Genital prolapse definition:
Protrusion of one or more genital organs below their normal anatomical position.
Genital prolapse Incidence:
* 10 – 30 % of multiparous females.
* 2 % of nulliparous females.
Anatomical supports of the genital tract:
A. Major supports:
1) Endopelvic fascia:
a) Fascial sheaths.
b) Pelvic condensations: parametrium & paracolpos.
c) Pelvic ligaments: Mackenrodt’s ligament, uterosacral ligament & pubocervical ligament.
2) Pelvic floor:
a) Levator ani including coccygeus muscle.
b) Pelvic fascia covering previous muscle.
c) Transverse perineal muscles. (Superficialis and profunda)
3) Position of the uterus (Anteverted anteflexed).
B. Minor supports:
a) Bony pelvis.
b) Perineal body.
c) False uterine ligaments: round, ovarian & broad.
d) Pelvic peritoneum & sub-peritoneal retinaculum.
Genital prolapse aetiology:
A. Predisposing factors
1) Weakness of cervical ligaments:
a) Obstetric trauma: the commonest cause.
♦♦♦ Prenatal: large fetus.
♦♦♦ Intranatal: bad obstetric management:
– 1st stage: bearing down before full cervical dilatation.
– 2nd stage: Forceps application before full cervical dilatation.
– 3rd stage: improper management to deliver the placenta.
♦♦♦ Postnatal: early ampulation, & lack of pelvic floor exercise postnatally.
b) Congenital weakness: weak mesenchymal tissue, nulliparous prolapse.
c) Postmenopausal atrophy: ligaments are estrogen dependent.
2) Weakness of pelvic floor:
a) Repeated successive improperly managed vaginal deliveries.
b) 2nd degree perineal tear (more than 3rd degree?!)& also hidden tear.
c) Defective innervations of levators.
3) RVF position of the uterus (1st degree):
♦♦♦ Disturbing weight bearing mechanism of pelvis, as long axis of the uterus comes with that of the vagina.
B. Precipitating factors:
1) Persistent high intra-abdominal pressure:
* Chronic cough. * Chronic constipation.
* Ascites. * Abdominal mass.
2) ↑Weight of the uterus: -Small fibroid rather than large one.
– Early pregnancy rather than late one.
Genital prolapse classification:
a) Vaginal prolapse:
I. Anterior vaginal wall prolapse:
1) Cystocele: Upper part of anterior vaginal wall descends with bladder base.
2) Urethrocele: Lower part of anterior vaginal wall descends with urethra.
3) Cystourethrocele: combination of both types.
II. Posterior vaginal wall prolapse:
1) Enterocele: Peritoneal sac from Douglas pouch (containing intestine)
bulging through upper part of posterior vaginal wall. (if empty, it’s called hernia of Douglas pouch).
2) Rectocele: Anterior rectal wall bulging through the lower part of posterior vaginal wall.
III. Vault prolapse:
♦♦♦ Only in hystrectomatized women.
b) Uterine prolapse:
♦ Level of ischial spine is the normal anatomical landmark of external os.
1. 1st degree uterine prolapse:
♦♦♦ On straining; external os descends below the level of ischial spine, No protrusion
♦♦♦ Diagnosed only by PV examination: cervix is felt below the level of ischial spine.
2. 2nd degree uterine prolapse:
♦♦♦ On straining; the cervix only protrudes through the vulva.
♦♦♦ Finger test is negative i.e. the fingers can’t be approximated at the vulva
because only part of uterus that protrude outside the vulva.
3. 3rd degree uterine prolapse:
♦♦♦ On straining; the uterine body with its cervix protrudes outside the vulva
& the vaginal wall is completely covering it (complete procidentia).
♦♦♦ Finger test is positive i.e. the fingers can be approximated at the vulva
because the whole uterus is prolapsed outside the vulva.
False Prolapse:
– Congenital elongation of portiovaginalis.
– Fornices appear deep and not inverted.
c) Combined prolapse:
I. Utero-vaginal prolapse (congenital):
♦♦♦ Descent of the uterus followed by the vagina.
♦♦♦ Congenital weakness of cervical ligaments.
♦♦♦ Called nulliparous prolapse before pregnancy.
II. Vagino-uterine prolapse (acquired):
♦♦♦ Descent of the vagina followed by the uterus.
