1. Genital prolapse Dr. Samar D. Sarsam

4. Pathophysiology of pelvic organ support
Maintained by interaction among:
Pelvic floor muscles
Pelvic floor connective tissue
Vaginal wall

5. Role of levator ani Striated muscle of three regions:
Iliococcygeal portion: between side walls of pelvis.
Pubococygeus muscle: from pubic bone on either sides, attached to vaginal wall, urethra, anus and perineal body and inserts on the coccyx ( it is important in in suspending the vaginal wall to the pelvis.
Puborectalis muscle: sling from pubic bone around the rectum.
Role of levator ani

6. The levator act as a hammock, has openings through which the urethra, vagina and rectum traverse

8. Role of connective tissue
System of connective tissue and ligaments surrounds the pelvic organs and attaches them to the levator ani and bony pelvis. (Arcus tendineus fascia and Uterosacral ligament) are vital in support of vaginal wall, Vaginal apex, uterus, cervix and urethra.

9. Role of vaginal wall Vaginal wall composed of:
Mucosa ( epithelium and lamina propria).
Fibroelastic muscularis layer.
Adventitial layer (loose areolar tissue, elastic fibers, neurovascular bundles).
So vaginal wall outer layers are attached to arcus tendineus and fascia of levator ani.
In the lower third of vagina: the wall is attached to perineal membrane and perineal body.

11. Urogenital diaphragm
A triangular sheet of muscle between the ischiopubic rami, composed of the sphincter muscle of the urethra and the deep transverse muscles of the perineum. Urogenital hiatus is closed by perineal membrane.

12. Levels of vaginal support
Level I: cardinal and uterosacral ligaments.
level II: paravaginal attachments.
Level III: Perineal body, superficial and deep perineal muscles and fibromuscular connective tissue.

13. Genital prolapse:
It is a protrusion of an organ or structure beyond its normal confines.
This is classified according to its location and the organ contained within it.

14. Prevalence:
12-13% of multiparous
2% of primiparus
Grading:
Three degrees are described, the lowest portion of the prolapse is assessed while the patient is straining.
1st descent within the vagina
2nd descent to the introitus
3rd descent outside the introitus
In case of uterine prolapse the cervix is the most dependent portion.
Third degree uterine prolapse is termed procidentia and is usually accompanied by cystourethrocele and rectocele

18. Classification:
*Anterior Vaginal Wall prolapse
Cystocele—bladder descent
Urethrocele—urethral descent
Cystourethrocele- descent of urethra and bladder
*Posterior Vaginal Wall prolapse
Rectocele—rectal descent
Enterocele- small bowel descent
*Apical vaginal prolapse
Uterovaginal – uterine descent with inversion of vaginal apex
Vault –inversion of vaginal apex post hysterectomy

19. Another system, introduced more recently, employs objective measurements from fixed anatomic points.
The Pelvic Organ Prolapse Quantification (POP-Q) system standardizes terminology of female pelvic organ prolapse.
Prolapse in each segment is evaluated and measured relative to the hymen, which is a fixed anatomic landmark that can be consistently identified. The plane at the level of the hymen is defined as zero.

20. Etiology:
The connective tissue, levator ani and nerve supply are vital for maintaining position of the pelvic organs.
They are influenced by pregnancy, child birth, aging and congenital or acquired conditions.
**Congenital: it occurs more in multiparous women due to congenital weakness of the connective tissue. Also it is rare in Afro-Carribean women suggesting genetic difference.
**Child birth and raised intra abdominal pressure.
Vaginal delivery may cause nerve and mechanical damage in the levator ani and fascia.
During pregnancy prolapse is thought to be mediated by the effect of progesterone and relaxin.
Raised intra abdominal pressure as in pregnancy, chronic cough or constipation.
**Aging: causes loss of collagen and weakness of fascia particularly during post menopause as a consequence of estrogen deficiency.
**Post operative: causes mechanical displacement after gynecological surgery.

21. Pathophysiology:
Three components responsible for supporting the position of the uterus and vagina.
1-Ligaments and fascia at the pelvic side wall.
2-levator ani muscles by constricting to maintain organ position.
3-posterior angulations of the vagina which is enhanced by rises in intra abdominal pressure causing closure of the flap valve.

22. Damage to any of these mechanisms lead to uterine prolapse
The segment of fascia that support the bladder lies between the bladder and vagina is known as pubo cervical fascia and that between the rectum and the vagina is the recto vaginal fascia.

23. Clinical features:
History
Abdominal examination
Pelvic examination
Symptoms: non specific: lump, discomfort, backacke, dyspareunia
Specific: urgency, voiding difficulty, UTI, stress incontinence, incomplete bowel emptying.
Investigations:
Accordingly urine microscopy, cystmetry, cystoscopy, U/S, serum urea and creatinine.

