GENITAL PROLAPSE

Genital prolapse is the downward descent of the uterus and /or the vagina towards or through the introitus
Occurr in about 10-30% of multiparous women and in 2% of nulliparous women .
TYPES
PELVIC SUPPORT
ETIOLOGY & PATHOPHYSIO
PREVENTION
UTERINE
VAGINAL
UTERUS
Weakening of and damage to the
Genital
supporting structures of the pelvic
prolapse is a
1st degree:
Cystocele: Prolapse i) Transverse @
organs:
preventable
Cardinal @
Descent of the
of the upper 2/3 of
1. Childbirth: (most imp)
disease
cervix within
the anterior vaginal Mackenrodts
Increasing
parity,
prolonged
labour,
1. Prevention
cervical
the vagina.
wall and the
bearing
down
before
full
cervical
during
ligaments.
2nd degree:
bladder.
dilatation and difficult instrumental
childbirth:
ii) Uterosacral
Descent of the Urethrocele:
deliveries.
Good labor
ligaments
cervix thru the
Prolapse of the
2. Chronic elevation in intramanagement,
iii) Pubocervical
introitus.
lowest 1/3 of the
abdominal
pressure:
Obesity,
postnatal pelvic
ligaments
3rd degree
anterior vaginal
smoking,
chronic
cough,
chronic
floor exercises,
wall and the
(Procidentia):
constip, heavy lifting at work, abd
family planning.
Dont give
urethra.
Descent of the
masses
and
ascites
.
support
to
the

Rectocele:
Prolapse
2. Avoiding
cervix and the
3.
Menopause:
Weakness
of
the
pelvic
uterus,
ie
broad
whole uterus
of the posterior
intra-abd
support due to collagen and
ligaments, round
through the
vaginal wall and
pressure
weakness of the connective tissue
ligaments and the
introitus.
the rectum.
Obesity ,
4. Pelvic surgery :
levator ani
Enterocele: True
smoking,

Abd
/
vaginal
hysterectomy

muscles
chronic cough
hernia of the pouch
Vault prolapse
and chronic
of Douglas through
Composuspension Rectocele
VAGINA
constipation
the posterior
and enterocele.
3. Prevention
vaginal fornix - may Pelvic floor
muscles
(the
5.
Congenital
prolapsed
congenital

postmenopa
contain bowel or
levator
ani
amount
of
collagen
and
weakness
usal:
omentum.
muscles mainly
of connective tissue of the pelvic
Balanced diet,
Vault prolapse:
and the
support. For the prolapse in 2% of
exercise,
Inversion of the
superficial
and
nulliparous
women
.
calcium & by
vaginal apex which
deep
transverse
6.
Racial
variation
.
the increased
occur after
perineal
muscles)
Common
in
Caucasian
women
,
less
use of HRT.
abdominal or
and by the pelvic
common in Asians , and rare in Blacks .
vaginal
floor fascia.
Variation in the amount of collagen and
hysterectomy.
connective tissue in the pelvic support.

DIAGNOSIS
EXAMINATION
DDx:
- Inspection of the vulva with cough and
Anterior
straining demonstrate severe prolapse and
vaginal wall
A feeling of something coming down below or a lump may demonstrate stress incontinence
prolapse:
(provided the bladder is full)
within the vagina or protruding from the introitus DDx: Congenital
- Speculum examination either dorsal
Gartners cyst,
worse at the end of the day, on standing and
position
(Bivalve)
or
left
lateral
position
inclusion dermoid
coughing, and by lying down.
(Sims).
cyst & urethral
- Other sx, depends on the organ which prolapsed into
- Rectal examination - differentiate between diverticulum.
the vagina.
rectocele (finger goes thru it) from
Uterine
Uterine prolapse: Low backache - central, worse at
enterocele (finger goes high up) .
prolapse:
the end of the day, on standing and by lying
DDx: large
down.
INVESTIGATIONS:
cervical or
Cystocele: Urinary sx, pt has to reduce the cystocele - MSU for analysis and culture.
endometrial
to empty her bladder.
- Renal ultrasound and IVU in cases of
polyp & chronic
Rectocele: Constipation, incomplete rectal
procidentia and severe cystocele to exclude
uterine inversion
evacuation and the patient has to reduce the
hydroureter & hydronephrosis.
rectocele digitally to empty her rectum.
- Cystometry in cases of incontinence, to
exclude urge incontinence
Procidentia: Ulcer, blood stained or purulent vaginal
discharge.
Coital problems - uncomfortable or difficult intercourse
in uterine and vaginal prolapse.
MANAGEMENT
CONSERVATIVE TREATMENT: PESSARY
INDICATIONS
TYPES
SIDE EFFECTS & THEIR MANAGEMENT
- Patient unfit for surgery .
Vaginal infection and discharge, ulceration and bleeding.
Ring pessary
- Patient refuses surgery .
commonly used
- During pregnancy and after delivery .
Precautions:
pessary.
- During waiting time for surgery.
Shelf pessary Use silicon pessary.
- As a therapeutic test to confirm that
Change the pessary yearly or earlier if infection or
rarely used
HISTORY
Sx depends on the site, type & degree of the prolapsed.

surgery may help.

ulceration occurred.
Use of vaginal estrogen cream in menopausal patients.

SURGICAL TREATMENT
PRE-OPERATIVE ASSESSMENT
TYPE OF SURGERY
Aims of surgery: Correct prolapse, maintain
Depends on: 1. Type of prolapsed, 2. Age and parity
UTERINE
VAGINAL
continence and preserve coital function.
i.
Vaginal
hysterectomy
the
i)
Cystocele
&
Success of the surgery depends on:
preferred operation in
Urethrocele:
1. Preoperative preparation of the patient such as
uterine prolapsed. For young Anterior
reduce weight in obese, stop smoking and
colporrhaphy.
treatment of chronic cough. (Gynaecologist cant do patients who complete the
family and in menopausal
ii) Rectocele:
his part unless the patient fulfills hers).
patients.
Posterior
2. Postoperative care
colpoperineorrhaphy
POST-OPERATIVE CARE
ii. Manchester (Fothergill)
.
Immediate postoperative care :
operation.
iii) Enterocele:
Vaginal pack remove within 24h.
Indicated
in
young
patients
Resection of
Foleys catheter - remove after 1- 2 days.
who not complete the
enterocele sac.
Prophylactic antibiotics: Metronidazole and
family.
iv) Vault prolapsed:
cephalosporin
Consisted
of
:
Abdominal
Instructions after discharge - to minimize recurrence
1. Partial amputation of
sacrocolpopexy.
Avoiding intercourse for 6 wks.
the cervix
Gradual return to normal activities over 2
2. Shortening of the
months.
transverse cervical
Avoiding smoking, obesity, constipation and
ligaments and suturing
lifting of heavy objects.
them to the front of cervical
Elective C.S. in the subsequent pregnancy.
stump.
RECURRENT PROLAPSE

of the patient
LEFORT
- Rarely
indicated in
elderly and
frail patients
who are unfit
for vaginal
hysterectomy
or pelvic floor
repair.
- Rectangular
strips of
vaginal
epithelium are
removed from
the anterior
and posterior
vaginal walls in
order to obtain
a partial
closure of the

Recurrence occur in about 20-25%

Even with expert surgery and good postoperative
care, recurrence can occur, esp in the presence
of obesity, smoking and constipation.

3. Anterior and posterior

repair.
iii. Sacrohysteropexy
In patients who complete
the family and wish to
conserve the uterus

vagina.