Management Of Genital Prolapse

Associate Professor Semyatov S.M.

Department of Obstetrics and Gynecology
with course Perinatology
Peoples’ Friendship University of Russia, Moscow
 DEFINITION
Prolapse/Procidentia is downward decent of
uterus &/or vagina.
(Procidentia is from Latin procidere - to fall).
It is a state of pelvic relaxation due to a
disorder of pelvic support structures that is,
the endopelvic fascia.
It is not a disease but a disabling condition.
 CAUSE
• WEAKNESS OF THE SUPPORTS OF THE
UTERUS & VAGINA
• Precipitating / Exaggerating / Unmasking Causes -
– INCREASED INTRA ABDOMINAL PRESSURE
• Chronic cough
• Chronic Constipation
• Heavy Wt.Lifting / domestic Work
• Obesity, Ascitis
– WEAKNESS OF THE SUPPORTS & MUSCLES
• Chronic ill health, malnutrition dysentery, anemia
• Inadequate rest during pureperium
• Menopause
 TYPES OF PROLAPSE
• Vaginal • Uterine/Utero-vaginal-
• Anterior –cystocele & Acquired or Congenital.
urethrocele – First degree.
• Posterior - Enterocele & – Second degree &.
Rectocele – Third degree-(total
Prolapse / complete
• Vault Prolapse - a procidentia).
special term applied to • However Procidentia is
the prolapse of upper often used only to
vagina denote third degree
uterine prolapse.
 EFFECTS OF PROLAPSE
• NO SYMPTOM- mild & moderate prolapse.
• Discomfort & disability.
• Sexual Dysfunction.
• URINARY- Frequency, Dysuria, Stress
incontinence, infection.
• Incomplete emptying of rectum.
• Discharge.
• Backache.
• Ulceration & Infection.
 WHEN TO TREAT ?
• Should be treated only when it is symptomatic
(Be certain symptoms are due to Prolapse )
• Interferes with the normal activity of the
woman
• The patient seeks treatment
 HOW TO TREAT ?
• NON-SURGICAL Methods: -Limited Role
– PELVIC FLOOR REHABILITATION (pelvic muscle
exercises, galvanic stimulation, physiotherapy,
rest in the purperium).
– HORMONE REPLACEMENT, both systemic and
local.
– PESSARY TREATMENT for temporary relief
• During Pregnancy, Puerperium & Lactation
• When Operation is Unsafe due to Extreme
Senility/Debility and Diseases
• Preoperatively
• For therapeutic test
 HOW TO TREAT ?
• SURGICAL TREATMENT:
-RECONSTRUCTIVE SURGERY is invariably
needed and has to be a COMBINATION OF
PROCEDURES to correct the multiple
defects.
 SURGICAL TREATMENT
• It is the definitive & curative treatment of
Prolapse.
• It is a cold operation. So complete
investigation should be done & all existing
diseases & disorders should be treated first.
• Pre operative pessary/tampoon & or Hormone
treatment should be given as indicated.
• Meticulous and through examination under
anaesthesia should be done before deciding
the surgery.
 SURGICAL TREATMENT
• Depending on the type & extent of Prolapse, surgery
should be tailor made not only to rectify the defect
but also to suit the individual patient’s requirement.
• Absolute haemostasis is mandatory. Diathermy
should be liberally used.
• Vaginal suturing should be with interrupted stitches.
Synthetic absorbable fine sutures are preferable.
• Catheter for more than 48 hrs should be exceptional.
• Strict antibiotic prophylaxis is essential
 VAGINAL OPERATIONS FOR
PROLAPSE
• Anterior colporrhaphy
• Posterior colporrhapry- High / Low
• Enterocele repair
• Perineorrhaphy
• Amputation of cervix
• Paravaginal repair
• Hysterectomy with or without Colporrhaphy /
Perineorrhaphy
 VAGINAL OPERATIONS FOR
PROLAPSE
• Manchester/ Fothergill’s operation &
Shirodkar’s modification
• Uterus/Cervix suspension/fixation
• Vaginal vault suspension/fixation
• Retro-rectal levatorplasty and post. anal repair
for associated rectal prolapse
• Vaginectomy ?
