Genital prolapse

Prepared by:

Dr. Gehanath Baral

MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU, China

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 Definition

Genital prolapse:
• Descent of vaginal wall and/or the uterus from the normal position
due to loss of support from pelvic floor.
1. Cyctocele =Ant.wall, upper 2/3rd
2. Urethrocele =Ant.wall, lower 1/3rd
3. Rectocele =Post.wall, lower 2/3rd
4. Enterocele =Post.wall, upper 1/3rd
5. Uterine prolapse =Descent below the level of ischial spine.
6. Vault prolapse =Enterocele after hysterectomy
Genital displacement:
• Change of position of uterus beyond its normal limits.
1. Fixed retroversion
2. Acute inversion
3. Chronic inversion
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Uterine prolapse

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Cystocele/ Urethrocele

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Rectocele/ Enterocele

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 Aetiology

1. Birth injury

1. Overstretching of ligaments and fascia

2. Subinvolution of supporting structures

2. Congenital weakness

3. Atonicity at menopause

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 Risk factors

• Malnutrition

• Increased intra-abdominal pressure

• Downward traction by polyp or vaginal wall

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Uterine supports1

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Uterine supports2

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Uterine supports3

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 Degree of uterine prolapse

• 1st =Descent up to the vaginal introitus

• 2nd =Partial descent outside vagina

(uterine fundus still inside)

• 3rd =Complete descent outside vagina

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Degree of uterine prolapse

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 Diagnosis: Clinical

1. Something coming down from vagina

2. Symptoms from traction: Backache

3. Pressure symptoms:
• Urinary:-
1. Incomplete voiding
2. Retention
3. Stress incontinence
4. Infection
• Bowel:-Difficulty passing stool

4. Trophic :- Decubitus ulcer, Vaginitis, Cervicitis

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UVProlapse

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 O/E:

1. Ask pt to strain, squat or

1. Inspection cough.

2. Palpation 2. Feel ischial spine

3. Per speculum 3. Palpate fundus of uterus

if you can get above it or
not.
4. Per rectal
4. Test on full bladder for
stress incontinence.

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 D/D:

• Fibroid polyp • Cx polyp or growth

• Cx elongation • Vulval cyst

• Chronic inversion • Vaginal cyst

• Rectal prolapse • Urethral diverticulum

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 Prevention

1. Optimum wt. gain during pregnancy

2. Proper management of 2nd stage
3. Episiotomy
4. Not to allow to prolong labor
5. Proper management of 3rd stage
6. Repair perineal tear
7. Early postnatal ambulation
8. Adequate rest postpartum
9. Perineal exercise
10. Birth spacing and decrease multiparity
11. HRT in menopause
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 Management:

1.General 2.Pessary

• Nutrition • Decubitus ulcers

• HRT • Early pregnancy
• Safe delivery • Puerperium
• Treat complication: • Unfit/Unwilling for
• Infection surgery
• Decubitus ulcer
3.Surgery

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 Surgery

1. Vaginal hysterectomy + PFR 1. Le Fort operation= Apposition

of vaginal wall
2. PFR= Ant. + post. repair

3. Fothergill’s repair=Cx 2. Repair of vault prolapse:

shortening + Ant./Post.repair
1. Colpopexy
4. Anterior colporrhaphy 2. Cervicopexy
3. Le fort operation
5. Posterior
colpoperineorrhaphy

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Enterocele Repair1

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Enterocele Repair2

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 Steps of Fothergill’s repair

1. D & C

Incision all around the Cx

Anterior vaginal flaps made
Urinary bladder pushed up
Posterior vaginal flap made

2. Amputation of cervix
3. Plication of Mackenrodt’s ligament in front of Cx

New Cx made with vaginal flaps

4. Anterior colporrhaphy
5. Posterior colpoperineorrhaphy

Keep indwelling catheter

Keep vaginal pack

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Fothergill’s repair1

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Fothergill’s repair2

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Fothergill’s repair3

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Fothergill’s repair4

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 Vaginal hysterectomy + PFR

1. Hysterectomy

2. Anterior colporrhaphy

3. Posterior colpoperineorrhaphy

4. Keep indwelling catheter & vaginal pack

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 Vaginal hysterectomy:

1. Incision on the vaginal wall just over the Cx

2. Elevate vaginal wall flaps
3. Push up urinary bladder
4. Apply clamps on either side:
5. Clamp, cut & ligate Mackenrodt’s ligament
6. Clamp, cut & ligate uterine vessels
7. Clamp, cut & ligate uterine cornual structures:
1. Parametrium
2. Round ligament
3. Fallopian tube
4. Ovarian ligament
8. Remove uterus
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Anterior colporrhaphy after hysterectomy

1. Close pelvic peritoneum

2. Apply purse string suture beneath the bladder

3. Tie two cornual structures together

4. Tie two Mackenrodt’s ligaments together

5. Trim redundant anterior vaginal flap

6. Suture to close anterior vaginal flaps

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Vaginal hysterectomy:1

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Vaginal hysterectomy:2

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Vaginal hysterectomy:3

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Vaginal hysterectomy:4

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Vaginal hysterectomy:5

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Vaginal hysterectomy:6

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Vaginal hysterectomy:7

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Vaginal hysterectomy:8

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Anterior colporrhaphy for cystocele
without hysterectomy

1. Incision on the vaginal wall just over the Cx

2. Elevate vaginal wall flaps

3. Push up urinary bladder

4. Apply purse string suture beneath the bladder

5. Trim redundant anterior vaginal flap

6. Suture to close anterior vaginal flaps

7. Keep indwelling catheter & vaginal pack

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Anterior colporrhaphy1

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Anterior colporrhaphy2

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Anterior colporrhaphy3

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Anterior colporrhaphy4

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 Posterior colpoperineorrhaphy

1. Horizontal incision over the fourchete

2. Elevate posterior vaginal flap and trim it

3. Appose levator ani muscles together with

2-3 delayed absorbable interrupted
sutures

4. Suture to close anterior vaginal flaps

5. Suture skin as in episiotomy repair

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Posterior colpoperineorrhaphy1

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Posterior colpoperineorrhaphy2

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Posterior colpoperineorrhaphy3

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 Complication of PFR/Vag.Hyst.

Prolapse: Surgery:
1. Obstructive uropathy 1. Bleeding
2. Bowel obstruction 2. Injury to:
3. Persistent infection with 1. Bladder (VVF)
infective uropathy 2. Ureter
3. Rectum(RVF)
4. Decubitus ulcer may
change into cancer 3. Infection
5. Poor quality of life 4. Urinary retention
6. Need of surgical 5. Dyspareunia
intervention 6. Vault prolapse

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 Complication of Fothergill’s repair

1. Bleeding 1. Cx stenosis
2. Injury to: • Infertility
1. Bladder (VVF) • Hematometra
2. Ureter • Cx dystocia
3. Rectum(RVF)
3. Infection 2. Cx incompetence
4. Urinary retention • Recurrent abortion
• Preterm delivery
5. Dyspareunia

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