Genital prolapseGenital prolapse

ISMAEL YOUSIFISMAEL YOUSIF

DefinitionDefinition

Genital Prolapse:Genital Prolapse:

Is herniation of the genital Is herniation of the genital organsorgans

through the genital tract.through the genital tract.

Support of the pelvic Support of the pelvic organs:organs:

• The main support is by the :The main support is by the :

1-pelvic floor muscles:1-pelvic floor muscles:

-Levator ani -Levator ani

-Coccygeus -Coccygeus

-Internal Obturator-Internal Obturator

-Piriformis -Piriformis

-Transverse perineal muscles-Transverse perineal muscles

Support of the pelvic organsSupport of the pelvic organs

2- Pelvic ligaments:2- Pelvic ligaments:

- Transverse cervical ligaments (Cardinal)- Transverse cervical ligaments (Cardinal)

- Uterosacral ligaments- Uterosacral ligaments

- Pubocervical ligaments - Pubocervical ligaments

- Pubourethral ligaments - Pubourethral ligaments

3- Pelvic Fascia 3- Pelvic Fascia

Minor support:Minor support:

• Round ligamentRound ligament

• Broad ligamentBroad ligament

ClassificationClassification

• Vaginal wall prolapse:Vaginal wall prolapse:#Anterior:#Anterior:1- Urethrocele:1- Urethrocele: Descend of the lower part of the anterior Descend of the lower part of the anterior

vaginal wall containing the urethra.vaginal wall containing the urethra.2- Cyctocele: 2- Cyctocele: Descend of the upper part of the anterior Descend of the upper part of the anterior

vaginal wall containing the bladder.vaginal wall containing the bladder.

Vaginal wall prolapse:Vaginal wall prolapse:

#Posterior:#Posterior:1- Enterocele:1- Enterocele: Descend of the upper posterior Descend of the upper posterior

vaginal wall containing small bowl vaginal wall containing small bowl from the pouch of Douglas from the pouch of Douglas

2- Rectocele:2- Rectocele: Descend of the lower posterior vaginal Descend of the lower posterior vaginal

wall containing the rectum.wall containing the rectum.

Vaginal wall prolapse:Vaginal wall prolapse:

#Middle:#Middle:

Vault prolapse:Vault prolapse:

Descend of the vaginal vault after Descend of the vaginal vault after hysterectomy , usually contains : hysterectomy , usually contains : small bowl and omentum.small bowl and omentum.

Uterine Prolapse:Uterine Prolapse:

1- First degree:1- First degree:

The uterus is with in the vagina.The uterus is with in the vagina.

2- Second degree:2- Second degree:

The cervix protrudes outside through The cervix protrudes outside through the introitus .the introitus .

3- Third degree (Procidentia):3- Third degree (Procidentia):

The entire uterus has come out the The entire uterus has come out the vagina.vagina.

Uterine ProlapseUterine Prolapse

Uterine ProlapseUterine Prolapse

Vaginal Vault ProlapseVaginal Vault ProlapseVaginal Vault Prolapse

Vaginal Vault ProlapseVaginal Vault Prolapse

AetiologyAetiology

• Major causes:Major causes:1- 1- CCongenital weakness of the pelvic floor ongenital weakness of the pelvic floor

ligaments and fascia.ligaments and fascia. 2- 2- CChild birth:hild birth: Pregnancy, prolonged or difficult labour,Pregnancy, prolonged or difficult labour, bearing down before full cervical dilatation, bearing down before full cervical dilatation,

multiparity and instrumental delivery.multiparity and instrumental delivery.3- 3- CClimacteric: weakness and denervation of limacteric: weakness and denervation of

the pelvic floor muscles due to oestrogen the pelvic floor muscles due to oestrogen deficiency.deficiency.

AetiologyAetiology

• Minor causes:Minor causes:

--CChronic hronic CCoughough

-Chronic -Chronic CConstipationonstipation

-Increased Intra abdominal pressure:-Increased Intra abdominal pressure:

.Masses.Masses

.Ascitis.Ascitis

.Pulmonary disease.Pulmonary disease

.heavy lifting.heavy lifting

Presentation:Presentation:

• Minor Prolapse can be asymptomaticMinor Prolapse can be asymptomatic

• Uterovaginal prolapse patients can complain of Uterovaginal prolapse patients can complain of feeling of some thing coming down .feeling of some thing coming down .

. Pelvic insecurity. Pelvic insecurity

. Low backache ,relieved by lying flat.. Low backache ,relieved by lying flat.

• Procidentia may present with bloody stained Procidentia may present with bloody stained vaginal discharge some times purulent due to :vaginal discharge some times purulent due to :

Decubitus ulcer of the vaginal skin of the cervix.Decubitus ulcer of the vaginal skin of the cervix.

Presentation:Presentation:

• Cyctocele and cyctourethrocele :Cyctocele and cyctourethrocele :

.Dragging discomfort ..Dragging discomfort .

.Sensation of lump in the vagina..Sensation of lump in the vagina.

.Urinary symptoms..Urinary symptoms.

.Recurrent UTI..Recurrent UTI.

• Rectocele:Rectocele:

.Difficulty with defecation..Difficulty with defecation.

.Incomplete defecation..Incomplete defecation.

Diagnosis:Diagnosis:

• History:History:

.Age , Obstetric history, Medical history.Age , Obstetric history, Medical history

• Examination:Examination:

.General, weight , Chest, Abdomen, .General, weight , Chest, Abdomen, Speculum examination. Speculum examination.

• Investigations:Investigations:

.Urine, RFT , Chest X-Ray, U/S.Urine, RFT , Chest X-Ray, U/S

Management:Management:

• Prevention:Prevention:

.Reducing weight.Reducing weight

.Avoid smoking.Avoid smoking

.Avoid difficult labour.Avoid difficult labour

.Contraception.Contraception

.Pelvic floor exercise after delivery..Pelvic floor exercise after delivery.

Medical management:Medical management:

• HRT:HRT:

.Hormone replacement therapy:.Hormone replacement therapy:

Increases vaginal blood supply Increases vaginal blood supply and collagen turnoverand collagen turnover

Ring Pessaries:Ring Pessaries:

Indications:Indications:• Patient requestPatient request• Patient is medically unfit for surgeryPatient is medically unfit for surgery• Therapeutic test before surgeryTherapeutic test before surgery• To relieve symptoms while the To relieve symptoms while the

patient is awaiting surgerypatient is awaiting surgery• During and after pregnancies if the During and after pregnancies if the

patient want to preserve her fertilitypatient want to preserve her fertility

Surgical management:Surgical management:

• Cyctourethrocele:Cyctourethrocele:Anterior ColporrhaphyAnterior Colporrhaphy• Rectocele:Rectocele:Posterior ColpoperineorrhaphyPosterior Colpoperineorrhaphy• Uterine Prolapse:Uterine Prolapse:11stst 2 2ndnd Degree: Degree:Manchester RepairManchester Repair3ed Degree (procedentia):3ed Degree (procedentia):Vaginal hysterectomyVaginal hysterectomy