PROLAPSE PROLAPSE Supports of uterusSupports of uterus : :

-PASSIVE SUPPORTS -PASSIVE SUPPORTS -ACTIVE SUPPORTS -ACTIVE SUPPORTS

Passive SupportsPassive Supports : : Pubocervical Fascia Pubocervical Fascia Rectovaginal Fascia Rectovaginal Fascia

Cardinal uterosacral ligament complex. Cardinal uterosacral ligament complex.

Active SupportsActive Supports : : Pelvic diaphragm made up of Levator Pelvic diaphragm made up of Levator

Ani muscles. Ani muscles.

INCIDENCEINCIDENCE 10.20%10.20%AETIOLOGY : AETIOLOGY : - Atonicity & Aesthenia that follow menopause Atonicity & Aesthenia that follow menopause

-> due to estrogen deficiency. -> due to estrogen deficiency. - Birth injury of various kinds - Birth injury of various kinds - Home delivery Home delivery - Ventous extraction before full dilatation of cervix.Ventous extraction before full dilatation of cervix.- Prolonged bearing down in the second stage. Prolonged bearing down in the second stage. - Delivery of big baby Delivery of big baby - Crede’s method of extraction of placenta Crede’s method of extraction of placenta - Rapid succession of pregnancies Rapid succession of pregnancies - Raised intra abdominal pressure Raised intra abdominal pressure - Nulliparous prolapse Nulliparous prolapse - Previous surgeries – abdominoperineal excision of rectum, radical Previous surgeries – abdominoperineal excision of rectum, radical

vulvectomy vulvectomy

Classification : Classification : Anterior vaginal wall – Anterior vaginal wall – Cystourethrocele Cystourethrocele

Upper 2/3 – cystocele Upper 2/3 – cystocele Lower 1/3 – urethrocele Lower 1/3 – urethrocele

Posterior vaginal wall _Posterior vaginal wall _Upper 1/3 – Enterocele Upper 1/3 – Enterocele Lower 2/3 – Rectocele Lower 2/3 – Rectocele

Uterine descentUterine descent

11OO – Descent of the cervix into the vagina – Descent of the cervix into the vagina

22OO – Descent of the cervix upto the introitus – Descent of the cervix upto the introitus

33OO – Descent of the cervix outside the – Descent of the cervix outside the introitus introitus

ProcidentiaProcidentia – All of the uterus outside the – All of the uterus outside the introitus. introitus.

Complications : Complications : Decubitus Ulcer : Decubitus Ulcer : Caused by friction, congestion & circulating Caused by friction, congestion & circulating

changes in the dependent part of the prolapse. changes in the dependent part of the prolapse. It should be differentiated from Ca cervix. It should be differentiated from Ca cervix.

Elongation of cervix:Elongation of cervix: Happens with IIHappens with IIoo, III, IIIoo, uv prolapse. , uv prolapse.

Changes in the urinary tract : Changes in the urinary tract : - Obstructive Uropathy – Due to huge cystocele. Obstructive Uropathy – Due to huge cystocele. - Hydroureter due to procidentia Hydroureter due to procidentia - Hydronephrosis due to procidentia Hydronephrosis due to procidentia - Urinary tract infection. Urinary tract infection.

OthersOthers – Incarceration of prolapse. – Incarceration of prolapse.

SYMPTOMSSYMPTOMS

- C/o something descending in the vagina or C/o something descending in the vagina or something protruding either at the vulva or something protruding either at the vulva or externally. externally.

- Vague midsacral discomfort or backache Vague midsacral discomfort or backache relived by rest. relived by rest.

- Vaginal discharge : Due to chronic cervicitis, Vaginal discharge : Due to chronic cervicitis, vaginitis, decubitus ulcer. vaginitis, decubitus ulcer.

--Micturition disturbances : Micturition disturbances : stress incontinence stress incontinence frequency of Micturition : caused by frequency of Micturition : caused by

chronic cystitis / incomplete emptying of bladder. chronic cystitis / incomplete emptying of bladder. --Difficulty in micturition :Difficulty in micturition : In severe degrees of In severe degrees of

cystocele . cystocele .

--Coital difficulties :Coital difficulties : with III with IIIOO UV prolapse UV prolapse procidentia.procidentia.

