PELVIC ORGAN

PROLAPSE
By :
Sammon Khan Tareen
17069
 OBJECTIVES

• To know about different types of prolapses

• To know about different stages of prolapse
• Management of different prolapses
• Management of associated symptoms
 DEFINITION
A prolapse is defined as a protrusion of an organ beyond
its normal confines

For the purpose of better understanding, we subclassify

pelvic organ prolapse into :
1. Vaginal wall prolapse
2. Uterine prolapse
• Prolapse can be of two types :

1.Vaginal prolapse ( can occur alone )

2.Uterine prolapse ( can occur alone but mostly
associated with vaginal prolapse )
 Applied Anatomy

• Pelvic supports ( ligaments )

• Pelvic floor ( Pelvic diaphragm, Endopelvic fascia, Perineal
membrane and Perineal body )

• We divide pelvic cavity into 3 parts :

1. Anterior : bladder ( upper 2/3 of ant. Vaginal wall) and urethra
( lower 1/3 )
2. Middle : uterus, vaginal vault
3. Posterior : rectum ( lower 2/3 of post. Vag. Wall and anus.
Upper 1/3 is formed by Pouch of Douglas and its contents
 CLASSIFICATION
A. VAGINAL PROLAPSE : B. UTERINE PROLAPSE :

1st , 2nd and 3rd Degree

• Anterior wall :
1. Cyctocele
2. Urethrocele
3. Cystourethrocele
• Posterior wall :
1. Rectocele
2. Enterocele
• Apical Vaginal Prolapse :
1. Uterovaginal prolapse
2. Vault
Anterior Vaginal Wall Prolapse

CYSTOCELE URETHROCELE CYSTOURETHROCELE

It is the descent of When the urethra Descent of whole
upper 2/3 of along with the anterior vaginal
anterior vaginal wall lower one-third of wall and contains
by bladder the anterior wall both bladder and
prolapses (Rare urethra
stress incontinence)
Apical Vaginal prolapse ( Middle cavity )

UTEROVAGINAL VAULT
• Uterine descent with • Vault is the upper blind
inversion of vaginal apex end of vagina
• After hysterectomy
inversion of vaginal apex
Posterior Vaginal Wall Prolapse

RECTOCELE ENTEROCELE
• Descent of lower 2/3 of • Prolapse of upper 1/3 of
posterior vaginal wall posterior vaginal wall
• It contains rectum • It may contain loops of
small bowel or omentum
 UTERINE PROLAPSE
It is classified differently and is graded in 3 degrees based on severity of
descent
1st Degree 2nd Degree 3rd Degree

• The uterus has • The uterus has • Extreme form

descended from descended to the • Whole of uterus lies outside
its normal position level where cervix ontroitus
• But it still lies in appears introitus
• Commonly associated with
the vagina • While the body of cystocele, enterocele and
• Nothing appears uterus lies withing rectocele
outside of vagina vagina
• Also called Procidentia
Staging of Uterine prolapse
 Aetiology
The connective tissue, levator ani and intact nerve supply are vital for the
maintainence of position of the pelvic structures, and areinfluenced by pregnancy,
child birth and ageing.

1. Menopause
2. Multi parity (birth injury, Prolonged bearing down in the second stage, delivery of a
big baby, rapid succession of pregnancies, lack of rest in peuperium and peripheral
nerve injury
3. Raised intra-abdominal pressure
4. Surgeries ( vaginal hysterectomy and Burch colposuspension )
5. Congenital ( prolapse in nulliparous and those with spina bifida and ectopic vesicae
)
PRESENTATION
Chief Complains

1. Something protruding either at the vulva or externally

aggravated by straining and coughing, and by heavy
work, reduces itself when she lies down
2. Large prolapse, the external swelling
3. Difficulty in walking or carrying out her everyday duties
4. Backache
5. Uterosacral strain towards evening, relieves by rest
 Associated Complains

