Total Uterine Prolapse And Surgical Repair with Le fort Colpocliesis Tamara Twardowski

The Patient and Case Presentation A 76 y/o G4P3 female presented to the office with a complaint of “feeling as if something was falling out of her vagina” causing heaviness, pain, and discomfort Initially she felt it was just a nuisance, but now the pain was interfering with her hobbies and daily activities leading to a more sedentary lifestyle than she wished She denied vaginal bleeding, urinary incontinence, or change in bowel or bladder habits. Her ROS was negative otherwise The patient was 5’7” and 170lbs. General physical exam was unremarkable…

Her pelvic exam however…. Was quite another story!!!

Exam Revealed Total Uterine Prolapse

Pelvic Organ Prolapse Causes over 300,000 surgeries in the United States yearly Greater than one billion dollars are spent annually for correction of prolapse 11% of all females are treated surgically by age 80 Generally occurs in post-menopausal, multiparous females

Types and Degree of Prolapse Various types of vaginal herniation involve different organs Prolapsed bladder = cystocele Prolapsed urethra = urethrocele Prolapsed rectum = rectocele Prolapsed uterus = uterine prolapse/procidentia Degrees of uterine prolapse First degree = cervix remains within vagina Second degree = cervix protrudes beyond introitus Thrid degree = entire uterus is outside the vulva Complete procidentia/total uterine prolapse

Risk Factors Multiparous post-menopausal women Defects in the pelvic floor fascia, connective tissue and musculature are caused by the trauma of childbirth, but do not present until later It may be due to fibroelastic supports being converted to fibrous scar tissue years after the intrinsic damage has already occurred Increased intra-abdominal pressure conditions like COPD, constipation Waist circumference > 88cm Thought to cause increased mechanical forces exerted on the pelvic floor Organs susceptible to prolapse and the vagina are mainly supported by pelvic ligaments (i.e. round, cardinal, broad, uterosacral, transverse cervical) the muscles of the pelvic diaphragm, perineum/levator ani

Treatment Options Pessaries are often used for mild or first/second degree uterine prolapse Hysterectomies are a common surgical treatment for a patient who is able to withstand lengthy surgery and wishes to continue engaging in sexual intercourse Modified Le Fort colpocliesis is a good surgical alternative for patients unable to undergo general anesthesia or do not object to limited coital function

Le fort coplocliesis Local anesthesia and pudendal block used Traction is placed on the cervix to evert the vagina completely; a rectangular section of vaginal mucosa is removed anteriorly and posteriorly The cut edge of the anterior vaginal wall is sutured to the cut edge of the posterior wall Sutures are placed laterally with the knot tied so that the uterus and vaginal apex are gradually pulled inward When the vagina is inverted, the superior and inferior margins of the rectangle is sutured horizontally In this case the patient’s labia minora were ablated together to decrease the size of the vaginal opening. Perineorrhaphy and levatorplasty may be an alternate approach to achieve similar effects and prevent recurrence of future prolapse

So moral of the story… Do those kegels ladies!

Works Cited Domany B, Kopan M, Bodis J. (2004) Experience with combined treatment in cases of prolapse of pelvic organs. American Journal of Obstetrics and Gynecology 191(4). Mosby Inc. Handa V, Garrett E, Gold E, Robbins J. (2004) Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. American Journal of Obstetrics and Gynecology 190(1). Mosby Inc. Pernoll M. (2001) Benson and Pernoll’s handbook of Obstetrics and Gynecology 10/e. McGraw-Hill Inc.