CLINICAL EXAMINATION : CLINICAL EXAMINATION : Per speculum examination : Per speculum examination : - To determine vaginal prolpseTo determine vaginal prolpse- Degree of uterine descent / Degree of uterine descent /

conditions of cervix. conditions of cervix.

Pervaginal Examination :Pervaginal Examination : Length of cervix Length of cervix - Position & mobility of uterus. Position & mobility of uterus.

INVESTIGATIONS INVESTIGATIONS HB HB Urine Microscopy Urine Microscopy Urine for culture & Sensitivity Urine for culture & Sensitivity RBS RBS Blood urea Blood urea S. Creatinine S. Creatinine High vaginal swab in case of vaginitis High vaginal swab in case of vaginitis Cervical cytologyCervical cytology Fitness for surgery CXR, ECG Fitness for surgery CXR, ECG

DIFFERENTIAL DIAGNOSIS :DIFFERENTIAL DIAGNOSIS : Vulval cyst or tumor Vulval cyst or tumor Cyst of anterior vaginal wall Cyst of anterior vaginal wall Urethral diverticula Urethral diverticula Congenital elongation of cervix Congenital elongation of cervix Cervical fibroid polyp Cervical fibroid polyp Chronic inversion Chronic inversion Rectal prolapse Rectal prolapse

Prophylaxis : Prophylaxis : Antenatal physiotherapy,relaxation exercises.Antenatal physiotherapy,relaxation exercises. Attention to weight gain, anaemia. Attention to weight gain, anaemia. Proper management of 2Proper management of 2ndnd stage stage A generous episiotomyA generous episiotomy Early postnatal ambulationEarly postnatal ambulation Postnatal exercise & physiotherapy Postnatal exercise & physiotherapy Adequate rest for 6m after delivery. Adequate rest for 6m after delivery. Adequate spacing b/w pregnancies Adequate spacing b/w pregnancies Avoid multiparityAvoid multiparity Prophylactic HRT in menopausal women. Prophylactic HRT in menopausal women.

TREATMENT : TREATMENT : CONSERVATIVE TREATMENT CONSERVATIVE TREATMENT - Pessary - Pessary SURGERY SURGERY Pessary treatment : Pessary treatment : Made up of polyvinyl chloride Made up of polyvinyl chloride Indications : Indications : Young women planning a pregnancy Young women planning a pregnancy During early pregnancy During early pregnancy Puerperium Puerperium For temporary use For temporary use A women unfit for surgery A women unfit for surgery A woman refusing surgery A woman refusing surgery

LIMITATIONS : LIMITATIONS : Only a paliative measure Only a paliative measure Doesn’t cure stress incontinence Doesn’t cure stress incontinence Can cause vaginitis Can cause vaginitis Needs to be changed every 3 months. Needs to be changed every 3 months. May cause dysperunia May cause dysperunia May not be retained in the patulous vaginaMay not be retained in the patulous vagina A forgotten pessary can be the cause of ulcer, A forgotten pessary can be the cause of ulcer, carcinoma of vagina, vesicovaginal fistula. carcinoma of vagina, vesicovaginal fistula.

OPERATIVE TREATMENT : OPERATIVE TREATMENT : RADICAL RADICAL CONSERVATIVE CONSERVATIVE

Radical :Radical : Ward Mayo’s operation Ward Mayo’s operation Includes Includes a)a) Anterior Colporaphy – to repair cystocele, Anterior Colporaphy – to repair cystocele,

cystourethrocelecystourethroceleb)b) Posterior colporaphy & Colpoperineoraphy Posterior colporaphy & Colpoperineoraphy c)c) Vaginal HysterectomyVaginal Hysterectomy

CONSERVATIVE SURGERIES : CONSERVATIVE SURGERIES : FOTHERGILL’S REPAIR ( MANCHESTER OPERATION)FOTHERGILL’S REPAIR ( MANCHESTER OPERATION)

Combines anterior colporaphy, posterior Colpoperineoraphy, Combines anterior colporaphy, posterior Colpoperineoraphy, amputation of cervix, suturing the cut ends of the MackenRodt’s amputation of cervix, suturing the cut ends of the MackenRodt’s infront of the cervix, covering the raw area. infront of the cervix, covering the raw area.