24. Differential Diagnosis
Tumors as large uterine polyp.
urethral diverticulum may look and feel like a cystocele but usually is more lateral, sensitive, and painful; compression, as a rule, will express some purulent material from the urethral meatus.

25. Prevention:
Shortening of the second stage
Reducing traumatic delivery
The benefit of episiotomy have not been sub stanciated.
Antepartum, intrapartum and postpartum exercises, especially those designed to strengthen the levator and perineal muscle groups (Kegel’s).
Estrogen therapy following the menopause may help.

26. Treatment:
Depending on the patient's wish.
Prior to treatment, correct obesity, chronic cough or constipation.
If there is ulceration we need seven days local estrogen treatment.

27. A. MEDICAL MEASURES
1. Pessary—Pessary use in selected patients may provide adequate relief of symptoms. Prolonged use of pessaries, if not properly managed, may lead to pressure necrosis and vaginal ulceration.
Silicon rubber based ring pessary, shelf pessary may be used also.
Indications of pessary treatment:
Patients' wish
As therapeutic test
Childbearing not complete
Medically not fit
During and after pregnancy
Awaiting surgery

28. 2. Exercises—In younger patients, some improvement of pressure symptoms and of urinary control may be obtained by using Kegel isometric exercises for 6–12 months to tighten and strengthen the pubococcygeus muscles.

29. Kegel exercises can be of greatest benefit when used prophylactically, beginning in pregnancy and continuing during and after the purperium.
In older patients, Kegel exercises rarely provide more than partial relief.

30. 3. Estrogens—In postmenopausal women, estrogen replacement therapy for a number of months may greatly improve the tone, quality, and vascularity of the musculofascial supports.

31. SURGICAL MEASURES:
The aim of surgery is to restore anatomy and function.
There are vaginal and abdominal operations to correct the prolapse, the choice often depends on a women’s desire to preserve coital function.

32. CYSTOCELE & URETHROCELE
Cystocele, descent of a portion of the anterior bladder wall into the vagina, is usually associated with the trauma of parturition. The stretching, attenuation, or actual laceration of the so-called pubo vesicocervical fascia produced by the birth of a large baby, multiple or operative deliveries, and prolonged labors increases the possibility and severity of cystocele

34. Urethrocele is commonly associated with cystocele
Urethrocele is commonly associated with cystocele. It is often seen in women who have urinary stress incontinence, and is a continuum of a cystocele involving the most distal aspect of the anterior vaginal wall.
Cystourethrocele (simultaneous occurrence of cystocele and urethrocele) may occur in nulliparous women, apparently as a result of congenital inadequacy of the endopelvic connective tissues or fascia and of the musculature of the pelvic floor.
Contributing factors are likely inherent differences in collagen content and subtype.
Hypoestrogenism may facilitate tissue and muscle atrophy and weakness.

35. symptoms
No symptoms.
A cystocele may be large enough to bulge out of the vaginal introitus.
Relief can be obtained by rest.
urinary incontinence is the most common and most important symptom associated with cystocele, but this disorder as such does not cause incontinence, and its repair does not correct stress incontinence.
Significant residual urine leads to bladder infection
Sexual sensation is generally not impacted by vaginal wall prolapse

36. Surgery:
Cystocele alone, when the cystocele is large, when it is responsible for urine retention and recurrent bladder infections, or when it is associated with bladder and urethral changes responsible for stress incontinence that operative repair is required.
Anterior vaginal colporrhaphy is the most common surgical treatment for cystocele. Incision in the anterior vaginal wall is made and the fascial defect is closed.
This may be combined with vaginal hysterectomy and posterior colporrhaphy.  
Obliterative vaginal operations (vaginectomy, Le Fort's operation) are used primarily for severe uterovaginal prolapse in elderly patients and chronically ill patients.

37. RECTOCELE
Rectocele is a rectovaginal hernia caused by disruption of the fibrous connective tissue (rectovaginal fascia) between the rectum and the vagina often:
during childbirth, some degree of damage occurs—.
menopause.
Lifelong chronic constipation with straining may produce—or at least aggravate—a rectocele.

40. symptoms
usually causes no symptoms.
sensations of vaginal pressure, rectal fullness, and incomplete evacuation are typical complaints. The patient may report that it is necessary to manually reduce or “splint” the rectocele in order to defecate. The history may include prolonged, excessive use of laxatives or frequent enemas.
Other nonspecific symptoms like low back pain, dyspareunia, or even fecal and gas incontinence may be reported.

