Genital prolapse Definition Descent of an organ beyond

Genital prolapse

• Definition: - Descent of an organ beyond its normal confines. • Classification: 1. Anterior vaginal wall prolapse: a. Urethrocele: - Urethral descent. b. Cystocele: - Bladder descent. C. Cysto-urethrocele: - Descent of both bladder & urethra. 2. Posterior vaginal wall prolapse: a. Rectocele: - Rectal descent. b. Enterocele: - Small bowel descent.

• 3. Apical vaginal prolapse: a. Utero-vaginal prolapse: - Uterine descent with inversion of vaginal apex. b. Vault prolapse: - Post hysterectomy inversion of vaginal apex. 4. Uterine prolapse: - It is divided into three degrees: - a. First degree: Descent of uterus within vagina. b. Second degree: - Descent of uterus up to level of introits. c. Third degree: - Descent outside the introits so called (procedentia), usually accompanied with cystocele & rectocele.

• Incidence: - It affect (2%) of nulliparous & (12 -30%) in multiparous. There is (11%) risk of having operation for prolapse during her life time. • Etiology: - 1. Congenital: Congenital connective tissues defect appear to be important in etiology of prolapse & stress incontinence. This explain symptomatic prolapse in nulliparous. 2. Vaginal delivery: - It cause damage to levator ani muscles & nerve damage.

• WHO suggested that prolapse was (7) times more common in women who had more than (7) children compared to those with one. 3. Aging: - due to loss of collagen & weakness of pelvic fascia so that prolapse is common in postmenopausal women consequent to estrogen deficiency. 4. Post-operative: - Poor attention to vaginal vault support at time of hysterectomy lead to vault prolapse in (1%). Mechanical displacement as result of colposuspension (operation for stress incontinence) may lead to recto & enterocele.

• 5. Pregnancy: - It is rare. It is mediated by effect of progesterone & relaxin hormones & raised intra-abdominal pressure which put added strain on pelvic floor. • Path physiology: - Three components are responsible for support of uterus & vaginal position: - 1. Ligaments & fascia by suspension from pelvic side wall. 2. Levator ani muscle by constricting & maintain organ position. 3. Posterior angulations of vagina which enhanced by increased intra-abdominal pressure.

• Diagnosis: - 1. Symptoms: a. Non-specific: - 1. Lump coming down through introits. 2. Local discomfort. 3. Backache. 4. Dyspaurenia. 5. Vaginal bleeding if ulceration of cervix occur. 6. Rarely renal failure as result of ureteric kinking in sever cases. b. Specific: - 1. Cysto-urethrocele: Frequency, urgency, voiding difficulty, recurrent U. T. I. & stress incontinence.

• 2. Rectocele: - Incomplete bowel emptying. 3. Uterine prolapse: - Profuse vaginal discharge & vaginal bleeding if ulcer of cervix occur. 2. Signs: - 1. Patient should examined in left lateral position using (Sims speculum) while straining to asses anterior & posterior vaginal wall as well as cervical descent. 2. Prolapse may be obvious in dorsal position if it protrude beyond introits.

• 3. Combined rectal & vaginal digital examination can aid to differentiate rectocele from enterocele. • Differential diagnosis: 1. Congenital vaginal cyst. 2. Inclusion dermoid vaginal cyst. 3. Urethral diverticulum 4. Large uterine polyp. • Prevention: - 1. Shorten second stage of labor. 2. Reduce traumatic delivery. 3. The benefit of episiotomy & hormonal replacement therapy in menopause have not sub stained.

• Treatment: - A. Medical: 1. Silicon rubber-based ring: a. It is the most common form of conservative treatment. 2. It need replacement at annual interval. 3. Its use is complicated by infection & vaginal ulceration. 4. Indicated in the following: a. Patients wish. b. As therapeutic test to see if the symptoms caused by prolapse. c. Child bearing is not completed.

• d. Medically unfit for surgery. e. During & after pregnancy. f. Waiting for surgery. B. Surgical: - The aim is to restore anatomy & function of prolapsed organ. 1. Cystourethrocele: - treated by (anterior repair or colporrhaphy). It is the commonest but should avoided if there is concurrent S. I. 2. Rectocele: - treated by (posterior repair or colporrhaphy), its principles is same to anterior repair but work on posterior vaginal wall.

• 3. Utero-vaginal prolapse: A. Manchester operation: 1. Indicated in those wish to conserve uterus for fertility. 2. Involve partial amputation of cervix & approximation of cardinal ligaments below retained cervix. 3. Usually combined with anterior & posterior repair. B. Vaginal hysterectomy: - indicated in third degree prolapse & no need to conserve uterus & in menopausal women.

• C. Sacrohysteropexy: - It is an abdominal procedure done if uterine conservation is required. It involve attachment of synthetic mesh from utero-cervical junction to longitudinal ligament of sacrum then close P. O. D. 4. Vault prolapse: - 1. Sacrocolpopexy: It is an abdominal procedure similar to sacrohysteropexy but inverted vaginal vault is attached to sacrum using mesh. 2. Sacrospinous fixation: - It is vaginal procedure where the vault is sutured to one or other sacrospinous ligament.

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