• Colpocleisis ?
 Anterior colporrhaphy &
Urethroplasty
• For correction of Cystocele & Urethrocele
• Incision- Midline / Inv.T / Elliptical
• Excision of vagina according to the size & site
of laxity
• Avoid shortening &/or narrowing of vagina
• Closure with interrupted sutures
 Posterior colporrhaphy &
Enterocele repair
• For correction of Enterocele & Rectocele
• Enterocele repair can be done either by
vaginal or abdominal route depending on the
associated procedures.
• Approximation of uterosacral ligaments for
enterocele & prerectal fasciae and levator for
rectocele with interrupted sutures is essential
• Excision of vagina should be tailor made
• Perineorrhapy to be done only if perineal body
is torn
 Perineorrhaphy
• Not an Operation for prolapse, but Indicated
only for associated old 2nd degree perineal tear
• Performed along with posterior colporrhaphy
• Aim-Reconstruction of the Perineal body and
reduction of gaping introitus.
• Can cause Dyspareunea
• Essential steps - Excision of the scar tissue &
approximation of levator ani & superficial
perineal muscles
Vaginal Hysterectomy with/without
Vaginal repair
• Indicated when uterus needs removal, in old age &
in total prolapse.
• Patient’s consent is mandatory knowing that there
are alternatives to hysterectomy.
• Usually combined with Ant. & Posterior
colporrhaphy.
• Perineorrhaphy is not mandatory but case specific.
• Vault suspension is an essential step.
• If sexual function is not needed narrowing of vaginal
canal should be done.
 Amputation of cervix
• Not for Prolapse.Indicated only for cervical
elongation (Uterocervical length >12.5 Cm )
• To be done only as a part of Fothergill’s
repair/sling operations.
• Adequate cervical dilatation - a prerequisite
• Bladder displacement is a must
• Excision of cervix should not exceed 2 cm
• Likely to affect reproductive life
• Long-term complications are real risks
 Fothergill’s operation
• It is the operation of choice in uncomplicated
Utero-vaginal prolapse when uterus is to be
preserved but NO future child bearing is
required.
• It is a combination of, Amp. of Cx., Fixation of
the Meconrodt’s ligament to the anterior of Cx. &
Ant. Colporrhaphy. D&C is a must.
• Post. Colporrhaphy to be performed only if
Ent/Rectocele is present
• Perineorrhaphy is usually not required
 Fothergill’s operation
• Not useful if ligaments are weak & Uterus is of
normal size. Purandare’s modification may
help.
• Technically difficult operation, requiring high
degree of surgical skill.
• Threat of short-term complications.
• Real possibilities of long term complications.
• Recurrence/Failure.
• Sling operations are better alternatives
• HAS A BLEAK FUTURE
ABDOMINAL OPERATIONS FOR
PROLAPSE
• Sling operations
• Closure or repair of enterocele
• Sacrocolpopexy
• Anterior Colpopexy
• Colposuspension
• Paravaginal repair
 Abdominal Sling operations
• Indicated when the ligaments are extremely weak as
in nullipara & young women.
• Preserves reproductive function.
• Principle - With a fascial strip / prosthetic material
(Merselene tape or Dacron) the Cx is fixed to the
abdominal wall / sacrum / pelvis.
• Amp.of Cx should also be done if Utereocervical
length >12.5cm.
• Cystocele/Rectocele repair if needed can be done
vaginally before or after.
• Enterocele repair can also be done abdominally.
 Abdominal Sling operations
• It is a major abdominal operation & Synthetic
material is costly & not widely available in
India.
• Types-.
– Shirodkar’s posterior sling.
– Purandare’s anterior cervicopexy.
– Khanna’s sling.
– Virkud’s composite sling.
