Genital Prolapse Fayez Al-Jallad Ahmad Shaban

14 25 Piaster Genital Prolapse Fayez Al-Jallad Ahmad Shaban

Genital Prolapse This lecture contains important informations for osce and theory exams so enjoy Definition of Genetal prolapse is the downward descent of the uterus and /or the vagina through the introitus Introitus is another name for the vaginal orifice. We are concerned about two types of genitial prolapse we must differentiate between them in etiology, diagnosis, prevention, treatment. We have 2 types of genital prolapse : 1- Uterine prolapse 2- Vaginal prolapse U must be oriented about anatomy of uterus, cervix, vagina, external and internal ostium. From Wikipedia: The external orifice of the uterus (or ostium of uterus, or external os) is a small, depressed, somewhat circular aperture on the rounded extremity of the vaginal portion of the cervix. Through this aperture, the cervical cavity communicates with that of the vagina. 1- Uterine prolapse classified into Three types: First degree uterine prolapse : is the descent of the cervix through vagina '' the cervix within vagina '' but not come out through introitus.

Second degree uterine prolapse : is the descent of the cervix through introitus '' the cervix position outside the vulva '' by physical examination the cervix is completly descended through the introitus. Third degree uterine prolapse : we call it in Gynecology "procidentia" here the whole uterus and cervix all of them come outside introitus. 2- Vaginal Prolapse Look at the picture below and Imagine the anatomy of pelvic organs: uterus, cervix, vaginal wall ; anterior and posterior. We have anterior vaginal fornix and posterior vaginal fornix >>> Now Anterior to anterior vaginal wall we have in upper two third the bladder and in the lowest one third the urethra And posterior to posterior vaginal wall we have one organ '' rectum '' Posterior to posterior vagianal fornix we have pouch of doglus which contain the omentum and intestine. The anterior vaginal wall divided into two parts if the upper 2/3 two third of anterior vaginal wall Prolapse what we call that? Cystocele, Because the anterior two third will take the bladder with it. If the lower1/3 one third of anterior vaginal wall prolapse which is related to urethra we call that urethrocele. Now about the posterior vaginal wall prolapse, what we call it? Rectocele because the whole posterior vaginal wall will take the rectum with it. Now what we call the prolapse of posterior vaginal fornix and pouch of doglus through it? What will take with it? It will take intestine, so We call it enterocele.

Enterocele considered a true hernia of the pouch of doglus which contain intestine similar to inguinal or femoral hernia. >>> If you examine the enterocele, you will find intestene in the prolapsed part similar to femoral or inguinal hernia. Which of the following is Considered as true hernia? 1- Rectocele 2- Cystocele 3- Urethrocele 4- Enterocele Frequent McQ question asked in the theory The last vaginal prolapse type is the '' vault prolapse'' 'سقف Vault means apex of the vagina Occur after abdominal or vaginal hysterectomy ( when the uterus was removed ) ; the vault '' apex'' of vagina is inverted as doctor said. From internet: ( Vaginal vault prolapse occurs when the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina. It may occur alone or along with prolapse of the bladder (cystocele), urethra (urethrocele), rectum (rectocele), or small bowel (enterocele). Vaginal vault prolapse is usually caused by weakness of the pelvic and vaginal tissues and muscles. It happens most in women who have had their uterus removed (hysterectomy)).

So vaginal prolapse either cystocele 'upper2/3 of ant wall' or urethrocele 'lower1/3 ant wall ' or rectocele 'post v wall ' or Enterocele or vault prolapse. From Wikipedia: The fornices of the vagina are the deepest portions of the vagina, extending into the recesses created by the vaginal portion of cervix. The word 'fornix' is Latin for 'arch'. >> There are three named fornices: The posterior fornix is the larger recess, behind the cervix. It is close to the rectouterine pouch. There are two smaller recesses in front and at the sides: o The anterior fornix is close to the vesicouterine pouch. o The lateral fornix. Pelvic Support: 1- Uterus: Now about anatomy of the pelvic organ which classified as Gynaecological organ or surgical organ. In Gynaecological organs we have uterus, vagina and small gynaecological organs as ovary and fallopian tubes. Uterus that placed in pelvis imagine it as suspended in air it is supported in its place by three groups of ligament, each group considered as a pair of ligaments to prevent prolapse >>> 1- The transverse cervical ligament. 2- The uterosacral ligament. 3- The pubocervical ligament. # In anterior posterior view we have 2 ligament support the uterus to lateral side of pelvic bone. we call them transverse cervical ligament,and they considered as one pair of ligaments.

