16-Genital Prolapse

At the end of this lecture:
The student should be able to

1. Define prolapse.
2. Classify prolapse using a simple conventional system.
3. Understand the anatomical basis of genital prolapse.
4. Discuss the aetiological factors associated with genital prolapse.
5. Understand the clinical presentation of genital prolapse.
6. Initiate appropriate investigations in a patient with genital prolapse.
7. Understand the basis of non-surgical and surgical treatment of genital
prolapse.
8. Offer appropriate counselling for prophylaxis of genital prolapse.
9. Should be able to diagnose and offer basic advise on the treatment and
prophylaxis of genital prolapse.
A 56 year old para 6+2+4+7 who attained
menopause 2 years ago presented in the clinic with
the complaints of “something” protruding through
the vagina for about 8 months. In the last two
months she has had some backache, a troublesome
cough and more recently she had some difficulties
with her “water” control. Discuss the management
of this case
MAIN PROBLEMS
AGE - 56 years
PARITY: 6+2+4+7
MAIN SYMPTOMS:
- “Something” protruding through the vagina - 8 months
- Back ache
- Cough troublesome
- “Water” control
Prolapse is defined as:-
Herniation or protrusion or descent of one or more of
the pelvic viscera through the vagina as a result of a
defect in the pelvic floor due to damage or weakness.
Simply put-one of the pelvic viscera “falls through” or
“protrudes” through the vagina as a “mass”
Which pelvic viscera / organs are involved?
Urethra, Bladder
Uterus
Bowels, Rectum.
Urethrocele (Urethrocoele)
Sagging of urethra and the associated anterior vaginal
wall into the vaginal lumen
Cystocele (Cystocoele)
Herniation or protrusion of the bladder into the vaginal
canal
Usually involves anterior vaginal wall ,
May be mild, moderate or severe (or small, average,
Large).
May co-exist with prolapse of the urethra when the
terminology should be Cysto-urethrocele.
Uterovaginal prolapse
Descent of the cervix and uterus along the axis of the
vaginal canal.
In severe cases, the vagina is everted and the cervix

occupies a position outside vagina.
Degree of prolapse depends on location of cervix /

uterus in vagina.
Retroversion of uterus-
A NEW CLASSIFICATION OF THE VARIOUS STAGES
OF UTEROVAGINAL PROLAPSE EXISTS BUT WE
SHALL USE THE WELL ESTABLISHED STAGING
First Degree
Cervix descends within the vagina but does not reach
introitus
Second Degree
Descent of the cervix to the introitus
Cervix may descend beyond introitus with straining but
return to introitus later
Third Degree (Procidentia)

Descent of the cervix beyond the introitus
(without straining i.e. at rest)
In some cases – uterus lies completely outside vagina-
walls of vagina everted
Vault Prolapse
Hernation usually of bowels through vaginal vault after
hysterectomy.
Enterocele (Enterocoele)
Hernation / out pouching / protrusion of peritoneum
over pouch of Douglas (through posterior vaginal
fornix) Sca usually contains loops of bowl.
Rectocele (Rectocoele)
Sagging or protrusion of rectum into the vagina. May
be mild, moderate or severe (small, Average, Large).
Note
Utero-vaginal prolapse which technically applies to
prolapse of the uterus is frequently (almost
always) associated with
1. Prolapse of organs through the anterior vaginal wall
- Urethrocele / Cystocele
2. Prolapse of organs through the pouch of Douglas
and posterior vaginal wall
- Enterocele / Rectocele
Various combinations of above entities occur in
different patients
Laxity of the Introitus
INCIDENCE
Occurs World wide.
Variation with age / Parity
Increase with age
Increase with parity
More common amongst whites
Less common amongst Asians, Arabs, Afro Americans.
Africans
About 50% of patients are parous
Women have some degree of prolapse.
About 2% Nulliparous women may have symptomatic
prolapse.
ANATOMY OF THE PELVIC FLOOR AND SUPPORT OF
THE PELVIC ORGANS
Muscles of the pelvic floor
* Levator Ani Muscles
The Endopelvic fascia
* Pubocervical fascia
* Transverse cervical Ligaments
* (Cardinal Ligaments)
* Utero-sacral Ligaments
* Recto-vaginal fascia
Round Ligaments of the uterus
AETIOLOGY OF PROLAPSE
1. Congenital Weakness of pelvic floor