♦♦♦ Acquired weakness of pelvic floor.
♦♦♦ Usually due to obstetric trauma.
d) Ovarian prolapse:
I. Congenital:
II. Acquired: due to:
1) Subluxation of ovarian ligament: after labour.
2) Pelvic adhesions: fix the ovary in Cul de Sac.
3) RVF: pushing the ovary in Cul de Sac.
Pelvic organ prolapse quantification system (POP-Q)
Reference point: hymenal ring (more precise than the introitus).
Uses 6 points along the vagina in relation to the hymenal ring (zero).
♦♦♦ They are either proximal to the hymen (negative number), or
♦♦♦ Distal to the hymen (positive number):
Points Aa &Ap: 3 cm above the hymenal ring in ant. and post. wall respectively.
Points Ba & Bp: the lowest points of the prolapse.
Point C: cervix.
Point D: Douglas pouch.
Other 3 distances: genital hiatus (gh), perineal body(pb) & total vaginal length(TVL)
N.B.: all measurements are measured during maximal straining except TVL
Genital prolapse complications = anatomical changes = genito-urinary changes:
A. Genital:
1) Vagina:
a) Vaginal mucosa is congested leading to thickening, keratinization & pigmentation.
b) Trophic ulcers of the vaginal wall developed due to:
♦ Vascular cause: chronic congestion.
♦ Mechanical cause: friction by the patient thighs & clothes.
♦ Hormonal cause: postmenopausal atrophic changes.
2) Cervix:
a) Cervical tissue hypertrophied due to: * Chronic infection. * Chronic congestion.
b) Trophic ulcers appear in cervix.
c) Supravaginal elongation:
♦ Present in cases of vagino-uterine prolapse.
♦ Absent in cases of uterovaginal prolapse.
3) Tubes & ovaries:
a) Both tracked after prolapse of the uterus.
b) Tubes develop kinking and may be obstruction.
B. Urinary:
a) Urethra: large cystocele kinking of the urethra dysuria hidden stress
incontinence.
b) Bladder neck: descent of the bladder neck sphincteric stress incontinence.
c) Bladder: it forms pouch collection of urine irritation of the trigonecystitis.
d) Ureter: 3rd degree uterine prolapse kinking of ureterhydroureter & hydronephrosis.
C. Rectal:
♦ Sense of incomplete evacuation.
♦ Residual hard stool.
Genital prolapse diagnosis:
A. Symptoms:
1) History of predisposing & precipitating factors.
2) Actual prolapse:
♦♦♦ Early manifestations are sense of heaviness at the end of the day.
♦♦♦ Then mass arising from the related to decubitus.
3) Urinary symptoms:
a) Frequency of micturition: * 1st diurnal (irritation of trigone by residue).
* Then diurnal & nocturnal due to active cystitis.
b) Urine incontinence: due to *Stretch of internal urethral sphincter and /or
*Descent of the bladder neck.
c) Difficulty in micturition:
♦♦♦ Mass must be pushed upwards by fingers to complete micturition.
♦♦♦ This is to manage angulation & kinking of urethra.
d) Symptoms of UTI: * fever & rigors.
* loin pain radiating to the groin.
4) Rectal symptoms:
a) Rectal heaviness.
b) Difficulty in defecation Mass must be pushed to complete defecation.
c) Piles due to: * increased intra-abdominal pressure.
* Pelvic congestion.
* associated weak mesenchyme.
5) Backache:
Cause: stretch of uterosacral ligament.
Special characters: * aggravated by chronic cervicitis & marked at the end of the day.
* Absent in 3rd degree uterine prolapse due to damage of nerves.
6) Pelvic congestive symptoms:
a) Congestive dysmenorrhea.
b) Congestive menorrhagia.
c) Leucorrhea (also due to chronic cervicitis).
B. Signs:
1) General examination: exclude anemia & uremia.
2) Chest examination: exclude chronic bronchitis (a precipitating factor).
3) Abdominal examination:
♦♦♦ Associated hernia.
♦♦♦ Renal angle: tender in pyelonephritis.
♦♦♦ Visceroptosis in virginal prolapse.
4) Back examination: lipoma or tuft of hair points to spina bifida occulta.
5) Lower limb examination: varicose vein & flat foot in virginal prolapse.