# On lateral View we have 2 ligaments Extended posteriorly from cervix to sacral bone called uterosacral ligament. # Anteriorly we have 2 ligaments out from cervix to pubic symphysiss Called pubocervicalligament. >>So notice that uterus strongly supported by ligament to fixed organ which are the bone and that it is strongly supported from posterior, anterior and lateral side by bone. The strongest organ in your body is the bone and the second strongest organ is the ligament condensation of connective tissue the 3 rd strongest is the fascia, and the 4 th is muscle. We have two pairs of ligaments, Never Never foreget them which don t give any support to the uterus and considered as two false peritoneum ( Round ligament and Broad ligament). Broad ligament it is false of peritoneum not ligament ; because it is not condensation of connective tissue and don t give any support, extend from lateral side of uterus to the wall and floor of pelvis ; it contains blood vessels as ovarian artry, lymphnodes, uterine artry and suspensory ligament of ovary. Round ligament considered as one pair of ligaments, origin from 2 isthmus All of the following ligaments give support to uterus except : and descending till labia majora ( round ligament keep the uterus in antiverted 1- Pubocervical position and don t 2- Uterosacral give any support. 3- Round ligament 4- Broad ligament 5- both 3+4 So 3 pairs of ligaments support the uterus and 2 pairs don t give any support. Now talking about 2- Vagina: it is suppor rted by fascia and muscles levator ani and perineal muscles. Remember that uterus not supported by levator ani because it is far away from pelvic floor.

Aetiology: Aetiology of prolapse mainly based on three factors : 1- Child birth or multiparity. 2- Increase in the intra-abdominal pressure. 3- Menopause. So as a rule of genital prolapse, it caused by multiparity and aggrevated by increased intra-abdominal pressure, and accelerated by menopause. Prolapse rarely occuer in nulliparaous women but affect them due to congenitial reduction in the amount of collagen & weakness of connective tissue of the pelvic support. Now we are oriented about support of pelvic organs uterus and vagina? التهبيطة النساي ية prolapse So what is the Pathophysiology of genital Prolapse Pathophysiology: 1- Weakness of supporting organs as ligaments, fascia and muscles. 2- Trauma multiparity" or increased abdominal pressure or menupose. Now we are going in details about each factor. *1 st one, Factors Related to Childbirth (Trauma): 1- The most important factor which causes prolapse is multiparty, ( 10-30% of women with multiple child births has prolapse, so it is a disease of multipara ) because each delivery considered trauma, but this doesn t mean that all multipara must have a prolapse. 2- Difficult Instrumental Deliveries, Those who has difficult labor due to instrumental use is not considered as smooth labor process. 3- Prolonged labour, e.g. 6 hours labor woman not as a women with 20 hours Prolonged labor.

* 2 nd one, is chronic elevation of intra-abdominal pressure Factors which increase the intra-abdominal pressure includes: obesity, chronic constipation, chronic cough, abdominal masses & Ascites,..etc. e.g. a healthy 40 years women para 5 with no complains has 25% probability of prolapse. Another women healthy 40 years para 5 but obese has 50% prolapse probability BECAUSE obesity considered a risk factor that increase intraabdominal pressure. *3 rd one, is Menopause>> e.g avg weight women of 40 yrs has succiptibitity to prolapse 5%. Another avg weight women 60 years old menopause has 50 % prolapse to happen ; that s related to the connective tissue and collagen weakness. What happen to a connective tissue after menopause? Lack of estrogen lead to CT and collagen weakness due to poor blood supply. There is extreme variation in the amount of collagen between nations e.g. prolapse affect black women multipara less than 10%, Because they have high amount and strong condense collagen, so stronger pelvic area. than Caucasian white beautiful women which 30% of them may be affected more than Asian and middle east women. This racial variation is explained by the variation in the amount of collagen and connective tissue in the pelvic support. So Genital Prolapse is greater in Caucasian, less common in Asians, and rare in blacks. on the other hand we can see less fibroid diseases in Caucasian.

Incidence: of geni al prolapse in mul para 10-30 % but in nullipara its extremely rare. In Two specialized conditions, it may affect a Nulliparous at early age 10 to 20 years and cause prolapse : 1- Congenital deficiency of connective tissue and collagen. 2- Pediatric surgery in the pelvis. Diagnosis How to diagnose a patient with gential prolapse by history and physical examination? what are the symptoms and signs? 1- History: by history always there is one symptom in genital prolapse, shared in all types of prolapse feeling of something coming down below or a mass in the vagina which increase at the end of the day with standing & decrease with sleeping or resting The other symptoms depend on specific type of prolapse >>>> Constipation as symptom is related to rectocele. Urinary symptoms frequency urgency urge incontinence related to cystocele or urethrocele. Central backpain that aggrevated by standing, increase at the end of the day, and relieved by sleeping related to uterine prolapse why? Because the prolapsed uterus pull the nerve plexus causing back pain. you must ask 4 main Questions to the patient : 1- Ask about amass? (indiacate aprescence of prolapse)