- Rather less common
2. Congenital Elongation of the cervix – Rare
3. Race - Connective Tissue structure / Disorder

- Fibrous Tissue formation after injury
- Work Ethics / Physical Exertion
4. Age -
5. The role of pregnancy / Delivery
* Parity
* Prolonged labour
* Feto-pelvic disproportion
* Difficult vaginal / Instrumental Deliveries
(Forceps / Ventouse)
* Traumatic Lacerations
* Episiotomy
6. The role of hormones
* Estrogens and postmenopausal atrophy
7. Precipitating Factors-Increased Abdominal pressure
* Chronic cough
* Intra abdominal Masses / Tumours
* Ascites
* Chronic constipation with repeated
straining at stool
* Tight - fitting corsets
* Excessive physical exertion / lifting of
heavy objects
* Obesity
8. Previous surgery – May cause vault prolapse
or enterocele
* Abdominal Hysterectomy
* Vaginal Hysterectomy
* Manchester operation
(failure to recognise enterocele at the time of initial
surgery)
* Burch colposuspension (May leave
posterior vaginal defect enterocele)
CLINICAL PRESENTATION
Symptoms – Varied depending on:
a. Type of prolapse
b. Degree / severity
A. Most frequent symptom:
“Something coming down the vagina”
“Mass protruding from the vagina”
“Mass / Lump in the vagina”
“Pressure / fullness in the vagina”
“Worse with strain / exertion”
“Worse at the end of the day”
“ Relieved with bed rest”
“Mild symptoms at beginning of day”
B. Other symptoms include
Vaginal Discharge
Vaginal bleeding
(Decubitus ulceration of Cx-dependent protruding
area)
Dragging sensation / Abdominal pain
Backache
Dyspareunia
C. Problems with Micturition [Urethrocele]
[Cystocele severity]
Frequency
Urgency
Stress Incontinence
Difficulty with initiating micturition
Feeling of incomplete emptying of bladder
(Patient may have to push through the anterior vaginal
wall to assist with micturition)
Dysuria: symptoms of U.T.I
With severe prolapse (procidentia)
With severe prolapse (Procidentia
Hydro-ureter
Hydro-Nephrosis. U.T.I
D. Bowel difficulties: [Rectocele]
Constipation
Incomplete evacuation of rectum
(assistance with pressure on posterior
vaginal wall to assist bowel evacuation)
E. Precipitation Factors:
* Chronic cough
* Ascites
* Abdominal / Pelvic Tumours
Signs:
General Examination.
Blood pressure
Heart sounds
Respiratory system
Abdomen – Masses / Ascites
Vaginal Examination
A. Inspection
Stress Incontinence (If bladder empty, repeat
examination after 1 hour and encourage patient to
drink)
B. Speculum Examination
Sim’s position / Lateral position
Sim’s speculum
Anterior vaginal wall
Posterior vaginal wall
C. Digital Examination
Symptoms Frequency
Protrusion >90%
Pressure >90%
Impaired Coitus 37%
Difficulty voiding 33%
Urinary Incontinence 33%
Difficulty walking 25%
Difficulty Defaecating 25%
Pelvic pain 17%
Urinary frequency / urgency 14%
Nausea 10%
Low back pain 10%
Mucosal Irritation / Discharge 10%
Addision et al 1988
INVESTIGATIONS
Sickling / Hb Electrophoresis
Liver Function Tests
Renal Function Test
Fasting Blood sugar
Mid stream Urine-Protein / Sugar
Microscopy, Culture and Sensitivity
ECG (in elderly patients) Chest X ray (chronic cough)
Special
Stress Incontinence – Urodynamic studies
IVU – (Severe prolapse) Abdominal mass
CT Scan – (Abdominal Masses / Tumour / Ascites / )
MRI
Treatment
A. General
Health of patient-Respiratory
Disorders / Heavy smoking
Estrogen Therapy in menopausal patients
Physiotherapy
Pelvic floor exercises
Treat U.T.I if detected
Non - Surgical
(a) Temporary treatment
i In pregnancy
ii While awaiting surgery
(b) Long term treatment
i Frail / Elderly patient
ii Patient unfit for Anaesthesia
iii Unfit for surgery
iv Unwilling for surgery
Silicone Ring Pessary – Different sizes
- Main stay
Appropriate size of pessary
Change every 306 months
Regular check – up
Probable side Effects –vaginal discharge
Coital Problems
(with Rubber Pessaries) Ulceration / Cancer
Vaginal bleeding.
C. Surgical
Depends on
a. Type of prolapse
b. Age of patient
c. Desire for future reproduction
d. Coital activity
Surgery is the definitive cure for all forms of

