Management Of Prolapse

by: Siti Nur Hamizah

Preventive
 Conservativ
e
 Surgery
 Preventive
Antenatal General measures
&intranatal care Postnatal care
* Avoid strenuous
*Encourage early activities, chr.
* To avoid injury to
cough, constipation
the supporting ambulation & heavy weight
structures during * Encourage lifting
time of vaginal
delivery either
floor exercise by
pelvic
* Avoid future
sspontaneous or squeezing the pelvic pregnancy too soon
instrumental floor muscles in the & too many by
puerperium contraceptive
practise
Conservative: Pessary treatment

 Limitations
 It is never curative and only be palliative
 It can cause vaginitis
 Pessary needs to be changed every 3 months
 The wearing of pessary is not comfortable to some
women and may cause dyspareunia
 If the vaginal orifice is very patulous, the pessary is
often not retained.
 A forgotten pessary can be the cause of ulcer, rarely
carcinoma of vagina and a vesicovaginal fistula
 A pessary does not cure urinary stress incontinence
 Indications:
 A young woman planning a pregnancy
 During early pregnancy
 Puerperium
 Temporary use while clearing infection and decubitus ulcer
 A woman unfit for surgery
 In case a woman refuses for surgery
 Ring pessary is made of soft plastic polyvinyl chloride
& available in different sizes.
Surgery

 Type of surgery offered to the patient with prolapse

depends on the age of patient, her desire to retain
the uterus either for reproductive or menstrual
function, her menstrual history, general condition
as well as the degree of uterine prolapse and
uterine abnormality
 Aim:
 Relieve symptoms
 Restore anatomy
 Restore sexual function
Type of prolapse and the common
surgical repair procedures
 Anterior Colporrhaphy

 To correct cystocele & urethrocele.

 Principles: to excise a portion of the relaxed ant. Vaginal
wall, to mobilise the bladder and push it upwards after
cutting the vesicocervical ligament. The bladder is then
permanently supported by plicating the endopelvic fascia
under the bladder neck in the midline.
 Preliminaries:
 ↓ GA/ EA
 Pt in lithotomy position
 Vulva and vagina are to be swabbed with antiseptic solution
 Perineum to be draped with sterile towel and legs with leggings
 Bladder is to be emptied by metal catheter
 Vaginal examination is done to assess the type and degree of prolapse.
Perineorrhaphy/ Colpoperineorrhaphy
 Designed to repair the prolapse of post.vaginal wall.
 its uses and extent of repair are employed in:
 Relaxed perineum – the operation is extended to repair the torn perineal
body.
 Rectocele – correct rectocele by tightening the pararectal fascia
 Enterocele – high perineorrhaphy is to be done right upto the
cervicovaginal junction along with correction of enterocele.
 Lax vagina over the rectocele is excised, and rectovaginal
fascia
repaired after reducing the rectocele.
 Approximation of medial fibres of levetor ani helps to restore the
calibre of hiatus urogenitalis, restore perineal body & provide
adequate perineum separating the hiatus urogenitalis from the anal
canal
 Commonly combined with ant.corrporaphy, or vaginal hysterectomy
requiring PFR, & as part of Fothergill’s repair
Fothergill’s repair/ Manchester operation

 Combines an ant.colporrhaphy with amputation of cervix, sutures

the cut ends of the Mackenrodt ligaments in front of the
cervix, covers the raw area on the amputated cervix with vaginal
mucosa and follows it up with colpoperineorraphy.
 Preserves menstrual and childbearing functions
 Fertility reduced because of the amputation of the cervix causing
loss of cervical mucus.
 Suitable for women under 40 who are desirous of retaining their
menstrual and reproductive function.
 Cervical amputation may lead to incompetent cervical os, habitual
abortions or preterm deliveries.
 Excessive fibrosis → cervical stenosis and dystocia during labour
 Rarely cause haematometra.
 Recurrence may occur following vaginal delivery
 Shirodkar’s procedure

 Modified Fothergill’s operation

 Ant. Colporraphy performed, attachment of Mackenrodt
ligaments
to cervix on each side is exposed.
 Vaginal incision is then extended posteriorly round the cervix.
 POD is opened, uterosacral ligaments identified and divided close
to the cervix.
 The stumps of these ligaments are crossed and stiched together in
front of cervix.
 High closure of the peritoneum of POD is carried out.
 Cervix is not amputated, rest of operation similar to Fothergill’s
operation
 Vaginal hysterectomy with PFR
 Women more than 40 yrs
 Have completed her family
 No longer keen on retaining her childbearing & menstrual
functions
 Steps:
 Circular insicion over cervix, below bladder sulcus & vagina mucosa
dissected off the cervix all around.
 POD identified post & peritoneum incised
 Bladder pushed upwards until uterovesical peritoneum is visible &
incised
 Mackenrodt & uterosacral ligament are clamped, cut & pedicles
transfixed
 Uterine vessels are identified, clamped,cut & ligated
 Upper portion of broad ligament holding uterus contains round &
ovarian ligament & fallopian tube identified, clamped, cut & pedicle
transfixed.
 Uterus removed
 Peritoneal cavity is closed with purse-string suture
 Ant. Colporraphy & post colpoperineorraphy is performed as
required.
 Vaginal is packed with betadine pack for 24 hrs
 Cathetherize for 48 hrs.

 Complications:
 Hemorrhage
 Sepsis
 Anaesthesia
risks
 UTI
 Rarely trauma
to bladderand
rectum.
 Vault prolapse
as late sequela
 Le Fort’s repair
 Reserved for the very elderly menopausal ptwith advanced
prolapse or for those considered unfit for any major surgical
procedure.
 Pap smear & pelvic sonography to r/o pelvic pathology prior
to
procedure
 Procedure can be performed under sedation & LA or EA.
 Flaps of vagina from ant & post vaginal walls are excised,
the raw
areas apposed with catgut sutures
 Wide area of adhesion is created in the midline prevents uterus
from prolapsing, small tunnels on either side permitting drainage
of discharge.
 Operation limits marital function, not to be advised to women
with
active married life.
 Contraindicated in menstruating woman,a woman with diseased
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.
 Operation in common practise:
 Abdominocervicopexy
 Shirodkar’s abdominal sling operation
 Khanna’s abdominal sling operation
Vault prolapse

 Delayed complication of both abdominal and vaginal

hysterectomy when supporting structure become weak
and deficient.
 Also a result of failure to identify and repair an
enterocele during hysterectomy.
 Treatment:
 Right transvaginal sacrospinous colpopexy
 Transabdominal sacral colpopexy
 Colpocleisis
 Le forte
 Laparoscopic colpopexy
 Abdominoperineal surgery
 Ring pessary.