VAGINAL PROLAPSE
CYSTOCELE/CYSTOU RECTOCELE ENTEROCELE AND
RETHROCELE VAULT PROLAPSE
• Prolapse of bladder • Often asymptomatic
• Complaints related to urinary tract • When symp. : in addition to
something coming out of vagina, • Complains of perineal
• Common symp.s : stress heaviness and pelvic
incontinence, frequenc and urgency patient may complain of backache,
pelvic pain and coital difficulty pressure
• Severe cases : Hx of manual
• Large prolapse may cause difficult
reduction of prolapse prior to
defecation
micturirion
• Extreme form : urinary retention • Patient may have to reduce
maybe presenting complain prolapse digitally for complete
emptying of bowel
 Associated Complains

UTERINE PROLAPSE
1. Pain :
- With uterine descent, thenpatient may complain of dragging in low back
- Discomfort cause by abdominal tension on nerves and the tissues are being
stretched.
- Procidentia may rarely present withsevere pain when incarcerated
2. Bleeding :
- Mainly post menopausal bleeding maybe due to ulceration
- Maybe associated with purulent discharge
3. Coital difficulty :
- Due to altered vaginal anatomy
 COMPLICATIONS
1. Hypertrophy of cervix
- Congestion and edema
- Glandular hypertrophy
2. Ulceration ( Decubitus ulcer )
3. Incarceration associated with
severe pain
4. Keratinization
5. Urinary tract complications :
-Frequency of urine
-Stress incontinence
-Urinary retention
-Urinary tract obstruction
-Urinary tract infection
-Urinary calculus
EXAMINATION
General Physical Examination

1. Age
2. Built – obese
3. May have age related medical disorders – DM and HPt
4. Look for pulmonary disorders – Asyhma, chronic bronchitis and
tuberculosis
5. Record : BP, weight and thorough chest evaluation
6. If a pulmonary payhology suspected, take an opinion of chest
physician
Abdominal Examination

1. Renal angle: hydronephrosis or tenderness

2. Nulliparous prolapse: Spina bifida, visceroptosis, hernia
3. Abdominal mass
Pelvic Examination

• INSPECTION OF EXTERNAL GENITALIA :

1. Normal – minimal uv prolapse

2. Senile atrophy – post menuposal women
3. Procidentia – whole uterus and inverted vaginal walls protruding
out of introitus
4. Complications maybe seen : congestion, ulcer and keratinization
5. Moderate degree of prolapse appears out only when patient is
asked to cough or strain
Pelvic Examination

• SPECULUM EXAMINATION :

1. Central role in evavaulation of prolapse

2. Not only confirms the diagnosis, also helps in differentiating among
different types of prolapse
3. Sim’s speculum :
• Choice of instrument
• Retracts one vaginal wall at a time allowing assesment of the other.
• Best acrried out in left lateral position in out patient clinic and in lithotomy
position on operation table
 Pelvic Examination

• Anterior compartment :
1. Sim’s speculum retracting posterior vaginal wall
2. Look for cystocele, lateral cystocele or paravaginal defect, urethrocele and stress
incontinence
• Middle compartment :
1. Degree of uterine descent, ulceration of cervix, vagina may show keratinisation
2. Vaginal examination – length of cervix,position and mobility of uterus,any adnexal
mass
• Posterior compartment :
1. Sim’s speculum retracting anterior vaginal wall
2. Enterocele – bulge appears from above downwards
Pelvic Examination

• BIMANUAL EXAMINATION :

Must be performed in patients with uv prolapse as an abdominpelvic mass

maybe an underlying factor
Pelvic Examination

• Rectal examination –

- Impulse on :
1. tip of finger- enterocele
2. Pulp - rectocele
DIFFERENTIAL
DIAGNOSIS
Any lesion protruding outside inteoitus on cough or straining may mimic
uv prolpase

1.Anterior Vaginal wall prolapse ( reducible )

