2 BackgroundThe pelvis encloses organs that primarily function in storage, distension and evacuation. The pelvic viscera must maintain their normal anatomic relationships within this cavity so that these physiological functions can be sustained.
3 Background The uterus is normally anteverted, anteflexed Version: is the angle between the longitudinal axis of cervix, and that of the vaginaFlexion: is the angle between the longitudinal axis of the uterus, and that of the cervix
4 Genital ProlapseGenital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Pouch of Douglas or rectouterine pouch) through the fasciomuscular pelvic floor below their normal levelVaginal prolapse can occur without uterine prolapse but the uterus cannot descend without carrying the vagina with it.
6 Supports of the uterusDeLancey in 1994 defined three levels of vaginal support, reviving the importance of the connective tissue structures and giving a working basis for the present day understanding of the anatomy and surgical treatment.
8 Three level of Supports of Uterus Level I: The cardinal uterosacral ligament complexLevel II: The pubo- cervical and recto-vaginal fasciaLevel III: The pubo-urethral ligaments anteriorly & the perineal body posteriorly
9 Anterior vaginal wall prolapse Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystoceleProlapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele.Complete anterior vaginal wall prolapse is called cysto-urethrocele.
10 Anterior vaginal wall prolapse Weakness in theSupports of the bladder neckUrethero vesical junctionProximal urethraCaused byWeakness of pubocervical fascia and pubourethral ligaments
15 Uterine descentUtero-vaginal (the uterus descends first followed by the vagina): This usually occurs in cases of virginal and nulliparous prolapse due to congenital weakness of the cervical ligaments.Vagino-uterine (the vagina descends first followed by the uterus):This usually occurs in cases of prolapse resulting from obstetric trauma.
16 Degree of uterine descent 1st degree: The cervix desends below its normal Ievel on straining but does not protrude from the vulva (The extemal os of the cervix is at the level of the ischial spines)2nd degree: The cervix reaches upto the vulva on straining3rd degree: The cervix protrudes from the vulva on strainingProcidentia- whole of the uterus is prolapsed outside the vulva and the vaginal wall becomes most completely inverted over it. Enterocele is usually present
21 Pelvic organ prolapse quantitative (POPQ) exam In 1996, by the ICSPOPQ system describes the location and severity of prolapse using segments of the vaginal wall and external genitalia, rather than the terms cystocele, rectocele, and enterocele
22 AetiologyErect posture causes increased stress on muscles, nerves and connective tissueAcute and chronic trauma of vaginal deliveryAgingEstrogen deprivationIntrinsic collagen abnormalitiesDebilitationIatrogenic
23 Precipitating factors ↑ intra abdominal pressure↑ weight of the uterusTraction of the uterus by vaginal prolapse or by a large cervical polypObesity(40%--75%)SmokingPulmonary disease (chronic coughing)Constipation (chronic straining)Recreational or occupational activities (frequent or heavy lifting)
24 Symptoms of ProlapsePelvic floor disorders become symptomatic through either of two mechanisms:1. Mechanical difficulties produced by the actual prolapse,2. Bladder or bowel dysfunction, disrupting either storage or emptying.
25 Clinical presentation Before actual prolapse. the patient feels a sensation of weakness in the perineum. particularly towards the end of the dayLater the patient notices a mass which appears on straining. and disappears when she lies downUrinary symptoms are common and trouble some even with slight prolapse:a) Urgency and frequency by dayb) Stress incontinencec) Inability to micturate unless the anterior vaginal wall is pushed upwards by the patient's fingersd) Frequency when cystitis develops
26 Rectal symptoms are not so marked Rectal symptoms are not so marked. The patient always feels heaviness in the rectum and a constant desire to defaecate. Piles develop from straining.Backache, congestive dysmenorrhoea and menorrhagia are common.Leucorrhoea is caused by the congestion and associated by chronic cervicitis.Associated decubitus ulcer may result in discharge which may be purulent or blood stained
27 Diagnostic approachBeginning with a careful inspection of the vulva and vagina to identify erosions, ulcerations, or other lesionsThe extent of prolapse should be systematically assessedSuspicious lesions should be biopsied
28 Examination Local examination Per speculum examination Per vaginal/ Bimanual examinationBonney’s stress testEvaluation of tone of pelvic musclesRecto vaginal examinationPosition of patient for examination- standing & straining- dorsal lithotomy
29 Diagnostic approachThe maximal extent of prolapse is demonstrated with a standing straining examination when the bladder is emptyPelvic muscle function should be assessed after the bimanual examination → palpate the pelvic muscles a few centimeters inside the hymen, along pelvic sidewalls at the 4 & 8 o’clockResting tone & voluntary contraction of the anal sphincters should be assessed during rectovaginal examination
30 Evaluation of pelvic floor tone Place 1 or 2 fingers in the vagina and instruct the patient to contract her pelvic floor muscles (i.e., the levator ani muscles). Then gauge her ability to contract these muscles, as well as the strength, symmetry, and duration of the contraction.The strength of the contraction can be subjectively graded with a modified Oxford scale (0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 = strong).
