PELVIC ORGAN PROLAPSE IS COMMON PROBLEM IN OUR COUNTRY THESE SLIDES GIVES US SOME KNOWLEDGE REGARDING PROLAPSE..

1. Pelvic organ Prolapse
Dr. Hem nath subedi
II year OBGYN
COMSTH

2. DEFINITION
• The entity includes descent of the vaginal wall
and/or the uterus.
• It is infact a form of hernia.
• The uterus is normally placed in anteverted
and anteflexed position.

3. SUPPORTS OF THE UTERUS
• The external os lies at the level of ischial
spines.
• Apart from the normal position- anteverted
anteflexed there is a three tier system
• consisting of the following:
– Upper
– Middle (strongest and important)
– Lowers

4. • Upper Tier
– Weak
– Mostly by maintaining the uterus in anteverted position
– Endopelvic fascia
– Round ligaments
– Broad ligaments with intervening pelvic cellular tissues
• Middle Tier
– Strongest support of uterus
– Cervico vaginal junction
– Pelvic cellular tissue
• Inferior Tier
– Indirect support to the uterus
– Principally given by the musculofascial tone of the hollow vagina
which is amply supported by the fascial condensation at the vault and
by the pelvic floor at the lower end.

7. Anterior compartment defect

8. Midline defect

9. Posterior compartment

10. • Nine specific sites are considered. Hymen is taken as the fixed point. The plane of hymen is defined
as the zero level. Leading point of prolapse may be above (proximal) or below (distal) to the plane
of hymen. Prolapse measurements (cm) are recorded as negative numbers when above and
positive numbers when lies below the plane of hymen. Organ prolapse is measured with a wooden
PAP spatula with markings. The woman may be examined in lithotomy or standing position (or
even under anesthesia). She may be asked to do some maneuvers (valsalva) to demonstrate the
prolapse maximally. Total vaginal length (TVL) is measured after reducing the prolapse while rest of
the measurements are done when the prolapse is seen maximally.

12. Symptoms
following symptoms are usually associated:
(a) Feeling of something coming down per vaginum, especially
while she is moving about. There may
(b) Backache or dragging pain in the pelvis.
(c) Dyspareunia.
(e) Bowel symptom (in presence of rectocele).
– Difficulty in passing stool. The patient has to push back the posterior
vaginal wall in position to complete the evacuation of feces. Fecal
incontinence may be associated.

13. (d) Urinary symptoms (in presence of cystocele).
– Difficulty in passing urine.
– Incomplete evacuation.
– Urgency and frequency of micturition.
– Painful micturition is due to infection.
– Stress incontinence
– Retention of urine may rarely occur.
(f) Excessive white or blood-stained discharge per vaginum is due
to associated vaginitis or decubitus ulcer.

14. Complications
• Keratinization of the vagina
• Decubital ulceration
• Elongation of supravaginal cervix
• Congestion and edema of cervix
• Glandular hypertrophy
• Ureteric obstruction
• Renal failure
• Incarcerationof the prolapse
• Carcinoma of the cervix or vagina

15. Differential diagnosis
• Cystocele
– Gartner’s cyst
• Uterine Prolapse
– Congenital elongation of
the cervix.
– Chronic inversion
– Fibroid polyp

16. MANAG EMENT OF PROLA PSE
– Preventive
– Conservative
– Surgery

17. PREVENTIVE
The following guidelines may be prescribed to prevent or minimize
genital prolapse.
Adequate antenatal and intranatal care
• To avoid injury to the supporting structures during the time of
vaginal delivery either spontaneous or instrumental.
Adequate postnatal care
• To encourage early ambulance.
• To encourage pelvic floor exercises by squeezing the pelvic floor
muscles in the puerperium.
General measures
• To avoid strenuous activities, chronic cough, constipation and
heavy weight lifting.
• To avoid future pregnancy too soon and too many by contraceptive
practice.

18. CONSERVATIVE
• Indications of conservative management are:
– Asymptomatic women.
– Mild degree prolapse.
– POP in early pregnancy.
• Meanwhile, following measures may be taken :
Improvement of general measures (see above).
Estrogen replacement therapy may improve
minordegree prolapse in postmenopausal women.
Pelvic floor exercises in an attempt to strengthen the
muscles (Kegel exercises).
Pessary treatment.

20. Anterior colporrhaphy
• Preliminaries
• The operation is done under general or epidural anesthesia.
• The patient is placed in lithotomy position.
• Vulva and vagina are to be swabbed with antiseptic
solution.
• The perineum is to be draped with sterile towel and legs
with leggings.
• Bladder is to be emptied by metal catheter.
• Vaginal examination is done to assess the type anddegree
of prolapse.

21. Steps of anterior colporrhaphy

22. Periniorrhaphy

23. Enterocele correction

24. Composite steps of forthergill’s operation
Preliminary D and C
Amputation of cervix
Plication of Mackenrodt’s
ligaments in front of cervix
Anterior colporrhaphy
Colpoperineorrhaphy

25. Vaginal hysterectomy
Principles of the operation in prolapse
• Removal of the uterus through vaginal route.
• Correction of enterocele, if any.
• Approximation of the pedicles in the midline to have a
good buttress.
• Fixation of the uterosacral ligaments to the vault to
prevent vault prolapse.
• Bladder support is reconstituted utilizing the broad
ligaments and round ligaments as buttress.
• Repair of cystocele.
• Reconstruction of the perineum.

26. Vaginal hysterectomy

29. Sacrospinous culpoplexy

30. Leforts partial colpocleisis

31. Thank you
Take home message