Management Of Genital Prolapse

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Management Of Genital Prolapse

• Prof. Surendra Nath Panda, M.S.
• Department of Obstetrics and Gynecology
• M.K.C.G.Medical College
• Brahmapur, Orissa, India

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DEFINITION

• Prolapse/Procidentia is downward decent of uterus
  /or vagina (Procidentia is from Latin procidere
  - to fall)
• It is a state of pelvic relaxation due to a
  disorder of pelvic support structures that is,
  the endopelvic fascia
• It is not a disease but a disabling condition

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CAUSE

• WEAKNESS OF THE SUPPORTS OF THE UTERUS VAGINA
• Precipitating / Exaggerating / Unmasking Causes -
• INCREASED INTRA ABDOMINAL PRESSURE
• Chronic cough
• Chronic Constipation
• Heavy Wt.Lifting / domestic Work
• Obesity, Ascitis
• WEAKNESS OF THE SUPPORTS MUSCLES
• Chronic ill health, malnutrition dysentery,
  anemia
• Inadequate rest during pureperium
• Menopause

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TYPES OF PROLAPSE

• Vaginal
• Anterior cystocele urethrocele
• Posterior - Enterocele Rectocele
• Vault Prolapse - a special term applied to the
  prolapse of upper vagina

• Uterine/Utero-vaginal- Acquired or Congenital.
• First degree.
• Second degree .
• Third degree-(total Prolapse / complete
  procidentia).
• However Procidentia is often used only to denote
  third degree uterine prolapse.

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EFFECTS OF PROLAPSE

• NO SYMPTOM- mild moderate prolapse.
• Discomfort disability.
• Sexual Dysfunction.
• URINARY- Frequency, Dysuria, Stress incontinence,
  infection.
• Incomplete emptying of rectum.
• Discharge.
• Backache.
• Ulceration Infection.

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WHEN TO TREAT ?

• Should be treated only when it is symptomatic (Be
  certain symptoms are due to Prolapse )
• Interferes with the normal activity of the woman
• The patient seeks treatment

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HOW TO TREAT ?

• NON-SURGICAL Methods -Limited Role
• PELVIC FLOOR REHABILITATION (pelvic muscle
  exercises, galvanic stimulation, physiotherapy,
  rest in the purperium).
• HORMONE REPLACEMENT, both systemic and local.
• PESSARY TREATMENT for temporary relief
• During Pregnancy, Pureperium Lactation
• When Operation is Unsafe due to Extreme
  Senility/Debility and Diseases
• Preoperatively
• For therapeutic test

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HOW TO TREAT ?

• SURGICAL TREATMENT -RECONSTRUCTIVE SURGERY is
  invariably needed and has to be a COMBINATION OF
  PROCEDURES to correct the multiple defects.

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SURGICAL TREATMENT

• It is the definitive curative treatment of
  Prolapse.
• It is a cold operation. So complete investigation
  should be done all existing diseases
  disorders should be treated first.
• Pre operative pessary/tampoon or Hormone
  treatment should be given as indicated.
• Meticulous and through examination under
  anaesthesia should be done before deciding the
  surgery.

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SURGICAL TREATMENT

• Depending on the type extent of Prolapse,
  surgery should be tailor made not only to rectify
  the defect but also to suit the individual
  patients requirement.
• Absolute haemostasis is mandatory.Diathermy
  should be liberally used.
• Vaginal suturing should be with interrupted
  stitches. Synthetic absorbable fine sutures are
  preferable.
• Catheter for more than 48 hrs should be
  exceptional.
• Strict antibiotic prophylaxis is essential

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VAGINAL OPERATIONS FOR PROLAPSE

• Anterior colporrhaphy
• Posterior colporrhapry- High / Low
• Enterocele repair
• Perineorrhaphy
• Amputation of cervix
• Paravaginal repair
• Hysterectomy with or without Colporrhaphy /
  Perineorrhaphy

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VAGINAL OPERATIONS FOR PROLAPSE

• Manchester/ Fothergills operation Shirodkars
  modification
• Uterus/Cervix suspension/fixation
• Vaginal vault suspension/fixation
• Retro-rectal levatorplasty and post. anal repair
  for associated rectal prolapse
• Vaginectomy ?
• Colpocleisis ?

