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