2. GENITAL PROLAPSE
• Common complaint of elderly woman
• Mostly in post menopausal and multiparous women
• In prolapse straining causes protrusion of vaginal walls at vaginal
orifices
• Extreme cases uterus may be protrude
3. Normal axis
Axis of the uterus and vagina: anteverted and anteflexed
4.
5. PELVIC SUPPORTS
• PELVIC FLOOR
• Comprises
Pelvic diaphragm
Endopelvic fascia
Perineal membrane
Perineal body
18. Level 2 (attachment axis)
• Level II- Pelvic fascias and paracolpos
• Fascial septae connects mid vagina to the pelvic sidewalls
• Anteriorly
• Pubocervical
• Posteriorly
• Rectovaginal facia
• which connects the vagina to the white line on the lateral pelvic wall through
arcus tendinous
19.
20. Level II and III detail. In level III, the vagina is fused to the
medial surface of the levator ani muscles, urethra, and perineal
body. The anterior surface of the vagina at its attachment to
the arcus tendineus fascia pelvis forms the pubocervical fascia,
while the posterior surface forms the rectovaginal fascia.
22. Level 3 (fusion axis )
• Level III-Levator ani muscle
• supports the lower one-third of vagina.
• Anteriorly
• Urethra
• Urogenital diaphragm
• Pubis
• laterally
• Levator ani fascia
• Posteriorly
• Perineal body
23.
24.
25.
26. Etiology
• Menopause
• birth injury
• Prolonged bearing down in the second stage
• Delivery of a big baby
• Rapid succession of pregnancies
• Lack of rest in peuperium
• Peripheral nerve injury
• raised intra-abdominal pressure
• Surgeries
• Congenital
27. Etiology
• Menopause
• prolapse are of menopausal age when the pelvic floor muscles
• d/t oestrogen deficiency and decreased collagen content in fascias atonicity
and asthenia that follow menopause
28. Causes related to child birth
• Birth injury
excessive stretching
of the pelvic floor
muscles and
ligaments
overstretching causes
atonicity
Perineal tear is less
harmful than
overstretching
whereas torn
muscle could be
stitched or toned up
29. Causes related to child birth
• Peripheral nerve injury such as pudendal nerve during childbirth
• Delivery by untrained dais
• This is because the patients are made to bear down before full dilatation of
the cervix and when the bladder is not empty
• Prolonged bearing down in the second stage
• Lacerations of the perineal body during childbirth, unless sutured
immediately, will widen the hiatus urogenitalis
30. Causes related to child birth
• Delivery of a big baby
• Lack of rest in peurperium
• Lack of any pelvic exercises
• Rapid succession of pregnancies
31. Raised intra abdominal pressure
• chronic bronchitis,
• large abdominal tumours or
• obesity
• Smoking,
• chronic cough and
• constipation
32. Prolapse in unmarried or nulliparous women
• spina bifida occulta and
• split pelvis
• Collagen vascular diseases
33. congenital weakness of the pelvic floor
muscles
• in unmarried or nulliparous women
• h/o precipitate labour
• Family h/o uterine prolapse
34. Surgeries
• Abdominoperineal excision of the rectum and
• radical vulvectomy
• Operations for stress incontinence such as Stamey and Pereyra
operations
35. Classification of prolapse
Upper two-third-
Cystocele
Lower one-third-
Urethrocele
Anterior
vaginal
wall(anterior
compartment)
Uterine descent
Middle
compartment Upper one-third-
Enterocele
(pouch of
Douglas hernia)
Lower two-third-
Rectocele
Posterior
compartment
36.
37. Cystocele
the vesical and vaginal fasciae are thinned
out and fail to support the bladder, so that
the bladder prolapses with the anterior
vaginal wall.
38. Urethrocele
When the urethra along with the lower one-third
of the anterior wall prolapses (failure of
pubocervical ligament
Rare
stress incontinence
42. • Uterine descent
• - Descent of the cervix into the vagina
• - Descent of the cervix up to the introitus
• - Descent of the cervix outside the introitus
• -Procidentia-All of the uterus outside the introitus
43.