31 Bladder evaluationFor all patients with prolapse following information should be obtainedScreening for urinary tract infectionPostvoid residual urine volumePresence or absence of bladder sensationBonney’s stress test performed following reduction of prolapseIf test positive incontinence surgery should be performed at the time of prolapse surgery
32 Testing for Integrity of anal sphincter Should be assessed for resting tone and voluntary squeeze and sensation around the vulva with the bulbo-cavernous reflex and crude sensory testing for evidence of pudendal neuropathy
33 Prevention During labour &puerperium Avoid premature bearing down Avoid long second stageRepairs all tears &incisions accurately in layersUse delayed absorbable sutureDo not express the uterus when attempting to deliver placentaEncourage pelvic floor exerciseAvoid puerperal constipation-decreases bearing down
34 Prevention At hysterectomy Vault suspension with uterosacral and cardinal ligamentsObliteration of deep cul-de –sac by Moschowitz suturesSacropexy in high risk situations like collagen disordersIncrease acceptability of estrogen replacement therapy
35 Treatment Physiotherapy Kegel’s pelvic floor exercise Kegel’s perineometerInfluence only the voluntary musclesNo action to the fascial supporting systemVaginal cones of increasing weight .
36 Associated decubitus ulcer To relieve congestion, the prolapse can be reposited in the vagina with the help of tompoons ar pessary and this helps in healing of the ulcerHygroscopic agents like acriflavin-glycerine can help reduce the congestion further
37 Pessary During pregnancy Immediately after pregnancy, during lactation When future childbearing is intended in near futureRefusal to operation by patientAs a therapeutic testTo promote healing in a decubital ulcer
40 Complications of pessary ConstipationUrinary incontinanceB.vaginitis, ulceration of vaginal wallCervicitisCarcinoma of vaginal wallImpaction of pessaryStrangulation of prolapsed tissue
41 Principles of Management Physical examination must not be used in isolation to develop treatment strategy.Any decision for surgical intervention should take account of how prolapse is affecting lifestyle.
42 Aim of pelvic reconstructive surgery To restore anatomy, maintain or restore visceral function, and maintain or restore normal sexual function
43 Uterine descent- surgeries Vaginal hysterectomySling surgeriesShirodkarKhanna’sPurandaresFothergill’s surgery
44 Vault prolapseSeparation of the rectovaginal fascia from pubocervical fascia.In post hysterectomy patients it is important to reattach the rectovaginal fascia to the pubocervical fascia and to provide good support to the vaginal apex by reattaching the vaginal cuff to the uterosacral cardinal ligament complex.
45 Surgery for prolapsed vaginal vault Vaginal surgeryDecreased operative timeDecreased incidence of adhesion formationQuicker recovery timeAbdominal surgery.Failed previous vaginal approachHave foreshortened vaginaYoung patients with advanced prolapseWith other co existing conditionsObliterative procedures
46 Vaginal surgery Mc Call culdoplasty Sacrospinous ligament fixation InternalexternalSacrospinous ligament fixationHigh uterosacral ligament suspension with fascial reconstructionIliococcygeus fascia suspension
48 Obliterative procedures Le forte partial colpocleisisColpectomy and colpocleisis
49 Diagnosis of Stress Incontinence with Pelvic Organ Prolapse Loss of urine during coughing, sneezing, laughing or lifting something heavyThese activities cause an increase in "belly pressure” → forces the urine out of the bladderStress incontinence occurs almost exclusively in women & thought to be due to "pelvic (vaginal) relaxation" from childbirth or aging
50 Treatment of Stress Incontinence with Pelvic Organ Prolapse Conservative therapy- Pelvic floor exercises- Urinary meatel occlusion devices- Collagen injections Urinary incontinence surgery- Ant repair & Kelly’s plication- Pubo-vaginal sling procedure- TVT sling procedure- Burch Urethropexy