– Gartner’s cyst, urethral carbuncle periurethral cyst and mets from
uterine tumor ( choriocarcinoma and adenocarcinoma) – ( irreducible )
- Urethral diverticulum ( differentiated by passing sound into the
bladder )
2. Procdentia – whole uterus is outside
- Elongated and hypertrophied cervix, cervical and endometrial polyps –
cervical rim is seen on normal position on speculum examination
- Chronic inversion uterus : inability to palpate body bimanually
3. Vulval tumors and varicosities
4. Vaginitis – may give sensation of vaginal fullness. Easily excluded on
speculum examination
INVESTIGATIONS
 INVESTIGATIONS
• UV prolapse is diagnosed purely on clinical examinations and no investigations are
required for confirmation
• Certain investigations are required to evaluate associated problems :
1. Urine R/E and culture – midstream urine sample if symptoms of UTI appear
2. Urodynamuc studies – when urinary incontinence coexists with UV prolapse
3. USG – in cases of Procidentia, where ureteric obstruction is suspected, renal USG is
carried out to rule out hydroureter and hydronephrosis
4. RFT – BUN and creatinine are indicated when renal compromise is suspected due to
urinary tract obstruction
5. Radiological – IVU ( if USG fails to provide sufficient info aboutnurinary
obstruction). CXR in patient with chronic cough to evaluate pulmonary status
6. Routine preoperative tests – CBC, blood grouping, blood sugar and ECG
MANAGEMENT
 MANAGEMENT

1. Counselling
2. Prevention
3. Treatment
- Medical
- Surgical
 Counselling

1. Reassure the patient that in absence of urinary tract

obstruction/ingection, prolapse carries no risk to life
2. Young patients with mild to moderate degree prolapse, desiring to
have more children, should be explained that it is better to complete
the family before undergoing surgical treatment, because a
successful pelvic floor repair can be disrupted by further vaginal
delivery and childbirth will be most likely by c-section
3. Patient must be inquired about her coital activities as vaginal repair
has to be tailored accordingly
 Prevention

1. ANTENATAL CLASSES : Patients are explained in it about process of labour and

they aretaught not to bear down until the cervix is fully filated
2. CARE IN LABOUR - Trauma to uterovaginal supports can be minimized by :
- Avoiding proloned labour
- Shortening the 1st and 2nd stages of labour
- By appropriate surgical intervention
3. FAMILY SIZE
4. POSTNATAL EXERCISES – to improve pelvic muscle tone
5. HRT – Helps in prevention but cannot correct established prolaapse
6. AGGREVATING FACTORS – avoid smoking, heavybweight lifting and early
treatment of chronic couh and constipation
Treatment

• Depends upon the :

- Age
- Parity
- Future wishes of child bearing
- Severity of disease
- Extent of symptomatology
- Concomitant urinary symptoms
• Before deciding any mode, the patient’s choice must be considered
• Two types of treatment :
1. Medical 2. Surgical
Medical Treatment
1. General care :
- Obese (loose weight )
- Treat chronic cough and constipation
- Ulcerated prolapse ( by reducing prolapse and applying estrogen cream O.D at
night
2. PESSARY - Indicated in following conditions :
• Patients wish
• Therapeutic test
• Childbearing not complete
• Medically unfit
• During/ after pregnancy
• While waiting for sugery
Surgical Treatment

A. CYSTOCELE :
- When present alone > repaired vaginally ( Anterior Colporrhaphy)
- When associated with urinary stress incontinence > abdominal repair (
Burch Colposuspension )

B. UTERINE PROLAPSE :
- Vaginal hysterectomy
- Manchester ( Fothergill ) repair
- Abdominal approach
- 1. Abdominal hysterectomy 2. Uterosacropexy
Surgical Treatment

C. RECTOCELE :
- Colpoperineorrhaphy

D. ENTEROCELE :
- Abdominal approach > Moscowitz but better corrected by Coaptation of uterosacral
ligaments
- Vaginal approach > sacrospinous foxation operation

E. RECURRENT/VAULT PROLAPSE :
- Abdominal colposacropexy
- Zacharin repair
- Le forts operation
Pregnancy and UV prolapse

• Uv prolapse sometimes coexists with pregnancy

• No special problem arises during pregnancy and labour
• In 1st trimester, inc. Uterine weight associated witprolapse
• Ring pessary is inserted in this stage, holds uterus till it becomes an
abdomen organ in 2nd trimester
• Later, when uterus and contents rest on pelvic brim, the prolapse is less
troublesome.
• Delivery though aprolapsed cervix can be easily accomplished
• Rarely large recto/enterocele may obscure the presenting parg of the baby
giving false impression of obstruction.
• Simple manual reduction gives smooth delivery
THANKYOU