44. Symptoms
• something protruding either at the vulva or externally
• aggravated by straining and coughing, and by heavy work
• reduces itself when she lies down
• large prolapse, the external swelling difficulty in walking or
carrying out her everyday duties
45. Symptoms
• Backache
• uterosacral strain
• Towards evening
• relieved by rest
46. decubitus ulcer
• benign and is present on dependant part.
• d/t venous stasis tissue anoxia.
• treated by
• keeping the prolapse reduced, which will restore circulation and help in
healing. Prolapse can be kept in reduced position by packing.
47. micturition disturbances
• imperfect control of micturition
• Frequency of micturition
• (diurnal or nocturnal)
• (d/t chronic cystitis & incomplete emptying
of the bladder)
• Manual reduction of the cystocele into the vagina with their fingers
• Straining to pass urine
• Stress incontinence
49. Bowel symptoms
• Urgency
• Straining
• Feeling of incomplete emptying
• Pressure on vagina or perineum to start or complete defaecation
50. Discharge per vaginum
• Mild vaginitis
• Chronically inflamed lacerated cervix
• Decubitus ulcer – discharge and bleeding
51. Coital difficulties
• With third degree uterine prolapse and procidentia prevents
penetration and orgasm due to a lax outlet.
52. Signs
• Assessment of prolapse
• In lithotomy position
• Look for stress incontinence on a full bladder
• patient is asked to strain / perform valsalva manoeuvre
• Stress incontinence
• Vulva examined for perineal laceration
• Three compartments evaluated separately;
• decubitus ulcer
53. Per speculum examination
Anterior compartment
• Sim’s speculum retracting
posterior vaginal wall
• Look for cystocele
• Lateral cystocele or
paravaginal defect
• Urethrocele } stress
incontinence
Middle compartment
• Degree of descent
• Ulceration of cervix
• Vagina may show
keratinisation
• Vaginal examination –
length of cervix,position
and mobility of uterus,any
adnexal mass
• Cervical cytology
Posterior compartment
• Sim’s speculum retracting
anterior vaginal wall
• Enterocele – bulge
appears from above
downwards
• Rectal examination –
impulse on
• tip of finger- enterocele
• pulp - rectocele
• Bimanual examination-r/
o pelvic mass
54. Pelvic floor muscles
• Pubococcygeus part of levator ani assessed at 4 and 8o’clock position
• Perineal body
• Rectal examination – tone of anal sphincter
55. Lab investigations
• Hb
• Urine examination,Urine culture,Xray,ECG
• High vaginal swab in cases of vaginitis
• RFT in long standing prolapse
• Urodynamic investigations in case of incontinence
• USG to r/o pelvic mass and hydronephrosis
• IVP }massive prolapse
• CT/MRI}
56. Differential diagnosis
• Vulval cyst or tumour
• Cysts of anterior vaginal wall
• Urethral diverticula
• Congenital elongation of cervix
• vaginal portion of the cervix is elongated and
• no vaginal prolapse.
