prolapse

• Anteverted


  The uterus is tilted forward
• Anteflexed


  The body of the uterus is bent forward on the cervix
• Axial


  The uterus is in line with the long axis of the vagina
• Retroverted


  The uterus is tilted backward
• In the anatomical position four-fifths of uteruses are anteverted and one-fifth retroverted, at vaginal examination, about 40% are anteverted, 40% axial and 20% retroverted

  
• Pelvic organ prolapse (POP)


  Structures of the pelvis organ shift and protrude into or outside of the vaginal canal

  
• The Egyptians were the first to describe prolapse of the genital organs
• Prolapse


  Downward descent of the female pelvic organs due to weakness of the structures which normally retain them in position
• Pelvic organ prolapses


  Abnormal descent or herniation of the pelvic organs from their original attachment sites or their normal position in the pelvis

  
• Genital tract prolapse


  Descent or dropping of pelvic organs, such as the uterus, bladder, or rectum, from their normal positions

  
• Four most common types of genital prolapse

  • Cystocele
  • Rectocele
  • Enterocele
  • Uterine prolapse
• Cystocele


  Descent of the bladder into the vaginal space
• Cystocele


  • Weakened anterior vaginal wall support, often related to childbirth or aging
• Rectocele


  Descent of the rectum into the vaginal space
• Rectocele


  • Weakened posterior vaginal wall support, typically associated with childbirth and aging
• Enterocele


  Protrusion of the small intestine into the vaginal space

  
• Enterocele


  • Weakened pelvic floor support, often related to previous pelvic surgeries or childbirth

  
• Uterine prolapse


  Descent of the uterus into the vaginal canal or outside the body
• Uterine prolapse


  • Weakened pelvic floor muscles due to factors such as childbirth, aging, obesity, or repeated heavy lifting
• Degree of Uterine Prolapse

  • First degree: prolapse of the organ into the vaginal canal
  • Second degree: cervix descends to the vaginal introitus
  • Third degree: or procidentia when the cervix and some or all of the uterus is prolapsed outside the vaginal orifice

  
• Vaginal Vault Prolapse


  Descent of the upper part of the vagina after a hysterectomy
• Vaginal Vault Prolapse


  • Weakened support structures following removal of the uterus
• Risk Factors and Etiology

  • Childbirth
  • Aging
  • Heredity
  • Chronic Constipation
  • Obesity
  • Chronic Cough or Respiratory Conditions and or Smoking
  • Connective Tissue Disorders
  • Pelvic Surgery
  • Pelvic Trauma
  • Hormonal Changes
  • Heavy Lifting
  • Constant downward gravity because of erect human posture
• Symptoms


  • Feeling of fullness of the vagina
  • A lump coming down
  • A dragging sensation or bearing down in the back or lower abdomen
  • Vaginal discharge
  • Difficulty with coitus
  • Urinary symptoms
  • Rectal symptoms
• Symptoms of genital prolapse are variable and do not bear much relation to the physical signs found on examination but more to the degree of traction on the pelvic ligaments

  
• The symptoms tend to worsen with the day's activities and can be relieved by lying down
• Physical Signs


  • The woman should first be examined in the dorsal position when she is asked to strain and cough
  • The degree of descent of the cervix is tested with a finger in the vagina
• Differential Diagnosis


  • Varicose veins of the vulva
  • Haemorrhoids
  • Rectal prolapse
  • Cystitis
  • Vaginitis with congestion of the vagina
  • Pressure from a large abdominal tumour
  • Stress incontinence

  
• Prevention


  • Avoiding constipation to reduce straining during bowel movements
  • Dietary Adequate fluid intake and a high-fiber diet to promote regular bowel movements
  • Kegel exercises
  • Careful management of labor
  • Prevention of vault prolapse after hysterectomy
• Treatment


  • Physiotherapy
  • Palliative treatment / Pessary treatment
  • Surgery
• Behavioral/Lifestyle Modifications


  • Avoiding constipation to reduce straining during bowel movements
  • Adequate fluid intake and a high-fiber diet to promote regular bowel movements
  • Kegel exercises to strengthen the pelvic floor muscles to support the inner organs and prevent further prolapse
• Careful management of labor

  1. The woman must be discouraged from bearing down before full dilatation

  2. The second stage of labour should not be prolonged unduly

  3. Episiotomy and low forceps extraction may reduce the risk of later prolapse

  4. Episiotomies and tears must be carefully sutured in layers

  5. Postnatal exercises should be encouraged after every labour
• Prevention of vault prolapse after hysterectomy

  Suture of the cardinal and uterosacral ligaments to the vaginal vault
• Treatment of prolapse


  • Physiotherapy
  • Palliative treatment / Pessary treatment
  • Surgery
• Physiotherapy


  • Exercises to strengthen the pelvic floor muscles are carried out under the supervision of a physiotherapist
  • Can be successful, chiefly in young women after recent childbirth
  • Less effective in vault prolapse
• Palliative treatment / Pessary treatment


  • Many types of pessary and support have been devised for prolapse
  • Indications for pessaries: prolapse during pregnancy, prolapse immediately after delivery, when another pregnancy is desired within a short time, in patients unfit for operation on medical grounds, in patients who decline an operation
• Disadvantages of pessary treatment

  • Ulceration of the vagina and cervix
  • An neglected pessary may become embedded in the vaginal wall and may only be removed with great difficulty
  • A carcinoma of the vagina may develop
• Examples of pessaries


  • Support pessaries (e.g. Ring, Gehrung, and Hodge pessaries)
  • Space-occupying pessaries (e.g. cube, doughnut, and inflatable Gellhorn pessaries)
• Surgery


  • Surgical interventions might include anterior or posterior colporrhaphy (to repair a cystocele or rectocele) and vaginal hysterectomy (for uterine prolapse)
  • Vaginal hysterectomy is the treatment of choice for uterine prolapse
  • Can be combined with an anterior and posterior repair if a cystocele or rectocele is present
• Goals of operative procedures

  • To correct the cystocele and rectocele
  • Return the uterus to a forward position
  • Shorten the elongated cervix
  • Shorten the cardinal ligaments