Genital prolapse
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Transcript of Genital prolapse
GENITAL PROLAPSE
-dr.jason zachariah
Anatomy-supports of uterus and vagina What is prolapse? Aetiology Classification Symptoms Signs Differential diagnosis Complications Prophylaxis
DE LANCEY- 3 LEVEL SUPPORT
Level I- Uterosacral and cardinal ligaments-support the uterus and vaginal vault
Level II- Pelvic fascia and paracolpos- connects vagina to the white line on lateral pelvic wall through arcus tendinous
Level III- Levator ani- supports lower one third of vagina
WHAT IS PROLAPSE?
• 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
AETIOLOGY1.Atonicity and asthenia after menopause2.Child birth Birth injury, excessive stretching of pelvic
floor muscles and ligaments. Peripheral nerve injury -pudendal nerve Ventouse extraction-before cx is fully dilated Prolonged bearing down in second stage of
labor and Crede’s method Delivery at home, by untrained dais Big baby Rapid succession of pregnancies
3. Nulliparous Spina bifida Congenital weakness of pelvic floor
muscles4. Raised intra-abdominal pressure Chronic bronchitis abdominal tumors ascites obesity
5. Surgeries Abdominoperineal excision of rectum Radical vulvectomy Operations for stress incontinence6. Predisposition Smoking, chronic cough, constipation
CLASSIFICATION
Anterior vaginal wall Upper 2/3rd- Cystocele Lower 1/3rd- UrethrocelePosterior vaginal wall Upper 1/3rd- Enterocele(pouch of
Douglas hernia) Lower 2/3rd-Rectocele
cystourethrocele
CLASSIFICATION
Uterine descent 1st degree- Descent of cervix into the
vagina 2nd degree- Descent of cervix up to the
introitus 3rd degree- Descent of cervix outside
the introitus Procidentia- All of the uterus outside
the introitus
CYSTOCELE
ENTEROCELE
RECTOCELE
UTERINE PROLAPSE
1ST AND 2ND DEGREE PROLAPSE
3RD DEGREE PROLAPSE
SYMPTOMS
1. Mass coming down p/v (sensation of swelling or fullness in the vagina)
2. Backache3. Urinary symptoms: Difficulty in passing urine Incomplete evacuation-frequency Urgency and frequency (cystitis?) Painful micturition-infection Stress incontinence Retention of urine
4.Vaginal discharge- friction, decubitus ulcer
5. Coital difficulties6. Rectal symptoms-constipation
DECUBITUS ULCER
It is atrophic ulcer, found at the dependent part of the prolapsed mass lying outside the introitus
Surface keratinasation- cracks- infection- sloughing –ulceration
Impaired venous drainage, trauma due to friction
Reduction of prolapse and daily packing for 2 weeks
SIGNS When you ask the patient to cough it raises
the intra-abdomial pressure leading to:
Bulge in anterior vaginal wall in case of cystocele.
Bulging of the anterior and lower 1/3rd of vagina in case of cystourethocele,
Bulging of the posterior vaginal wall in case o f rectocele and enterocele.
Stress incontinence
Pinch Test:
Cough impulse in uterine prolapse leads to the expulsion of the mass PV.
In case of first degree prolapse examination is made by introducing speculum and one may see the cervical descent below the level of ischial spines.
DIFFERENTIAL DIAGNOSIS
Vulval cyst Cyst of anterior vaginal wall Urethral diverticula Congenital elongation of cervix Cervical fibroid polyp Chronic inversion Rectal prolapse
COMPLICATIONS
Kinking of ureter with resulting renal damage- procidentia, enterocele
UTI leading to upper renal tract infection and renal damage
Cancer of vagina-decubitus ulcer
PROPHYLAXIS
Antenatal physiotherapy,relaxation exercises Proper management of second stage of laboura)Generous episiotomyb)Low forceps deliveryc)Suturing of perenieal tear Post natal exercises Early postnatal ambulation Provision of adequate rest for first 6 months
after delivery Reasonable interval between pregnancies Prophylactic hormone replacement therapy