• deep fornices
• Cervical fibroid polyp
• Chronic inversion
57. COMPLICATIONS OF PROLAPSE
• Kinking of ureter with resulting renal damage
• Surgical injury to ureter
• Urinary tract infection (chronic) in large cystocele with residual urine
• decubitus ulcer and keratinisation pigmentation
• if ring pessary is left in over a long period malignancy
58. Prophylaxis
Antenatal physiotherapy ,relaxation exercises,due
attention to weight gain and anaemia
Proper supervision and management of second stage of
labour
A generous episiotomy
Low forceps delivery if there is delay in second stage
Suture perineal tear
Postnatal exercises and physiotherapy
early postnatal ambulation
Adequate spacing of births
Avoid multiparity
Prophylatic HRT in postmenopausal women
59. Treatment
• Surgical }
• in women over 40
• C/I in pregnancy
• Conservative management
• mechanical devices and
• pelvic floor muscle exercises ,abdominal massage,
• in mild degrees of prolapse,
• surgery not desired by patient ,
• in whom child bearing is not complete
• Should be advised 3 to 4 months following delivery
• Surgery Pregnancy – contraindication for surgery
60. Pessaries
• Indications
A young woman planning a pregnancy
During early pregnancy (<18 weeks)
Puerperium
Temporary use while clearing infection and decubitus ulcer
A woman unfit for surgery
In case a woman refuses for surgery
61. pessaries
Support
Space filling
eg:ring pessary
stage 1 and 2 prolapse
eg:gelhorn and cube pessaries
for advanced stages
soft plastic
polyvinyl chloride
material
62. Limitations
• Never curative only palliative
• Vaginitis
• Needs to be changed every 3 months
• Dyspareunia
• Expulsion (if vaginal orifice is very patulous)
• May cause ulcer,rarely Ca vagina and a vesico vaginal fistula
• Does not cure urinary stress incontinence
63. SURGICAL APPROACHES
• Ward-Mayo’s operation-vaginal hysterectomy with
pelvic floor repair with or without:
sacrospinous colpopexy –vault suspended from
sacrospinous ligament
• Fothergill’s or Manchester operation –uterus preserved
and part of cervix is cut
• Shirodkar’s Extended Manchester operation-both
cervix and uterus preserved
• Le Fort’s operation –obliterative procedure of anterior
and posterior walls of vagina
66. Anterior colporrhaphy
• TOC for anterior cystocele
• Procedure
Lithotomy position
Area cleansed and draped
Bladder emptied
Sim’s speculum introduced
Anterior lip of cervix pulled down using volsellum forceps
67. Inverted T-shaped incision on anterior vaginal wall
Vaginal flaps seperated from bladder
Vesicocervical ligament boldly cut,bladder pushed up
Bladder buttressing with delayed absorbable sutures
In large defects, plication in two layers
Excess vaginal mucosa trimmed and closed
Bladder drained
68. • Complications
Infection, bleeding, injury, recurrence, failure
• Aftercare
Avoid lifting weights, coughing, sneezing, straining at
stools, sexual intercourse
69.
70.
71. • Sim's speculum is introduced, posterior lip of cervix is held by by multiple
vulsellum and firmly brought down by assistant.
• Metal catheter is introduced to know the lower limit of bladder.
• Inverted T incision made to anterior vaginal wall.
• Horizontal incision is made below the bladder and
• vertical incision is made starting from midpoint of the transverse incision upto a point abount
1.5cm below the external urethral meatus.
• The triangular vaginal flaps including fascia on either sides are separated from the
endopelvic fascia covering the bladder by knife and gauze dissection.
• The bladder with the covering endopelvic fascia (pubocervical) is exposed as the
edges of the vaginal wall are retracted laterally.
• The vesico cervical ligament is held up with Allis tissue forceps and divided. The
bladder is then pushed up by gauze covered finger till the peritoneum of the
uterovesical pouch is visible. The vesico-cervical space is now exposed.
72.
73. • The pubocervical fascia is plicated by interupted sutures with No "O"
chromic catgut using round body needle.The lower one or two stiches
include a bite on the cervix thus closing the hiatus through which the
bladder herniates. The redudndant portion of the vaginal mucosa is cut on
either side.
• The cut margins of the vagina are apposed by interrupted sutures with No
'O' chromic catgut using cutting needle.
• The catheter is reintroduced once more to be sure that the bladder is not
injured.
• Toileting of the vagina is done.
• Vagina is tight packed with roller gauze smeared with antiseptic cream.
• A self retaining catheter is introduced
74. Paravaginal repair
• To correct lateral cystocele
• Done abdominally, vaginally or laparoscopically
• Repairing abdominally
Involves entering retropubic space till arcus tendinous fascia pelvis
seen
lateral vagina raised to arcus tendinous fascia
Both are approximated with interrupted sutures
75. WARD-MAYO REPAIR
• Commonest operation in case of utero vaginal prolapse in cases
where child bearing is complete
• Indication
• In an elderly women who has completed her family
78. Vaginal hysterectomy
A circular incision is made over the cervix below the bladder
sulcus, and the vaginal mucosa dissected off the cervix all
around.
79.
