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PROLAPSUS GENITALIA

TAMARA AYU WIDYASURI


IMO UROREPRO 2016

Background
The uterus
anteflexed

is

Version: is the
longitudinal axis of
vagina
Flexion: is the
longitudinal axis of
the cervix

normally

anteverted,

angle between the


cervix, and that of the
angle between the
the uterus, and that of

Genital Prolapse
Genital prolapse is the descent of one
or more of the genital organ (urethra,
bladder, uterus, rectum or Pouch of
Douglas or rectouterine pouch) through
the fasciomuscular pelvic floor below their
normal level
Vaginal prolapse can occur without
uterine prolapse but the uterus cannot
descend without carrying the vagina with
it.

Supports of the
uterus
DeLancey in 1994 defined three levels of vaginal support,
reviving the importance of the connective tissue
structures and giving a working basis for the present day
understanding of the anatomy and surgical treatment.
Level I: The cardinal uterosacral ligament complex
Level II: The pubo- cervical and recto-vaginal fascia
Level III: The pubo-urethral ligaments anteriorly & the
perineal body posteriorly

Etiopatologi terjadinya
prolaps genitalia?
Kelemahan otot-otot diafragma pelvis
diafragma urogenitalia
Kelemahan ligamentum endopelviks
Persalinan
pvg
bayi
aterm
dengan
normal/makrosomia
Penyakit
kronis
dengan
peningkatan
intraabdominal

dan

BB
tek.

Note : nulipara kelainan bawaan ; kelemahan


jaringan penyangga uterus

Klasifikasi? (According to
Baden
Walker)
Desensus uteri uterus turun, cx masih

dalam

vagina

Stadium I
uterus turun, cx paling
rendah turun hingga introitus vagina
Stadium II
sebagian uterus sudah
keluar dari vagina
Stadium III prosidensia uteri ; uterus
sudah seluruhnya keluar dari vagina

Derajat Prolaps Uteri

Klasifikasi (lagi) dengan


patokan anatomi lebih
jelas! lebih sulit

SISTEM POP-Q

Note (s)
Patokan : Himen
Diukur 6 titik , 2 ukuran eksterna & panjang total vagina
Struktur di atas himen : - cm
Struktur di bawah himen : + cm

ILUSTRASI POSISI ANATOMI


TITIK-TITIK PADA SISTEM
POP-Q

Format Numerik Pencatatan dari Sistem POP-Q

Diagram Posisi Normal Genitalia dan


Eversi Komplit dari Vagina

Diagram defek dinding anterior


vagina dan posterior vagina

Sistem Nilai Gradasi Prolaps Genitalia menurut ICS


Stadium 0 titik Aa,Ap,Ba,dan Bp semuanya -3 cm dan titik
yang lain (C,D) tidak lebih dari (x-2)cm
Stadium I

Kriteria stadium 0 tidak ditemukan dan ujung yang


terendah kurang dari 1cm

Stadium II Ujung terendah minimal -1 cm dan tidak melebihi +


1cm
Stadium
III

Ujung Terendah dari prolaps > 1cm tapi kurang dari


+(x-2)cm

Stadium
IV

Ujung terendah dari prolaps melewati + (x-2) cm

Ket : x = Panjang total vagina

Cara Mudah?
Patokan Himen!!!
Di atas
- 1cm
1 cm sp
+1cm
Di bawah +1cm
Eversi komplit

Grade I
Grade II
Grade III
Grade IV

Faktor risiko?
Trauma persalinan
Paritas
Tekanan intraabdominal kronis
Usia
Kelainan bawaan
Ras

Gejala klinis?
Pasien merasakan ada sesuatu yang turun atau keluar
dari introitus vagina.
Note : GK berbeda-beda tiap individu. Gejala yang
tampak hanya 15-20%, sisanya tidak bergejala sama
sekali
Terasa atau teraba ada benjolan di vagina
Terasa pegal di daerah belakang atau punggung
Susah berjalan ; if only sudah terjadi prosidensia uteri
Perdarahan pervaginam ; derajat II & III
Inkontinensia urin ; polimiksi (derajat III malam
hari)
Konstipasi
Gangguan saat koitus

PROSEDUR PEMERIKSAAN
Alat

: Spekulum Sims, Spekulum Graves, dan Sonde

Posisi : Berdiri, berbaring


Posisi berdiri :
Penilaian lebih baik Posisi aktif normal
Gejala timbul bila duduk/berdiri

Saat Penilaian :
Istirahat
Peregangan : Manuver Valsalva

Examination
Local examination
Per speculum examination
Per vaginal/ Bimanual examination
Bonneys stress test
Evaluation of tone of pelvic muscles
Recto vaginal examination
Position of patient for examination
- standing & straining
- dorsal lithotomy

