Genital Prolapse Prolapse is a common complaint of elderly women in gyn- ecological practice. Normally, when a woman strains there is no descent either of the vaginal walls or of the uterus. In prolapse, straining causes protrusion of the vaginal walls at the vaginal orifice, while in severe cases. the cervix of the uterus may be pushed down to the level of the vulva, In extreme cases, the whole uterus and most of the vaginal walls may extrude from the vagina. ‘This happens mostly in postmenopausal and multiparous ‘Nulliparous prolapse is seen in 2% and vault prolapse in 0.5% cases following hysterectomy. Supports of the Genital Tract DeLancey introduced three level system of support. = Level l—Uterosacral and cardinal ligaments support the uterus and vaginal vault, The cervix remains at or just above the ischial spines, and the vagina lies horizontally. = Level Il—Pelvic fascias and paracolpos which connects the vagina to the white line on the lateral pelvic wall through the arcus tendineus. This includes the pubocer- vical fascia anteriorly and the rectovaginal fascia and septum posteriorly. = Level Ill—Levator ani muscle supports the lower one- third of the vagina. The levator muscle forms a platform against which the pelvic organs (uterus and upper va~ gina) gets compressed during straining, = Level I damage causes ulerine descent, enterocele, vault descent, = Level Il damage causes cystocele, rectocel. = Level II damage causes urethrocele, gaping introitus and deficient perineum. For diagrammatic representations of DeLancey's three levels ‘of support to the genital tract, refer to Figures 25.1 and 25.2. Clinically unrecognized damages and breaks in these supports can be detected by ultrasound and MRI. A ‘The most important aetiological factor in prolapse is atonic- ity and asthenia that follow menopause. Most women who develop prolapse are of menopausal age when the pelvic floor muscles and the ligaments that support the female genital tract become slack and atonic. Many women de- velop minor degrees of prolapse soon after childbirth, yet if they exercise their pelvic floor muscles and improve their general muscular tone, they can control the prolapse. A. major degree of prolapse can be considerably reduced by postnatal pelvic floor exercises because in these young ‘women muscle tone can be regained by exercise. This does not however apply to menopausal women whose support hhas become atonic due to oestrogen deficiency and decreased collagen content in the fascias. A birth injury is another important aetiological factor. Initial unrecognized injury during childbirth may be considerable. A perineal tear is less harmful than the exces- sive stretching of the pelvic floor muscles and ligaments that occurs during childbirth because overstretching causes atonicity whereas a torn muscle can be stitched or toned 349 logy of Prolapse (Table 25.1)350 Shaw's Textbook of Gynaecology Ischia spine and ligament Levator an Pubocervical yy Lovel it ~ Rectovaginal fascia Figure 25.1 Supports of the genital tract (From Figure 21-5. lan Symonds and Sabarainam Arulcumaran’ Essential Obstetrics and Gynaecology, Sth Fe, Elsevier, 20°3) SSecrum Uterus Insertion of cardinal igarent Rectum Blader Uterosacral ligaments: Symphysis Pubocervcal fascia Uretnra Perineal body Vaginal vaut. Levator an (Pubococcygous) Figure 25.2 Various supports ofthe uterus Hz prolapse Aronicty + Menopause © Congenital weakness + Muttioarity Birth injuries + Prolonged labour + Perineal tear + Pudendal nerve injury + Operative delivery, + Muttiparity + Big baby + Raised intra-abdominal pressure + Chronic bronchitis up. For example, a patient with a complete perineal tear probably exercises her levator muscles continuously and to ‘an extreme degree in order to obtain some sphincteric con- trol over the rectum, and in this way, tones up not only the muscles of the pelvic oor but all the ligamentary supports in the pelvis. A complete perineal tear is therefore not fol- lowed by prolapse. Squatting position used during delivery may cause excessive stretching of the pelvic floor muscles and ligaments, and lead to genital prolapse a few years later. In recent years, perineal ultrasound imaging has contrib- uted to our understanding