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Anterior colporrhaphy Urethroplasty

• For correction of Cystocele Urethrocele
• Incision- Midline / Inv.T / Elliptical
• Excision of vagina according to the size site
  of laxity
• Avoid shortening /or narrowing of vagina
• Closure with interrupted sutures

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Posterior colporrhaphy Enterocele repair

• For correction of Enterocele Rectocele
• Enterocele repair can be done either by vaginal
  or abdominal route depending on the associated
  procedures.
• Approximation of uterosacral ligaments for
  enterocele prerectal fasciae and levator for
  rectocele with interrupted sutures is essential
• Excision of vagina should be tailor made
• Perineorrhapy to be done only if perineal body is
  torn

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Perineorrhaphy

• Not an Operation for prolapse, but Indicated only
  for associated old 2nd degree perineal tear
• Performed along with post. colporrhaphy
• Aim-Reconstruction of the Perineal body and
  reduction of gaping introitus.
• Can cause Dyspareunea
• Essential steps - Excision of the scar tissue
  approximation of levator ani superficial
  perineal muscles

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Vaginal Hysterectomy with/without Vaginal repair

• Indicated when uterus needs removal, in old age
  in total prolapse.
• Patients consent is mandatory knowing that there
  are alternatives to hysterectomy.
• Usually combined with Ant. Posterior
  colporrhaphy.
• Perineorrhaphy is not mandatory but case
  specific.
• Vault suspension is an essential step.
• If sexual function is not needed narrowing of
  vaginal canal should be done.

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Amputation of cervix

• Not for Prolapse.Indicated only for cervical
  elongation (Uterocervical length gt12.5 Cm )
• To be done only as a part of Fothergills
  repair/sling operations.
• Adequate cervical dilatation - a prerequisite
• Bladder displacement is a must
• Excision of cervix should not exceed 2 cm
• Likely to affect reproductive life
• Long-term complications are real risks

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Fothergills operation

• It is the operation of choice in uncomplicated
  Utero-vaginal prolapse when uterus is to be
  preserved but NO future child bearing is
  required.
• It is a combination of, Amp. of Cx., Fixation of
  the Meconrodts ligament to the anterior of Cx.
  Ant. Colporrhaphy. DC is a must.
• Post. Colporrhaphy to be performed only if
  Ent/Rectocele is present
• Perineorrhaphy is usually not required

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Fothergills operation

• Not useful if ligaments are weak Uterus is of
  normal size. Purandares modification may help.
• Technically difficult operation, requiring high
  degree of surgical skill.
• Threat of short-term complications.
• Real possibilities of long term complications.
• Recurrence/Failure.
• Sling operations are better alternatives
• HAS A BLEAK FUTURE

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ABDOMINAL OPERATIONS FOR PROLAPSE

• Sling operations
• Closure or repair of enterocele
• Sacrocolpopexy
• Anterior Colpopexy
• Colposuspension
• Paravaginal repair

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Abdominal Sling operations

• Indicated when the ligaments are extremely weak
  as in nulipara young women.
• Preserves reproductive function.
• Principle-With a fascial strip / prosthetic
  material (Merselene tape or Dacron) the Cx is
  fixed to the abdominal wall / sacrum / pelvis.
• Amp.of Cx should also be done if Utereocervical
  length gt12.5cm.
• Cystocele/Rectocele repair if needed can be done
  vaginally before or after.
• Enterocele repair can also be done abdominally.

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Abdominal Sling operations

• It is a major abdominal operation Synthetic
  material is costly not widely available in
  India.
• Types-.
• Shirodkars posterior sling.
• Purandares anterior cervicopexy.
• Khannas sling.
• Virkuds composite sling.