Diagnostic approach
The maximal extent of prolapse is
demonstrated with a standing straining
examination when the bladder is empty
Pelvic muscle function should be assessed
after the bimanual examination palpate the
pelvic muscles a few centimeters inside the
hymen, along pelvic sidewalls at the 4 & 8
oclock
Resting tone & voluntary contraction of the
anal sphincters should be assessed during
rectovaginal examination

Evaluation of pelvic
floor tone
Place 1 or 2 fingers in the vagina and instruct
the patient to contract her pelvic floor muscles
(i.e., the levator ani muscles). Then gauge her
ability to contract these muscles, as well as the
strength, symmetry, and duration of the
contraction.
The strength of the contraction can be
subjectively graded with a modified Oxford
scale (0 = no contraction, 1 = flicker, 2 =
weak, 3 = moderate, 4 = good, 5 = strong).

PENATALAKSANAAN
Konservatif

Pelvic floor muscle training


Stimulasi otot dg alat listrik
Penggunaan pesarium vagina
Indikasi penggunaan :

Kontraindikasi operasi (still in pregnancy)


Menunggu operasi (mengurangi simptom)
Trimester pertama kehamilan

A.Smith (silicone, folding)


B.Hodge without support (silicone. folding)
C.Hodge with support (silicone, folding)
D.Gehrung with support (silicone, folding)
E.Risser (silicone, folding)
F.Ring with support (slllcone, folding)
G.Ring without support (slllcone, folding)
H.Cube (silicone, flexible)
I.Tandem-Cube (silicone, flexible)
J.Rigid Gellhom (acrylic, multiple drain)
K.95% Rigid Gellhom (silicone, multiple drain)
L.Flexible Gellhom (silicone, multiple drain)
M.Ring incontinence (silicone)
N.Shaatz (silicone. folding)
O.Incontinence dish (silicone, folding)
P.Inflate Ball (latex)
Q.Donut (silicone)

Nonsurgical Management

Nonsurgical Management

Persiapan insersi ring pessarium

Langkah 2
Jari tangan kiri membuka labium minor sehingga introitus
vagina tampak
Pessarium dimasukkan ke dalam introitus vagina sejajar
dengan base dan didorong sepanjang dinding posterior

Cara memegang
Ring pesarium

Pessarium dimasukkan ke vagina


sejajar dinding posterior

Memegang pessarium agar dalam posisi


tertekuk

Memeriksa posisi pessarium

Mengait dan memutar pessarium


dengan 1 jari

Pessarium terpasang dalam vagina

PENATALAKSANAAN
OPERATIF
Kompartemen

Melalui Vagina

Melalui Suprapubik

Anterior

Vagina Anterior repair dgn


atau tanpa mesh

Kolposuspension

Middle

Vaginal hysterektomy; vault


repair ( fascia);
sacrospinous fixation;
bilateral iliococcygeal hitch

Sacrosphysteropexy ;
sacrocolpopexy

Posterior

Levator plication; fascia


Mesh interposition;
repair with or without mesh; sacrocolpopexy with
transanal repair
mesh interposition

Vaginal Apical Repair

Sacrospinous Ligament Suspension


Sacrospinous ligament
fixation entails attachment
of the vaginal apex to the
sacrospinous ligament, the
tendinous component of the
coccygeus muscle

Vaginal Apical Repair

Iliococcygeal vaginal suspension


Iliococcygeal vaginal
suspension involves
attachment of vaginal apex to
the iliococcygeus muscle and
fascia, usually bilaterally

Vaginal Apical Repair

Uterosacral Ligament Suspension


Used prophylactically at
hysterectomy or
therapeutically for vaginal
apical suspension

Once access to the posterior


cul-de-sac has been attained,
the uterosacral ligament
remnant can be found

Sutures in each ligament and


incorporated into the ant &
post fibromuscular layer of
vagina

Prolapse procedure

Comparison of Vaginal Approaches to


Apical Repair
Sacrospinous ligament suspension may leave the anterior vaginal
at greater risk for subsequent failure & because the procedure is
extraperitoneal rare ureteral and rectal injury

Iliococcygeal suspension is straightforward procedure to learn


and teach. It carriers virtually no risk of ureteral or small bowel
injury, there are no vital structures nearby at risk for surgical
injury

Uterosacral ligament suspension traditionally requires peritoneal


entry challenging in posthysterectomy prolapse, especially in
the setting of bowel adhesions engendering the rare
occurrence of bowel injury
Uterosacral ligament suspension carreies a risk of ureteral injury
(usually kinking due to medial displacement or suture ligation that
impedes urinary flow)