2- Do you have constipation? (rectocele) 3- Do you have urinary problems ( urinary symptoms ) as urgency, frequency, urge incontinence?(cysto or urethracele) 4- Do you have low back pain?(uterine prolapse) And sexual coital problems considered in all cases and all the time the prolapsed organ interfere with sexual intercourse it make incomfortable sexual activity. Note : * Some patient may presented to you in more than one type of prolapse that can be combined together e.g. a patient may have both rectocele with cystocele we call that combined prolapse. * Enterocele symptoms mainly feeling of a mass or something going down without other related symptoms as cystocele or rectocele. 2- Physical examination During physical examination put a patient in proper position for examination to determine the type of prolapse. According to P.E you can differentiate the following types of prolapse : uterine prolapse degrees 1 st 2 nd -3 rd anterior vaginal wall cystocele (upper2/3) mass or urethrocele (lower 1/3) mass. posterior vaginal wall ( rectocele). Now we are able to differentiate types of prolapse by history and physical examination.

Management and Prevention before going to management of prolapse. some points essential to prevent prolapse because definitely most cases of prolapse can be prevented. how to prevent a prolapse? Prevention of Prolapse Both physician and patient playing a role in prevention of prolapse by following physician instructions to : 1- Prevent trauma from child birth (by family planning, use contraception methods, post natal pelvic exersise). 2- Prevent trauma from increased intra abdominalpressure (by instructions to patient to limit obesity). 3- Prevent trauma from menopause (by excersise, balanced diet,hormonal replacement therapy after menoupase). 4- Good labour management (avoid instrumental use, prolongedlabor, avoid bearing down before full cervical dilatation). Management of Prolapse Now if a patient women come to the physician with something coming down below and patient diagnosed with uterine prolapse, vaginal prolapse, or combined prolapse how to manage and treat? There are two methods of management >>>>>>> حلقة او آعكة 1- Conservative treatment pessary 2- Curative therapy surgical Considered a definitive treatment.

From Wikipedia: A pessary is a small plastic or silicone medical device which is inserted into the vagina or rectum and held in place by the pelvic floor musculature. 1- Pessaries: This picture contain different types and size of pessaries. Choice of treatment method depends on a. Age of patient. b. Fitness of patient. c. Wish of the patient (some may refuse surger). >>> Consevative treatment used to return the prolapsed organ In Which cases the conservative treatment is better than surgery? 1. Patient refuses surgery. 2. Pregnant patient ( we never operate surgical in such case we put a pessary till delivery ). 3. Unfit pa ent ( old women 90 years old with renal and heart problems we avoid surgical operations and use pessary instead). 4. Patients on waiting list for surgical operation (e.g. patient with prolapse and fit for surgery after one month; during this period we put a pessary). Pessaries are two types: 1- Ring Pessary حلقة داي رية ; it is a silicon ring with multiple sizes commoly used in our hospitals. 2- Shelf Pessary حلقة صلبة معدنية ; extremely rare to be used. What is the adverse effect result from pessary use? Some types of Pessary considered as a forign body in the vagina, so it put a patient at high risk for infections, ulceration, and bleeding. especially a rubber pessary which was used before silicon type the new version.

To limit side effects >>>>> If a patient is old menopouse women we give her a Vaginal estrogen cream to minimize ulceration and infection. and ask her to be Rou nely checked every 6 months to one year after pessary use, and Using a silicon pessary because it is more safer than the rubber one regarding infections. Now we finished conservative and skip now to surgical treatment. 2- Surgery Dr. FAYEZ said there is always Osce station about surgical operations There is 3 scenarios you may face in the osce exam U may asked about management of a patient, preoperatively how to manage and care to your patient? Or post operative management and care? Or which operation is proper to do for that patient condition? <<<<<<<<<<< So becareful here Surgery considered a definitive treatment, but remember even with good surgeon and good surgery there is a risk of recurrence of prolapse. In order to minimize the the risk of prolapse recurrence we make 1- Preoperative assessment and preparation of the patient. 2- Operative care expert seurgeon. 3- Postoperative care.

