Staging and Management of Staging and Management of Genital ProlapseGenital Prolapse

Dr. V.P.Paily Dr. V.P.Paily MD; FRCOGMD; FRCOG

Professor Professor Jubilee Mission Medical College, Thrissur, Kerala.Jubilee Mission Medical College, Thrissur, Kerala.

Consultant, Consultant, Mother Hosp and Raji Nursing Home , Thrissur, KeralaMother Hosp and Raji Nursing Home , Thrissur, Kerala

ProlapseProlapse

Very common problem.Very common problem.

Confusion regarding assessing Confusion regarding assessing

degree / stage degree / stage

Conventional StagingConventional Staging

Cervix is the main point.Cervix is the main point.

Conventional stagingConventional staging

Difference between British and Difference between British and American System.American System.

Baden WalkerBaden Walker

Halfway SystemHalfway System

Prolapse quantificationProlapse quantification

Pelvic organ prolapse Pelvic organ prolapse quantification(POP-Q)quantification(POP-Q)

Recommended by ICS, society of Recommended by ICS, society of Gyn.Surgeons &Amer. Urogyn. Gyn.Surgeons &Amer. Urogyn. SurgeonsSurgeons

Pelvic organ prolapsePelvic organ prolapse

QuantificationQuantification POP QPOP Q

QuantificationQuantification

Vault, Cx or Posterior fornixVault, Cx or Posterior fornix Anterior & Posterior wallsAnterior & Posterior walls IntroitusIntroitus Perineal bodyPerineal body Length of vaginaLength of vagina

QuantificationQuantification

Anterior (a) -- Point A & BAnterior (a) -- Point A & B Posterior (p) -- Point A & BPosterior (p) -- Point A & B Point C -- Lips of CervixPoint C -- Lips of Cervix Point D -- Post.fornixPoint D -- Post.fornix

QuantificationQuantification

Length of vaginaLength of vagina

Diameter of introitusDiameter of introitus

Perineal bodyPerineal body

POP- QPOP- Q

QuantificationQuantification

AaAa BaBa CC

ghgh pbpb tvltvl

ApAp BpBp DD

POP-Q DrawbacksPOP-Q Drawbacks

Appears complicatedAppears complicated

Doesn’t include lateral prolapse. Doesn’t include lateral prolapse.

Comprehensive pattern Comprehensive pattern required incorporating defects required incorporating defects at various levels & at various levels & compartments compartments

Look for defectsLook for defects

At 3 levelsAt 3 levels

UpperUpper

MiddleMiddle

LowerLower

Look for defectsLook for defects

At two compartmentsAt two compartments

AnteriorAnterior

PosteriorPosterior

Compartmental approachCompartmental approach

Level 1Level 1

Descent of cervixDescent of cervix

Descent of vaultDescent of vault

EnteroceleEnterocele

Compartmental ApproachCompartmental Approach

Level 2Level 2

Anterior segment –Anterior segment – cystocelecystocele

Posterior segment – rectocele Posterior segment – rectocele

Lateral detachmentLateral detachment

Compartmental ApproachCompartmental Approach

Level 2Level 2 High rectocele can extend up to High rectocele can extend up to

post fornix and has to be post fornix and has to be differentiated from enterocele.differentiated from enterocele.

Compartmental ApproachCompartmental Approach

Level 2Level 2 Midline defects are due to tear or Midline defects are due to tear or

weakness of fascial envelope weakness of fascial envelope – pubo vesico cervical fascia and – pubo vesico cervical fascia and rectovaginal fascia rectovaginal fascia

( Denonvilliers).( Denonvilliers).

Compartmental ApproachCompartmental Approach

Level 3Level 3 Anteriorly – Urethrocele Anteriorly – Urethrocele Posteriorly – Detached Posteriorly – Detached

perineal body perineal body

Compartmental ApproachCompartmental Approach

Level 3Level 3

Detached Perineal bodyDetached Perineal body

Reattach to recto vaginal fasciaReattach to recto vaginal fascia

Practical approach to Practical approach to Level 3 defectsLevel 3 defects

Common complaintCommon complaint

Sound of air being sucked inSound of air being sucked in

Compartmental ApproachCompartmental Approach

Lateral detachmentLateral detachment

Reattach to Arcus Tendineus Reattach to Arcus Tendineus

Fascia pelvis or Arcus Tendineus Fascia pelvis or Arcus Tendineus

Fascia RectovaginalisFascia Rectovaginalis

Compartmental ApproachCompartmental Approach

Anterior Lateral detachmentAnterior Lateral detachment Richardson’ s operationRichardson’ s operation TransvaginalTransvaginal TransabdominalTransabdominal EndoscopicEndoscopic

Compartmental ApproachCompartmental Approach

Posterior Lateral detachmentPosterior Lateral detachment

Reattach to Arcus tendineus fascia Reattach to Arcus tendineus fascia

rectovaginalisrectovaginalis

SymptomatologySymptomatology

Record symptoms related to Record symptoms related to Anatomical descentAnatomical descent Urinary functionUrinary function Sexual functionSexual function Reproductive needReproductive need GI symptomsGI symptoms Air suctionAir suction

ManagementManagement

Restore anatomy by correcting Restore anatomy by correcting the defectthe defect..

Special SituationsSpecial Situations

Nulliparous Nulliparous prolapseprolapse

Older age with weak Older age with weak tissuestissues

Mesh for RepairMesh for Repair

Concept borrowed from Hernia repairConcept borrowed from Hernia repair

Special mesh being developed.Special mesh being developed.

(Gyne mesh)(Gyne mesh)

We have tried prolene mesh.We have tried prolene mesh.

ConclusionsConclusions

Detailed record of defectsDetailed record of defects

Detailed record of symptomsDetailed record of symptoms

Individualised surgeryIndividualised surgery