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92. To proceed as that of anterior
colporraphy up to pushing up of
bladder
the UV fold of peritoneum incised
The cervical incision is extended
posteriorly along the cervicovaginal
junction and the pouch of douglas is
opened
Uterus is delivered anteriorly
First clamp on utero sacral and cardinal
ligaments,tissues cut and ligated on
both sides
Second clamp involves uterinevessels
which are cut and ligated
Third clamp on round
ligament,fallopian tube and ovarian
ligament which are cut and ligated
93. Uterus removed
Peritoniumclosed by purse
string suture
enterocele correction done by
McCall’s culdoplasty
Anterior colporrhaphy is
completed
Posterior colpoperineorrhaphy
performed if there is rectocele.
94.
95.
96.
97.
98. SACROSPINOUS COLPOPEXY
• Apical suspension procedure in
procidentia with complete vaginal eversion
Vault prolapse
• Sacrospinous ligament is used to suspend the vault,by an approach
through rectovaginal space
99. Abdominal sacrocolpopexy
• Abdominal method of apical suspension
• Used in Vault prolapse mainly
• A mesh in the form of Y is used
100. • Long arm y anterior longitudinal ligament of sacrum @ sacral
promontory
• Short arms anterior & posterior vagina
101. Manchester/Fothergill’s operation
• In a women who has completed her family
• With lesser degrees of uterovaginal prolapse with supra vaginal
elongation of cervix
• but wishes to retain the uterus and opts for a vaginal procedure
• it can be combined with AC , PC or enterocele repair
102. Manchester/Fothergill’s operation
Dilatation of cervix
Anterior colporrhaphy
Isolation and ligation of
cardinal ligaments
Amputation of cervix
Suturing the cardinal
ligaments to the front of cervix
Reforming the lips of cervix
using the vagina
103. The patient is placed in the dorsal lithotomy position.
Thorough examination of the pelvis is performed. The bladder
is not catheterized because it can be identified and dissected
with greater safety when partially filled than when empty.
105. The labia may be tacked to the perineum for retraction if they
are redundant. A Jacobs tenaculum is placed on the anterior lip
of the cervix. Downward traction on the cervix exposes the
junction of the vagina and cervix where a 360° circumcision
incision is made. The bladder is sharply and bluntly dissected
off the lower uterine segment up to the vesicouterine fold
106. A right-angle retractor is placed under the bladder to expose
the vesicouterine peritoneal fold. This is picked up and opened.
107. The anterior cul-de-sac is opened, a finger is inserted, and the
fundus and adnexa are explored.
108. A right-angle Heaney retractor is placed in the anterior cul-de-sac,
allowing elevation of the bladder and ureter. The cervix is
rotated anteriorly, and the posterior cul-de-sac is exposed. The
peritoneum of the posterior cul-de-sac is picked up and
opened.
The posterior cul-de-sac is opened. A finger may be inserted
into the cul-de-sac, and the uterus and adnexa explored.
109.
110.
111.
112. the ligaments are fixed using Fothergill's stitch. Fothergill's
stitch is used to make the uterus anteverted. The stitch passes
through the following tissues in sequence. Vaginal skin at the
level of Fothergill's lateral point->Mackenrodt's ligament-
>through the cervical tissue from outside inwards->cervical
tissue from inside outwards->Mackenrodt's ligament of the
other side -> vaginal skin(Fothergill's lateral point) of the other
side.
113.
114.
115.
116. Both Mackenrodt's ligaments have now been ligated and the
cervix almost completely amputated. A vulsellum is attached to
the anterior lip of the cervix above the amputation
117. A covering for the posterior lip of the cervix has been fashioned
from the mobilized vaginal skin of the posterior fornix and this
has been secured to the new cervix by deep sutures.