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Shirodkars sling

• Tape is fixed to the post. Aspect of isthmus
  sacral promontory
• Anatomically most correct but difficult to
  perform
• Risks of complication

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Purandares cervicopexy

• Tape is anchored to the ant.aspect of isthmus and
  ant. abd. Wall
• Easy to perform
• Dynamic support

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Virkuds composite sling operation

• Tape is anchored from the post aspect of isthmus
  to sacral promontory on the Rt. side ant. abd.
  Wall on the Lt. Side
• Utrosacral ligament is plicated
• Technically easy

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Khannas sling operation

• Tape is anchored to ant aspect of isthmus ant.
  sup. Iliac spine
• Easier to perform and safer
• But tape is superficial
• Risk of infection

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Abdominal Colpopexy / Colposuspension

• Indicated when vault prolapse occurs after
  hysterectomy or vaginal laxity is to be corrected
  at abdominal hysterectomy.
• Major abdominal operation technically
  difficult.
• Sexual function is preserved.
• Methods-.
• Sacrocolpopexy.
• Ant.Colpopexy.
• Colposuspension.

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Sacrocolpopexy

• Vault is fixed to 3rd 4th sacral vertebrae with
  a facial strip / proline mesh under the
  peritoneum to the right of rectum
• Enterocele repair can be done if required

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Ant.Colpopexy

• Corrects ant. vag laxity stress inc.
• Useful at abdominal hysterectomy / for vault
  prolapse.
• Extra peritoneal supra pubic approach if done
  alone.
• Enterocele repair if required.
• Vagina stitched to the ileo-pectineal ligaments.

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Vault / Colposuspension

• Vault is fixed to the abdominal wall by a facial
  strip or merseline tape

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LAPAROSCOPIC SURGERY PROLAPSE

• Advantages of M I S-small incision, better view,
  haemostasis, no packing, minimal tissue bowel
  handling, short recovery, less pain,
  insignificant scar
• Can all types of prolapse be treated?- Yes.
• Ant. / Post. Lower vaginal repairs if needed can
  also be done vaginally before or after
  lap.Surgery
• However extended period of rest is essential
• Expertise is needed
• Presently cannot be widely practised
• This is the surgery of the future today

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LAPAROSCOPIC SURGERY PROLAPSE

• PROCEDURES-
• Cervicopexy / Sling operations with/without
  Lap.Paravaginal repair / Vaginal repair
• VH / LAVH / LH / TLH Colposuspension
• VH / LAVH /LH/TLH Lap.Pelvic reconstruction
• Rectocele repair levatorplasty
• Enterocele repair with suturing of uterosacral
  ligaments
• Colpopexy- Ant / Post

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Laparoscopic Cervicopexy/sling Operations

• All types of sling operations can be better
  performed by laparoscopy
• Associated vaginal prolapse can also be repaired
  laparoscopically (Lap.Paravaginal repair)
• Vaginal Ant./Post. colporrhaphy can be done
  before / after laparoscopy

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Laparoscopic Vault suspension/ Culdoplasty)

• Can be done with VH / LAVH / LH / TLH
• Corrects mild laxity
• Prevents vault prolapse

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Laparoscopic Pelvic Reconstruction With VH /
LAVH / LH / TLH

• An alternative to Ward-Mayos operation
• Before Hys., Lap.Ureteral dissection is done and
  suture placed in uterosacral ligament near sacrum
  left long, for latter vaginal vault suspension
• Lap. levator plication if needed
• Enterocele repair and suturing of uterosacral
  ligaments if needed
• Retro pubic Colposuspension (Bruch) if required

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Laparoscopic Rectocele repair Levatoroplasty

• Rectovaginal space is opened rectum dissected
• Interrupted sutures given in the levator in the
  midline
• Enterocele repair done if indicated
• Vaginal vault suspension done

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Laparoscopic Enterocele repair

• Rectovaginal space is opened, sac excised and
  purse string suture given
• Uterosacral ligament sutured

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Laparoscopic Post Colpopexy / Sacrocolpopexy

• Indicated for vault prolapse
• Enterocele if present is first repaired
• Prolene mesh is fixed to the vault 3rd-4th
  sacral vertebrae, under the peritoneum in the
  Rt.para rectal space

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Time has come for Laparoscopic Surgery for
ProlapseSo move with the times. Practice
laparoscopy.This is the Surgery of the future
today.
THANK YOU