6) Local examination: – Inspection,
– Palpation,
– Special tests.
Inspection
a) For stress incontinence: on coughing, inspect urethral meatus.
b) For prolapsed mass: on straining comment on :
♦ The type of prolapse:
Vaginal: no cervix is detected.
Uterine: cervical os is seen (if seen 2nd or 3rd degree).
♦ Trophic ulcers if present.
c) For perineum: * intact or deficient. * intergluteal cleft.
Palpation
a) For hidden stress incontinence: after reduction of the prolapsed mass & ask your patient to cough (Youssef’s test).
b) For the prolapsed mass: PV examination.
♦ Vaginal:
Differentiates anteriorly between cystocele & urethrocele.
Differentiates posteriorly between rectocele & enterocele.
♦ Uterine:
Differentiates no prolapse & 1st degree by external os level.
Differentiates between 2nd degree & 3rd degree by finger test.
c) Tone of levator ani muscle:
♦ Feel the tone then ask the patient to contract her pelvic floor to feel levator action (levator test).
d) PR examination: is it rectocele or enterocele.
e) Complete bimanual examination: Feel uterus & adnexa.
Special tests
a) Catheter:
♦ Catheter enters urethrocele and cystocele.
♦ Differentiates it from other anterior vaginal wall swellings.
b) Q-Tip test: urethral hypermobility in urethrocele (angle > 20º).
c) Speculum examination
♦ Visualize interior of vagina and detects cervical lesions.
d) Sound: detects supravaginal elongation of the cervix.
e) Malpus test: combined PR & PV examination.
♦ Value: differentiates between rectocele & enterocele.
♦ Method: in standing position, put the middle finger in the vagina & index finger in the rectum.
♦ Result: in cases of enterocele, mass descends separating the 2 fingers on straining.
C. Investigations:
1) Hb: as this condition treated by a bloody operation.
2) Urological investigations:
Urine analysis, culture & sensitivity.
IVP: done in cases of 3rd degree.
3) Routine preoperative investigations.
D. Differential diagnosis:
a) Vaginal prolapse
1) Cystocele: from Gartner cyst which is characterized by:
Arise from anterolateral vaginal wall.
Incompressible (closed space).
No urinary manifestations (urinary system not included).
Catheter: normal direction of the urethra (not enters the mass).
2) Urethrocele:
a) From urethral diverticulum: compressible releasing pus or urine from external urethral meatus (collected stored urine).
b) From cyst of Skene’s duct: irreducible firm cyst in posterior wall of urethra.
3) Rectocele: from implantation dermoid cyst which is:
*Incompressible (closed space).
*PR: the rectum doesn’t forming part of the mass.
4) Enterocele: from rectocele.
a) Enterocele: * bulges through posterior fornix.
*Associated with gurgling sensation & expansible impulse on cough.
b) PR: in enterocele, the rectum doesn’t form part of the mass.
c) Combined PV & PR on straining: the rectum is pushed backwards.
b) Uterine prolapse
1) Congenital elongation of portiovaginalis:
Vaginal vault: kept at its normal level.
Fornices are deep.
2) Large fibroid polyp: the protruding mass has no external os.
3) Chronic inversion: the protruding mass has no external os.
Genital prolapse treatment:
A. Prophylactic treatment:
avoid possible predisposing & precipitating factors.
B. Active treatment:
a) Pessary:
Indications:
a) Temporary contraindication for surgery e.g. lactation & early pregnancy.
b) Permanent contraindication for surgery e.g. very old patient.
Precautions:
a) Daily vaginal douches.
b) Monthly vaginal examination.
Types:
a) Ring pessary: used if levators are strong.
b) Cup & stem pessary: used if levators are weak.
b) Pelvic floor exercise:
Indication: young female with mild prolapse & not accepting surgery.
Value: more effective in the treatment of stress urinary incontinence than prolapse.
c) Surgery
Timing:
a) Post-menstrual: to exclude pregnancy &↓ bleeding during operations.
b) 3- 6 months after delivery or abortion: to allow maximum involution.
c) 3- 6 months after previous attempt to repair: to allow maximum fibrosis.
Preoperative measures:
a) Improve general condition:
Correction of anemia.
Correction of DM & hypertension.
Correction of chronic cough & chronic constipation.
b) Improve local condition:
Reposition of prolapse & kept in place by vaginal pack.
