1. Genital prolapse What is genital prolapse?
On straining the vaginal wall and/or cervix protrude outside the introitus

2. Aetiology of prolapse Atonicity and asthenia following menopause
Birth injuries
Resume work soon after delivery
Rapid succession of deliveries
Raised intra-abdominal pressure by chronic cough

3. Birth injuries
Excessive stretching of the pelvic floor muscles and ligaments
Peripheral nerve injury during childbirth
Bearing down before full dilatation of cervix
Vacuum extraction before full dilatation
Delivery of big baby

4. Classification by position
Anterior vaginal wall—
Upper two third—cystocele
Lower one third—urethrocele
Posterior vaginal wall—
Upper one third—enterocele
Lower two third—rectocele

5. Classification by degree of descent
1st degree—descent of cervix below the ischial spine but above introitus
2nd degree— descent of cervix up to the level of introitus
3rd degree—descent of cervix below the level of introitus but portion of uterus still inside vagina
4th degree—complete procidentia—descent of cervix and uterine fundus below the level of introitus

6. Cystocele The upper two third descents causing cystocele
In severe cases it protrudes outside uterus
When lower one third also protrudes, urethrocele
Support of the urethra—posterior urethral ligament—is lost by stretching

7. Descent of cervix Hypertrophy and ulcerations Keratinisation
Supravaginal elongation of cervix

8. Supra-vaginal elongation of cervix
Supra-vaginal portion
In second and third degree prolapse
Congenital elongation of cervix
In congenital elongation, posterior fornix is very deep
The vaginal portion, not supra-vaginal elongates

9. Complications Decubitus ulcer Obstructions in the urinary tract
Incarceration

10. Decubitus ulcer Most dependent part Ulceration and congestion
Should be differentiated from cancer cervix

11. Obstruction in the urinary tract
A huge cystocele causes obstructive uropathy
Hypertrophy of bladder
Hydroureter and hydronephrosis due to kinking of distal ureters

12. Incarceration Incarceration due to congestion and oedema
Becomes irreducible
Magnesium sulphate and ice packing

13. Symptoms Something descending per vaginam Low backache
Bleeding from decubitus ulcer
Discharge per vaginam
Imperfect control of micturition
Frequency of micturition
Difficulty in voiding

14. Signs Mass in the introitus On standing position more obvious
Perineal lacerations present
Relaxation of vaginal orifice
Tone of levator ani lost
Sings of stress incontinence

15. Differential diagnosis
Vulval cyst
Cyst of the anterior vaginal wall
Urethral diverticulum
Congenital elongation of cervix
Cervical fibroid polyp
Chronic inversion

16. Investigations Cervical cytology, improper in 3rd degree prolapse
Urine culture and sensitivity
All investigations mandatory prior to major surgery

17. Treatment
Pelvic floor exercise
Pessary treatment
Surgical treatment

18. Pessary treatment Ring pessary Only for a temporary period
Changed every 3 months
When surgery is contraindicated
Complications—
Infection
Vesico-vaginal fistula if retained for many months

19. Aim of surgery To relieve symptoms To restore anatomy
To restore sexual function

20. Various surgical procedures
Anterior colporrhaphy
Posterior colporrhaphy and colpo-perineorrhaphy
Fothergill’s surgery
Shirodkar modification of Fothergill’s surgery
Vaginal hysterectomy with pelvic floor repair
Le Forte’s surgery
Abdominal sling operations
Enterocele repair—Moschowitz surgery

21. Postoperative complications
Haemorrhage
Infection
Stress incontinence

22. Vault prolapse As a complication of hysterectomy
Improper vault fixation and failure to enterocele correction during surgery
Predisposing factors are—age, parity, obesity and chronic cough
Incidence—0.4%
Treatment—
Trans-vaginal sacro-spinous colpopexy
Trans-abdominal sacral colpopexy
Laparoscopic colpopexy