Advantages : Advantages : Preserves menstrual & Child bearing function. Preserves menstrual & Child bearing function. Disadvantages : Disadvantages : Incompetent OS Incompetent OS cervical dystociacervical dystocia Hematometra Hematometra Recurrence of Prolapse. Recurrence of Prolapse.

ANTERIOR REPAIR

ANTERIOR REPAIR

ANTERIOR REPAIR

POSTERIOR REPAIR

POSTERIOR REPAIR

POSTERIOR REPAIR

SHIRODHKAR’S SHIRODHKAR’S Uteroscaral ligaments are crossed & Stitched in front of the cervix. Uteroscaral ligaments are crossed & Stitched in front of the cervix.

LEFORT’S REPAIRLEFORT’S REPAIR : : Ind :Ind : -Very elderly menopausal patient with advanced -Very elderly menopausal patient with advanced prolapse. prolapse. - Women with medical risk factors. - Women with medical risk factors.

Procedure : Procedure : Creation of raw area on the anterior & posterior vaginal wall & Creation of raw area on the anterior & posterior vaginal wall &

apposition with catgut. apposition with catgut.

Limitation : Limitation : Limits marital function.Limits marital function. Some may develop stress incontinence. Some may develop stress incontinence. Contraindication : Contraindication : menstruating woman menstruating woman

diseased cervix & uterus. diseased cervix & uterus.

ABDOMINAL SLING OPERATION : ABDOMINAL SLING OPERATION : For young women suffering from second or third For young women suffering from second or third

degree UV prolapse. degree UV prolapse.

Aim : Aim : To buttress the weakened support by providing a To buttress the weakened support by providing a

substitute ( Nylon or dacron tape) substitute ( Nylon or dacron tape)

ABDOMINO CERVICOPEXY : ABDOMINO CERVICOPEXY : Elevation of two musculofascial lining from rectus sheath Elevation of two musculofascial lining from rectus sheath

laterally & anchoring them infront of the uterine isthmus. laterally & anchoring them infront of the uterine isthmus.

PURANDARE & MHATRE OPERATION :PURANDARE & MHATRE OPERATION : Attaching the tape posteriorly on the cervix Attaching the tape posteriorly on the cervix

close to the attachments of uterosacrals, close to the attachments of uterosacrals, anteriorly to the external oblique aponeurosis. anteriorly to the external oblique aponeurosis.

KHANNA’S SLING OPERATION : KHANNA’S SLING OPERATION :

Mersilene tape is fixed to the isthmus posteriorly Mersilene tape is fixed to the isthmus posteriorly & anterior superior iliac spine anteriorly. & anterior superior iliac spine anteriorly.

OTHERS : OTHERS : Shirodkar’s abdominal sling operation Shirodkar’s abdominal sling operation Virkud’s sling operation Virkud’s sling operation Mangeshkar’s laparoscopic techniqueMangeshkar’s laparoscopic technique Neeta warty’s technique. Neeta warty’s technique.

VAULT PROLAPSE VAULT PROLAPSE

Incidence :Incidence : 3-6 per thousand. 3-6 per thousand.

Aetiology : Aetiology : Weak supports Weak supports Failure to identify enterocele Failure to identify enterocele Technical errors in previous surgery Technical errors in previous surgery Age, parity, estrogen deficiency Age, parity, estrogen deficiency Obesity, chronic cough. Obesity, chronic cough.

VAULT PROLAPSEVAULT PROLAPSE

Treatment : Treatment : a)a) Right transvaginal sacrospinous colpopexy. Right transvaginal sacrospinous colpopexy. b)b) Transabdominal sacral colpopexy. Transabdominal sacral colpopexy. c)c) Colpocleisis. Colpocleisis. d)d) Lefort’s repair Lefort’s repair e)e) Laparoscopic colpopexy Laparoscopic colpopexy f)f) Abdomino perineal surgery – If associated Abdomino perineal surgery – If associated

with rectal prolapse. with rectal prolapse. g)g) Ring Pessary – for patient unfit for surgery. Ring Pessary – for patient unfit for surgery. h)h) Posterior intravaginal sling. Posterior intravaginal sling.