approximation of levator ani & superficial
perineal muscles
Aboubakr Elnashar

42. Vaginal Hysterectomy
with/without Vaginal repair
 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 Ant. & Posterior
colporrhaphy.
 Perineorrhaphy is not mandatory but case
specific.
 Vault suspension is an essential step.
 If sexual function is not needed narrowing of
vaginal canal should be done.Aboubakr Elnashar

43. Amputation of cervix
 Not for Prolapse.Indicated only for cervical
elongation (Uterocervical length >12.5 Cm )
 To be done only as a part of Fothergill’s
repair/sling operations.
 Adequate cervical dilatation - a prerequisite
 Bladder displacement is a must
 Excision of cervix should not exceed 2 cm
 Likely to affect reproductive life
 Long-term complications are real risks
Aboubakr Elnashar

44. Fothergill’s operation
 It is the operation of choice in uncomplicated
Utero-vaginal prolapse when uterus is to be
preserved but NO future child bearing is
required.
 It is a combination of, Amp. of Cx., Fixation of
the Meconrodt’s ligament to the anterior of Cx.
& Ant. Colporrhaphy. D&C is a must.
 Post. Colporrhaphy to be performed only if
Ent/Rectocele is present
 Perineorrhaphy is usually not required
Aboubakr Elnashar

45.  Not useful if ligaments are weak & Uterus is of
normal size. Purandare’s modification may help.
 Technically difficult operation, requiring high degree
of surgical skill.
 Threat of short-term complications.
 Real possibilities of long term complications.
 Recurrence/Failure.
 Sling operations are better alternatives
 HAS A BLEAK FUTURE
Aboubakr Elnashar

46. ABDOMINAL OPERATIONS
FOR PROLAPSE
 Sling operations
 Closure or repair of enterocele
 Sacrocolpopexy
 Anterior Colpopexy
 Colposuspension
 Paravaginal repair
Aboubakr Elnashar

47. Abdominal Sling operations
 Indicated when the ligaments are extremely weak as
in nulipara & young women.
 Preserves reproductive function.
 Principle-With a fascial strip / prosthetic material
(Merselene tape or Dacron) the Cx is fixed to the
abdominal wall / sacrum / pelvis.
 Amp.of Cx should also be done if Utereocervical
length >12.5cm.
 Cystocele/Rectocele repair if needed can be done
vaginally before or after.
 Enterocele repair can also be done abdominally.
Aboubakr Elnashar

48.  It is a major abdominal operation & Synthetic
material is costly & not widely available in
India.
 Types-.
 Shirodkar’s posterior sling.
 Purandare’s anterior cervicopexy.
 Khanna’s sling.
 Virkud’s composite sling.
Aboubakr Elnashar

49. Shirodkar’s sling
 Tape is fixed to the post. Aspect of isthmus &
sacral promontory
 Anatomically most correct but difficult to
perform
 Risks of complication
Aboubakr Elnashar

50. Purandare’s cervicopexy
 Tape is anchored to the ant.aspect of isthmus
and ant. abd. Wall
 Easy to perform
 Dynamic support
Aboubakr Elnashar

51. Virkud’s composite sling
operation
 Tape is anchored from the post aspect of
isthmus to sacral promontory on the Rt. side &
ant. abd. Wall on the Lt. Side
 Utrosacral ligament is plicated
 Technically easy
Aboubakr Elnashar

52. Khanna’s sling operation
 Tape is anchored to ant aspect of isthmus &
ant. sup. Iliac spine
 Easier to perform and safer
 But tape is superficial
 Risk of infection
Aboubakr Elnashar

53. Abdominal Colpopexy /
Colposuspension
 Indicated when vault prolapse occurs after
hysterectomy or vaginal laxity is to be
corrected at abdominal hysterectomy.
 Major abdominal operation & technically
difficult.
 Sexual function is preserved.
 Methods-.
 Sacrocolpopexy.
 Ant.Colpopexy.
 Colposuspension.Aboubakr Elnashar

54. Sacrocolpopexy
 Vault is fixed to 3rd & 4th sacral vertebrae with
a facial strip / proline mesh under the
peritoneum to the right of rectum
 Enterocele repair can be done if required
Aboubakr Elnashar

55. Ant.Colpopexy
 Corrects ant. vag laxity & stress inc.
 Useful at abdominal hysterectomy / for vault
prolapse.
 Extra peritoneal supra pubic approach if done
alone.
 Enterocele repair if required.
 Vagina stitched to the ileo-pectineal ligaments.
Aboubakr Elnashar

56. Vault / Colposuspension
 Vault is fixed to the abdominal wall by a facial
strip or merseline tape
Aboubakr Elnashar

57. LAPAROSCOPIC SURGERY
PROLAPSE
 Advantages of M I S-small incision, better view,
haemostasis, no packing, minimal tissue & bowel
handling, short recovery, less pain, insignificant scar
 Can all types of prolapse be treated?- Yes.
 Ant. / Post. Lower vaginal repairs if needed can also
be done vaginally before or after lap.Surgery
 However extended period of rest is essential
 Expertise is needed
 Presently cannot be widely practised
 This is the surgery of the future today
Aboubakr Elnashar

58.  PROCEDURES:-
 Cervicopexy / Sling operations with/without
Lap.Paravaginal repair / Vaginal repair
 VH / LAVH / LH / TLH + Colposuspension
 VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction
 Rectocele repair & levatorplasty
 Enterocele repair with suturing of uterosacral
ligaments
 Colpopexy- Ant / Post
Aboubakr Elnashar

59. Laparoscopic
Cervicopexy/sling Operations
 All types of sling operations can be better
performed by laparoscopy
 Associated vaginal prolapse can also be
repaired laparoscopically (Lap.Paravaginal
repair)
 Vaginal Ant./Post. colporrhaphy can be done
before / after laparoscopy
Aboubakr Elnashar

60. Laparoscopic Vault
suspension/
Culdoplasty)
 Can be done with VH / LAVH / LH / TLH
 Corrects mild laxity
 Prevents vault prolapse
Aboubakr Elnashar

61. Laparoscopic Pelvic
Reconstruction
With VH / LAVH / LH / TLH
 An alternative to Ward-Mayo’s operation
 Before Hys., Lap.Ureteral dissection is done and
suture placed in uterosacral ligament near
sacrum & left long, for latter vaginal vault
suspension
 Lap. levator plication if needed
 Enterocele repair and suturing of uterosacral
ligaments if needed
 Retro pubic Colposuspension (Bruch) if required
Aboubakr Elnashar

62. Laparoscopic Rectocele
repair & Levatoroplasty
 Rectovaginal space is opened & rectum
dissected
 Interrupted sutures given in the levator in
the midline
 Enterocele repair done if indicated
 Vaginal vault suspension done
Aboubakr Elnashar

63. Laparoscopic Enterocele
repair
 Rectovaginal space is opened, sac excised
and purse string suture given
 Uterosacral ligament sutured
Aboubakr Elnashar

64. Laparoscopic Post Colpopexy
/ Sacrocolpopexy
 Indicated for vault prolapse
 Enterocele if present is first repaired
 Prolene mesh is fixed to the vault & 3rd-
4th sacral vertebrae, under the peritoneum
in the Rt.para rectal space
Aboubakr Elnashar

65. Aboubakr Elnashar