Estrogen cream for postmenopausal female.
Treatment of trophic ulcers in vagina & cervix.
c) Preoperative investigations:
Blood sample: blood sugar, CBC, KFT& LFT.
Urine sample: urine analysis.
ECG.
Operative measures:
Factors affecting choice of the operation:
a) Patient factors: * Age of the patient. * Parity of the patient.
b) Disease factors: * Type & degree of prolapse. * Presence of complications.
Choice of operation:
i. Vaginal prolapse
A. Rectocele: posterior colpoperineorraphy is sufficient.
B. Cystocele: classical repair is the trend (anterior colporraphy &
posterior colpoperineorraphy).
C. Cystorectocele: classical repair.
D. Enterocele:
Vaginal repair with culdoplasty.
Abdominal repair: Moschowitze operation( obliteration of
Douglas pouch by purse string sutures)
E. Vault prolapse:
Prevention: suturing the vaginal vault to cervical ligaments
during hysterectomy.
Treatment:
a) Vaginal repair: opening the vault & suturing the
cervical ligament to it firmly.
b) Abdominal repair: colposacropexy.
ii. Uterine prolapse
1) Young age:
Normal length of the cervix: classical repair + suturing
Mackenrodt’s ligament together in front of the cervix.
Supravaginal elongation of the cervix: FothergillManchester operation (cervical amputation).
2) Old age:
Vaginal hysterectomy with suturing of cardinal ligament to
the vaginal vault to avoid subsequent vault prolapse.
Le-fort’s operation: partial colpocleisis (for sexually inactive
patients with poor general condition).
iii. Nulliparous (virginal) prolapse
Vaginal repair is difficult so Cervicosacropexy is done.
Fothergill’s operation
Steps:
1) Dilatation of the cervix.
2) Curettage: not essential step.
3) Anterior colporraphy.
4) Amputation of the cervix.
5) Suturing Mackenrodt’s ligament together in front of the cervix.
6) Posterior colpoperineorraphy.
Complications:
1) Long duration with excessive blood loss.
2) Complication of cervical amputation.
Stenosis spasmodic dysmenorrhea, cervical dystocia,
infertility & prolapse.
Incompetence.
3) Recurrent prolapse.
Post-operative care:
i. Early
1) Local:
a) Vaginal pack & urinary catheter for 24 hours.
b) Cleaning the perineum with diluted antiseptic solution.
c) Local application of antibiotics.
2) General: fluids, antibiotics & analgesics.
ii. Late
1) No hard work for one month.
2) No coitus for 2 months.
3) No pregnancy for 12 months.
4) Subsequent labour at hospital by either:
* Vaginal delivery with early generous episiotomy.
* CS (better).
Complications of vaginal operations:
A. Intra-operative :
1) Complications of anesthesia.
2) Shock.
3) 1ry hemorrhage.
4) Injury of important structures e.g. ureter & bladder.
B. Post- operative:
1) Early:
Reactionary & 2ry hemorrhage.
Infection: wound & urinary tract infection.
Pulmonary embolism: due to DVT.
2) Late:
Dyspareunia.
Cervical amputation.
Recurrence.
Recurrent genital prolapse
Definition
Protrusion of the genital organs within or out vagina after previous surgical repair.
Incidence: 7 %.
Causes:
A. Pre-operative causes:
1) Bad timing of operation: premenstrual & immediate post-operative or post-partum.
2) Bad general condition: no correction of possible predisposing factors e.g. anemia.
3) Bad local condition: vaginitis & trophic ulcers.
B. Operative causes:
1) Bad choice of operation: e.g. no amputation of supravaginal elongation.
2) Bad surgical technique: e.g. bad hemostasis.
3) Missing a finding in the diagnosis: enterocele & stress incontinence.
C. Post-operative causes:
1) Early: * early ampulation. * complications e.g. infection.
2) Late: * early intercourse before 2 months. * bad management of subsequent labour.
Hazards:
1) Scarring & atrophy of vaginal epithelium: need more difficult surgical technique.
2) Increase the risk of injuring bowel & UB.
3) Dyspareunia due to vaginal stenosis & vaginal shortening.
Treatment:
1) As usual.
2) Use of synthetic mesh in patients with recurrent fascial defects.