Fothergill's stitch is illustrated and it should be noticed that it
passes through vaginal skin in the region of Fothergill's lateral
point, through Mackenrodt's ligament and through the anterior
lip of the cervix into the cervical canal, and thence out to the
other side and through Mackenrodt's ligament and vaginal sk
118. Shirodkar’s Extended Manchester
operation
• Shirodkar’s Extended Manchester operation- in a women who wants
to conceive
• Vaginal sling operation
• Uterus and cervix are preserved
• Strenghthening of uterosacral ligaments
• Best for women with strong uterosacrals
119. STEPS..
AC done
Vaginal incision extended posteriorly around the cervix
The pouch oh Douglas is then opened
The uterosacral ligaments identified and divided close to cervix
They are isolated to form slings
They are crossed and stitched together infront of the cervix
120. Le Fort’s operation
• Le Fort’s operation In very elderly women who is medically unfit for a
repair procedure and not desirous of vaginal intercourse.
• Colpocleisis
• Obliterative procedure
• Total colpocleisis-total obliteration of cavity
• Partial colpocleisis-some part of vaginal epithelium is left unsutured
to provide drainage tract ,useful in women with uterus to drain
cervical secretions
121. Le Fort’s operation
Vaginal epithelium is
removed
Suturing of anterior
and posterior wall of
the denuded vagina
122. • Repairing vaginally
More difficult
More risk of hemorrhage
If a paravaginal defect is present,retropubic space can be
reached readily vaginally
4-6 permanent sutures between arcus tendineus and
lateral edge of fibromuscular layer
124. Posterior colporrhaphy
• Procedure
Pair of Allis forceps at lower end of labium minus and a third one on
posterior vaginal wall above rectocele
Incision put joining first two forceps
Vaginal mucosa dissected from prerectal fascia(Denonvillier’s fascia)
upto third forceps
Vertical incision put from middle of this incision to the apex
125. Prerectal fascia approximated in the midline with
delayed absorbable sutures
If defect identified, better to do a defect repair
Usually anterior plication of pubococcygeus part of
levator ani also performed across the rectum
Then vaginal mucosa trimmed and closed
Combined with perineorrhaphy when defective
perineal body
Superficial perineal muscles are plicated in the
midline and skin closed
126. Mesh repair
In repeat sx
Replace patients own weak tissue
• 4 types
• Type 1 monofilament mesh preferred(pore size >75 micrometre)
• Mesh of choice : Monofilament macroporous light weight
polypropylene mesh
(eg : Gynemesh)
• Main problem with use of mesh is mesh erosion
127. Postoperative care
• Parental fluids until bowel sounds return.
• Early oral fluids are now advocated.
• Antibiotics, sedatives, metronidazole for 24 hours IV.
• Indwelling catheter for 48 hours.
• Vaginal pack for 28 hours.
• Early ambulation
• DVT prophylaxis
131. ENTEROCELE
• Herniation of upper third of posterior vaginal wall
• Contain omentum or even loop of small bowel
• Always look for and correct during prolapse repair
• Prophylactic correction during vaginal or abdominal hyterectomy
132. MANAGEMENT
• VAGINAL CORRECTION
• STEPS
Inverted T shaped incision
Dissect and expose sac
Sac opened and contents pushed away
Peritoneum dissected and excised
Purse string suture – neck of the sac
Cervix pulled up ,interrupted suture around uterosaral ligaments
133. • VAGINAL CORRECTION OF POST HYSTERECTOMY
ENTEROCELE
• Uterus absent
• internal Mc call suture
• ABDOMINAL CORRECTION
• Vaginal vault – suspend to uterosacral ligament
• Other procedure
HALBAN PROCEDURE
MOSCOWITZ PROCEDURE
134. SECONDARY VAULT
PROLAPSE
Prolapse of vaginal vault following
hysterectomy
Due to failure to recognise and correct –
enterocele- during hyserectomy
Can be
Vaginal eversion – vault suspension
Cystocele Anterior and posterior
Rectocele colporrhaphy
135. MANAGEMENT
Vaginal approach
Sacrospinous colpopexy + anterior and posterior colporrhaphy
Preferred in old and less healthy women
• Abdominal approach
Sacrocolpopexy + Halban procedure
Preffered in young women bcoz resultant vagina is longer
136. NULLIPAROUS PROLAPSE
• More likely to have spina bifida or connective
tissue disorder
• Uterine +vaginal prolapse , may include
complete vaginal inversion
• Mesh required for repair
• Following repair- aviod vaginal delivery –
perform elective caesarean section