Preoperative assessment, You must take care about your patient a- Avoid operation at high weigth (in obese patients) till she reduce her weight (e.g. women 100kg ask her to reduce her weight to 70 kg then operate ; that to prevent recurrence of prolapse). b- Avoid operation if a patient complain from chronic constipation till her condition treated; to prevent prolapse recurrence. c- If apatient is smoker ; ask her to stop smoking (e.g. if awomen refuse to stop smoking never never operate for her). d- If menapouse ; give her local vaginal estrogen cream 1 to 2 month preoperative to increase blood supply and aid in good healing after surgery. Osce station about preoperative management >>> a 58 years women old 100kg smoker. after taking history and physical exam diagnosed with rectocele and cystocele. Preoperatively, what is your role as a physisian? This women has risk factors increase recurrence of prolapse so I ask her to reduce her weight ll reach 70 kg then operate and in this period till her weight decrease we must put a pessary. Another risk factor is smoking so never operate in smoker women because that increase the risk of prolapse recurrence So ask her to stop smoking completely. If she was menapoused we give local vaginal estrogen cream before surgery ( 1 to 2 months ) to allow good healing postoperatively. Dr.fayez frequently ask this question in Osce Station What operation to be done? That depends on the patient conditions: 1- Age and family : Young women with incomplete family, different from women who completed their families. 2- Nature of prolapse : combined prolapse need different operation than one specific type of prolapse as cystocele.

Surgical operation for uterine prolapse is not the same for that of vaginal prolapse. There are 3 Types of surgical operations for uterine prolapse 1- vaginal hysterectomy ( considered the best choice and best operation in a patient completed her family ). 2- Manchester ( fothergill) operation by prof. fothergill for women who still need more babies. 3- Sacrohysteropexy (rarely used; but applied to women who refuse amputation of the cervix or vaginal hysteropexy (complete her family & wish to conserve the uterus). Mini osce Question Dr. frequently asked what is the best operation in patient with uterine prolapse? the answer is ( vaginal hysterectomy) if you said hysterectomy alone you will lose half of your mark, so becareful Osce station about operative management Which operation to do? Three scenarios about uterine prolapse surgery 1 st scenario 2 nd scenario in case of young patient complain of uterine prolapse 2 nd or 3 rd degree and completed her family what is the proper surgical operation here? vaginal hysterectomy ( in case of 1 st or 2 nd or 3 rd type uterine prolapse, and considered the best operation in case of a patient completed her family and don t want more childs). In case of young patient complain of uterine prolapse 2 nd or 3 rd degree and not complete her family what is the proper surgical operation here? The proper choice here is Manchester operation (fothergill) operation for women who still need more childs and not complete their families ( which is simple operation through vagina based on amputation part of the cervix partially,the normal length of healthy cervix is 3 cm but in case of prolapse it may reach 7 cm so we make par al amputa on and return it to its original length).

3 rd scenario 4 th scenario Similar to the case above but women completed her family the best choice is the vaginal hysterectomy. If a patient refuse any amputation or uterus resection And that what physician may face in elderly women. they may have uterine phobia and refuse any resection? NOW we finished talking about surgical operations related to uterine prolapse and we are going to talk about vaginal prolapse surgeries. The choice of treatment here is sacrohysteropexy sacro- sacrum >> hystero- indicating the uterus- >> pexy - surgical fixation of the organ. It is considered a simple operation, by laparotomy we open the abdomen and fix the uterus and strain it to the sacrum as we said it is rarely done As we mentioned, vaginal prolapse can be anterior vaginal wall prolapse as cystocele or urethrocele or posterior vaginal wall prolapse as rectocele and enterocele. Types of vaginal prolapse surgeries 1- Anterior colporrhaphy (for cystocele or urethrocele )Colpo in greek. ترقيع وتصليح repair Raphy means - غمدالسيف vagina 2- Posterior colpoperinorrhaphy for (rectocele) perino -perinium. 3- Resection of enterocele sac as hernial operations. 4- Abdominal Sacrocolpopexy (for vault prolapse). 5- Lefort s operation by professor lefort s ( applied in elder patient with vaginal and uterine prolapse ). Now summary about vaginal surgical operations in 4 cases Anterior vaginal wall prolapse we apply anterior colporrhaphy. If a women diagnosed with anterior vaginal wall prolapse cystocele or urethrocele our choice in surgery is (anterior colporrhaphy).

If a women diagnosed with posterior wall prolapse (rectocele) our choice of surgery here is (posterior colpoperineorrhaphy) We repair the perineum in addition to colpous posterior wall. If a women diagnosed with enterocele we cosider this situation as true hernia we resect the enterocele sac. If elder women diagnosed with vault prolapse how to treat surgically? By sacrocolpopexy we fix the vault of vagina to the sacrum. Look at this surgical process ; we are going to talk about this last surgical operation which discovered by professor le fort that helped elderly patints with combined prolapse (both vaginal and uterine ) and not responded to pessary. it is very simple operation, external to the vulva of vagina we take rectangular skin parts strips and make partial closure of the vagina; why partial closure?? To allow vaginal discharge to go outside, and that process make the prolapsed vagina and uterus behind the vaginal orifice introitus. And as we said le fort operation indicated to elderly women and frail patient who are unfit for Vaginal hysterectomy or pelvic floor repair, but it is rarely used. تمت بحمد الله تعالى Done by: Ahmad Shaban