prolapse
There are complications after various surgical
operations
1. Cystourethrocele
Anterior Colporrlaphy
Modify if stress incontinence present. TOT/TVT
Complications: Haemorrhage
Haemorrhage
Vesico-Vaginal fistula
Retention of urine / UTI
Post operation
* Dyspareunia
* Recurrence
2. Rectocele *Posterior Colporrhapy
*Posterior Colpo-perineorrhapy
( Where perineum is deficient)
*Complications – Haemorrhage
Recto-vaginal fistula
* Dyspareunia
Uterovaginal Prolapse
Young patient / Sexually Active / Wants more
children
Manchester Type operation
* Dilation and Curettage
* Amputation of cervix
* Shortening of cardinal ligaments and
Approximation in front of cervix.
Forthergill and Stumdorf stitches
Combine with
Anterior Colporrhaphy
Posterior colpo-perineorrhaphy
Repair of Enterocele
Complications of Manchester Operation:
- Dyspareunia
- 2° Infertility-cervical factor
- Recurrence of prolapse
Mainly Obstetric
- Recurrent abortion-Mid trimester
- Premature labour
- Cervical dystocia
- Obstructed labour
Cervical laceration
Delivery after Manchester Operation
Some authors advocate Tubal Ligation with
Manchester operation
Delivery by Elective C/S
Vaginal delivery
Shorten second stage
(Easy Forceps/Ventouse)
3.2.1. Utero-vaginal prolapse [1° -2° Degree Prolapse]
Sexually active / Family size complete
EITHER
Manchester Type operation
With anterior colporrhaphy and as indicated
Posterior colpoperineorrhaphy
Repair of enterocele
OR
Vaginal Hysterectomy
AND
Pelvic repair (as indicated)
[Anterior colporrhaphy/posterior colpo perineorrhaphy]
3.2.2 Utero-vaginal Prolapse
Elderly patients (post Menopause)
All others-especially when procidentia present
Vaginal hysterectomy and
Pelvic floor repair
4. LE FORT’S Operation
Rarely performed Nowadays
Closure of vagina
Colpocliesis
In frail elderly patients
Complications of vaginal Hysterectomy
Haemorrhage
Ureteric Injury
Bowel Injury
Pelvic Haematoma
Pelvic Absess
Dyspareunia Delayed
Vault Prolapse
OTHER SURGICAL OPERATIONS

d. Prophylaxis (Prevention)
Improvement in general health
Good Obstetric care
* Posnatal pelvic floor exercises
* Prevent prolonged labour
* Shorten second stage
* Prevent difficult deliveries
* Prevent lacerationof the genital tract
* Proper Repair of Episiotomy
* MORE CAESAREAN SECTIONS!
Reduce parity
Hormone Replacement Therapy

(Menopause)
QUESTIONS????
Write short notes on

1. The common symptoms of genital prolapse.
2. The complications of vaginal hysterectomy.
3. The complications of anterior colporhaphy.
4. The aetiological factors that may predispose to
uterovaginal prolapse.
5. Prevention of uterovaginal prolapse.

16-Genital Prolapse

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At the end of this lecture:

The student should be able to

In severe cases, the vagina is everted and the cervix

Degree of prolapse depends on location of cervix /

Third Degree (Procidentia)

1. Congenital Weakness of pelvic floor

2. Congenital Elongation of the cervix – Rare

3. Race - Connective Tissue structure / Disorder

Surgery is the definitive cure for all forms of

OTHER SURGICAL OPERATIONS

Hormone Replacement Therapy

Write short notes on

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