of birth injuries to the pelvic floor muscles and sphincters caused by vaginal delivery. Peripheral nerve injury such as to the pudendal nerve dur ing childbirth causes prolapse which is reversible in 60%: it may also be responsible for stress incontinence of urine. In India, a higher incidence and a more severe degree of, uuterovaginal prolapse occurs in women who are delivered at home by dais (untrained midwives). This is because the patients are made to hear down before full dilatation of the cervix and when the bladder is not empty. Moreover, the second stage of labour is prolonged with undue stretching of the pelvic floor muscles as episiotomy is not employed by the dais. Episiotomy prevents muscle stretching and thereby atonicity, Likewise, the use of forceps in the case of pro- longed second stage protects against prolapse. Another reason for a high incidence of prolapse is that circum- stances force poor women to resume their heavy work soon after delivery without any rest or pelvic floor exercises. Cases delivered by caesarean section hardly ever develop prolapse. Prolapse seen in unmarried or mulliparous women is at- twibuted to spina bifida occulta and split pelvis which result im inherent weakness of the pelvic floor support. Patients who demonstrate congenital weakness of the pelvic floor mus: cles have an easy or a precipitate labour. Congenital pro- lapse in the newborn has been reported and though it can be controlled. itslikely that such a prolapse may recur later in hfe or following childbirth. A family history of prolapse confirms the congenital nature of prolapse. Ventouse extraction of the fetus before the cervix is fully dilated can result in overstretching of both Mackenrodt'sliga- ments and the uterosacral ligaments. and cause prolapse, Prolonged bearing down in the second stage and Cred's method of downward vigorous push on the uterus to expel the placenta may weaken the ligamentary supports of the genital tract. Lacerations of the perineal body during childbirth, un- less sutured immediately, will widen the hiatus urogenitalis Delivery of a big baby also stretches the perineal muscles and leads to patulous introitus and prolapse. Precipitate labour and fiandal pressure may also be responsible for prolapse. Rapid succession of premancies preclude proper puerps rehabilitation, and there will bea tendency to develop prolapse ‘Raised intra-abdominal pressure due to chronic bronchitis, large abdominal tumours or obesity tends to increase any degree of prolapse which may previously be present. Smoking, chronic cough and constipation are the predisposing factors. Abdominoperineal excision of the rectum and radical vulvee tomy are surgical procedures that are known to cause prolapse postoperatively. Operations for stress incontinence such as Stamey and Pereyra operations leave a hiatus in the vaginal wall causing cystocele and enterocele, while elevating the blad- der neck. Classification of Prolapse (Figures 25.3 and 25.4) Anterior vaginal wall (Figure 25.5) Upper two-third—Cystocele TDeerantart—trtmae | OseFigure 25.3 Pelvic organ prolapse quantification system (POP-Q). (from Figure 29. an. Symonds and Sabarainam Arukumaran Essential Obstetrics ang Gynaecology, Sth Fa, Flsevier, 2013] Chapter 25 + Genital Prolapse 351 Posterior vaginal wall Upper one-third—Enterocele (pouch of Douglas hernia) igure 25.6) Lower two-third—Rectocele 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 (Figures 25.7- 25.9) Cystocele ‘The bladder is supported by pubocervical fascia which extends laterally to the arcus tendineus and fuses with the levator ani muscle below. The urethra is supported by the posterior urethral ligament which is fixed to the pubic bone, ‘naBa SD c | cBp y Bp x Ap au] a | 420 aul aa | 6c 45m | 156 | Su 450 | te | Bu ae] 2% | - we | ase | 8 Profile A Profile B Figure 25.4 Pelvic organ prolapse quantification (POP-) system for staging pelvic organ prolapse. Aa: Point A anterior, Ap: Point A posterior: 8a: Point B anterior Bp: Point & posterior; C:, Cervix or vaginal cutf D: Posterior fornix (if cervix is present}, gh: Genital hiatus; pbb: Perineal body; tv: Total vaginal length, (From Figure 111. Vicot Nt: Vaginal Surgery for the Urologist. Saunders: evi, 2012)