 Shirodkar’s sling
• Tape is fixed to the post. Aspect of isthmus &
sacral promontory
• Anatomically most correct but difficult to
perform
• Risks of complication
 Purandare’s cervicopexy
• Tape is anchored to the ant.aspect of isthmus
and ant. abd. Wall
• Easy to perform
• Dynamic support
Virkud’s composite sling operation
• Tape is anchored from the post aspect of
isthmus to sacral promontory on the Rt. side &
ant. abd. Wall on the Lt. Side
• Utrosacral ligament is plicated
• Technically easy
 Khanna’s sling operation
• Tape is anchored to ant aspect of isthmus &
ant. sup. Iliac spine
• Easier to perform and safer
• But tape is superficial
• Risk of infection
 Abdominal Colpopexy /
Colposuspension
• Indicated when vault prolapse occurs after
hysterectomy or vaginal laxity is to be corrected
at abdominal hysterectomy.
• Major abdominal operation & technically difficult.
• Sexual function is preserved.
• Methods-.
– Sacrocolpopexy.
– Ant.Colpopexy.
– Colposuspension.
 Sacrocolpopexy
• Vault is fixed to 3rd & 4th sacral vertebrae
with a facial strip / proline mesh under the
peritoneum to the right of rectum
• Enterocele repair can be done if required
 Ant.Colpopexy
• Corrects ant. vag laxity & stress inc.
• Useful at abdominal hysterectomy / for vault
prolapse.
• Extra peritoneal supra pubic approach if done
alone.
• Enterocele repair if required.
• Vagina stitched to the ileo-pectineal
ligaments.
 Vault / Colposuspension
• Vault is fixed to the abdominal wall by a facial
strip or merseline tape
 LAPAROSCOPIC SURGERY
PROLAPSE
• Advantages of M I S-small incision, better view,
haemostasis, no packing, minimal tissue & bowel
handling, short recovery, less pain, insignificant scar
• Can all types of prolapse be treated?- Yes.
• Ant. / Post. Lower vaginal repairs if needed can also
be done vaginally before or after lap.Surgery
• However extended period of rest is essential
• Expertise is needed
• Presently cannot be widely practised
• This is the surgery of the future today
 LAPAROSCOPIC SURGERY
PROLAPSE
• PROCEDURES:-
– Cervicopexy / Sling operations with/without
Lap.Paravaginal repair / Vaginal repair
– VH / LAVH / LH / TLH + Colposuspension
– VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction
– Rectocele repair & levatorplasty
– Enterocele repair with suturing of uterosacral
ligaments
– Colpopexy- Ant / Post
 Laparoscopic Cervicopexy/sling
Operations
• All types of sling operations can be better
performed by laparoscopy
• Associated vaginal prolapse can also be
repaired laparoscopically (Lap.Paravaginal
repair)
• Vaginal Ant./Post. colporrhaphy can be done
before / after laparoscopy
 Laparoscopic Vault suspension/
Culdoplasty)
• Can be done with VH / LAVH / LH / TLH
• Corrects mild laxity
• Prevents vault prolapse
 Laparoscopic Pelvic
Reconstruction
With VH / LAVH / LH / TLH
• An alternative to Ward-Mayo’s operation
• Before Hys., Lap.Ureteral dissection is done and
suture placed in uterosacral ligament near
sacrum & left long, for latter vaginal vault
suspension
• Lap. levator plication if needed
• Enterocele repair and suturing of uterosacral
ligaments if needed
• Retro pubic Colposuspension (Bruch) if required
 Laparoscopic Rectocele repair &
Levatoroplasty
• Rectovaginal space is opened & rectum
dissected
• Interrupted sutures given in the levator in the
midline
• Enterocele repair done if indicated
• Vaginal vault suspension done
 Laparoscopic Enterocele repair
• Rectovaginal space is opened, sac excised
and purse string suture given
• Uterosacral ligament sutured
 Laparoscopic Post Colpopexy /
Sacrocolpopexy
• Indicated for vault prolapse
• Enterocele if present is first repaired
• Prolene mesh is fixed to the vault & 3rd-4th
sacral vertebrae, under the peritoneum in the
Rt.para rectal space
Time has come for Laparoscopic
Surgery for Prolapse
So move with the times.
Practice laparoscopy.
This is the Surgery of the future
today.