Prolapse procedure

Abdominal Apical Repair


Abdominal Sacral Colpopexy uses graft material attached
to the anterior and posterior vaginal apex and suspended
to the anterior longitudinal ligament of the sacrum for
repair of apical prolapse
Peritoneal closure over the graft & obliteration of the cul-desac for treatment or prevention of enterocele
The cure rate range from 78% to 100%
Complications
: intra-operative hemorrhage, laparotomy (adhesion & small
bowel
obstruction) , and graft infection or erosion

Prolapse procedure

Comparison of Abdominal and Vaginal


Approaches
to Apical Repair
Success rates appear to favor the abdominal approach to
apical vaginal prolapse

Abdominal sacral colpopexy is more durable in providing


apical support, but at the cost of increased complications

Younger women benefit more also likely to be more from


durability, with the reduced chance they will need prolapse
surgery in future

Prolapse procedure

Colpocleisis
In a healthy, sexually active woman the vagina may be surgically
attached to the sacrospinous ligament, sacrum or fascia support
system. But, they can be associated with occasional serious
complications such as severe hemorrhage or major nerve injury

In those frail elderly women who do not wish to be sexually active


in the future total colpocleisis is a simple, safe, and effective
surgical procedure that reliably relieves these women of their
symptoms

Total colpocleisis procedure often coupled with a tension free


vaginal tape (TVT) sling procedure for urinary incontinence

Vagina Normal

Prolaps Uteri Grade III Dengan Penonjolan Dinding


Depan Vagina Yang Dominan

Prolapsus Grade IV

INVERSIO UTERI
TAMARA AYU WIDYASURI
IMO UROREPRO 2016

UTERINE
INVERSION
UTERINE
INVERSION MAY OCCUR

IMMEDIATELY POSTPARTUM OR, MUCH


LESS FREQUENTLY, OUTSIDE THE
PREGNANCY.

INVERSIONS ARE USUALLY DESCRIBED


AS ACUTE (<30 D AFTER DELIVERY) OR
CHRONIC (>30 D AFTER DELIVERY).

Degree ?
In first-degree inversion, the inverted wall extends to but
not through the cervix.
In second-degree inversion, the inverted wall protrudes
through the cervix but remains within the vagina.
In third-degree inversion, the inverted fundus extends
outside the vagina.
In fourth degree or total inversion, both the vagina and
uterus are inverted.

Possible etiology?
Excessive cord traction or a short umbilical cord
Cred (fundal) pressure
Placenta accreta or increta or percreta
Fundal implantation of the placenta
Fetal macrosomia
Trials of vaginal birth following cesarean delivery
Myometrial weakness
Precipitate labor
Myoma geburt traction (outside pregnancy)

S&S
The classic observations include :
Shock
Hemorrhage
Patient really in pain
Fundal uterine lower umbilicus
The sudden appearance of a vaginal mass

Management(s)?

Patient in shock!!!
1.Initiate fluid resuscitation with 2 large-bore
intravenous lines. Promptly administer 1 or more liters
of an isotonic salt solution such as lactated Ringer
parenterally.
2.Submit specimens to the laboratory for possible
transfusion and for determination of baseline values of
hemoglobin (Hgb), hematocrit (Hct), and coagulation
factors.
3.Insert a Foley catheter.
4.Immediately summon an anesthesiologist.
5.Treat aggressively (manual replacement, hurry!!!)
6.Order appropriate surgical equipment and assistants
to ready the operating room for a possible laparotomy.
7.Administer tocolytics to promote uterine relaxation.
These may include nitroglycerin , or magnesium sulfate
at 4-6 g IV over 20 minutes.

Attempt prompt uterine


replacement. First, proceed
with a trial of simple manual
replacement. If this is
unsuccessful, promptly perform
a laparotomy for a surgical
replacement At laparotomy,
general anesthesia employing
a uterine relaxing agent is
best!

Manual replacement of the inverted uterus

POST-PROCEDURE CARE
Once the inversion is corrected, infuse
oxytocin 20 units in 500 mL IV fluids
(normal saline or Ringers lactate) at 10
drops per minute:
- If haemorrhage is suspected, increase the
infusion rate to 60 drops per minute;
- If the uterus does not contract after
oxytocin, give ergometrine 0.2 mg or
prostaglandins.
Give a single dose of prophylactic antibioti
cs after correcting the inverted uterus
:
- Ampicillin 2 g IV PLUS metronidazole 500
mg IV;
- OR cefazolin 1 g IV PLUS metronidazole
500 mg IV.