41. Signs
Inspection of the area, with the patient straining and perhaps with slight depression of the perineum, discloses a soft mass bulging into the rectovaginal septum and distending the vaginal introitus.
Not infrequently, this traumatic attenuation involves some or the entire anal sphincter. Rarely, a small rectovaginal (or rectoperineal) fistula may also be present. Careful questioning about incontinence of feces or flatus and careful inspection of the area should disclose these associated defects.

42. Treatment
Treatment consists of avoidance of constipation by management of bowel function with daily stool softeners.
Fecal impaction may require digital extraction or use of tap water enemas.

43. Surgery:
Rectocele alone, seldom requires surgical management. However, when the rectocele becomes so large that fecal evacuation is difficult, surgical repair is indicated
The traditional repair is colpoperineorraphy, incision in the posterior vaginal wall is made to repair the fascial defect.
Postoperative avoidance of straining, coughing, and strenuous activity is advisable. Careful instruction about diet to avoid constipation, about intake of fluids, and about the use of stool-softening laxatives and lubricating suppositories is necessary to ensure durable integrity of the rectocele repair.

44. ENTEROCELE
Enterocele is a herniation of the rectouterine pouch (pouch of Douglas) into the rectovaginal septum. This presents as a bulging mass in the posterior fornix and upper posterior vaginal wall. A similar hernial sac through the cul-de-sac, but extending posteriorly, may present through the anal canal as a rectal prolapse.
Enterocele may be congenital or acquired.
Uterine prolapse is almost always accompanied by some degree of enterocele, and, as the degree of uterine descent progresses, the size of the hernial sac increases.
Similarly, post-hysterectomy prolapse of the vaginal vault.

46. symptoms
nonspecific
Aching discomfort frequently is described, along with the sensation of vaginal pressure and fullness.
Gastrointestinal symptoms can rarely, if ever, be attributed to an enterocele.
Signs
Rectovaginal examination, especially with the patient standing, reveals a reducible thickness or bulging of the upper rectovaginal septum.
With similar exposure of the posterior vaginal wall, failure of a proctoscopic light source to trans illuminate the upper rectovaginal septum may suggest the presence of an enterocele. In the case of a large, thin-walled enterocele, small bowel peristalsis will be visible. Occasionally, to obtain filling of the hernial sac, it is essential to examine the patient in a standing-straining position.

47. Surgery
Enterocele repair may be accomplished trans abdominally or trans vaginally.
Vaginally similar to anterior (cystocele) and posterior (rectocele) colporrhaphy plus excision of the sac containing the small bowel. Also closure of the pouch of Douglas by approximating the peritoneum and the uterosacral ligaments.

48. Vaginal vault prolapse Vaginal vault suspension can be performed abdominally by attaching the vaginal cuff to the sacral promontory. Abdominal sacrocolopexy is an excellent primary procedure for vaginal vault prolapse and enterocele and is the procedure of choice for patients with recurrent vaginal prolapse.

50. UTERINE PROLAPSE
Uterine prolapse is descent of the uterus/cervix through the vaginal canal. It is due to defects in the support structures of the uterus and vagina, including the uterosacral ligaments, the cardinal ligament complex, and connective tissue of the urogenital membrane

53. Etiology:
Uterine prolapse occurs most commonly in multiparous women as a gradually progressive result of childbirth injuries to the endopelvic fascia (and its condensations, the uterosacral and cardinal ligaments) and lacerations of muscle, especially the levator muscles and those of the perineal body.

54. Additional factors promoting uterine prolapse are:
1- systemic conditions, including obesity, asthma, chronic bronchitis, and bronchiectasis.
2- local conditions such as ascites and large uterine and ovarian tumors. pelvic tumor; sacral nerve disorders, especially injury to S1–S4 (as in spina bifida); diabetic neuropathy; caudal anesthesia accidents; and presacral tumor.
3-A congenital weakness in the pelvic fascial supports may be causative of uterine prolapse as it is occasionally demonstrated in nulliparous, even virginal, females.
failure of the supporting structures and attenuation of pelvic fascial support are potentially latent sequelae of neuronal injury that becomes clinically manifest with aging.
A uterus that is in a retroverted position is especially subject to prolapse; with the corpus aligned with the axis of the vagina, anything increasing intra-abdominal pressure exerts a piston-like action on the uterus, driving it down into the vagina.

55. The degree of uterine prolapse parallels the extent of separation or attenuation of its supporting structures.
*In slight intravaginal or incomplete prolapse, the uterus descends only part of the way down the vagina;
*in moderate prolapse, it descends to the introitus, and the cervix protrudes slightly beyond;
*in marked or complete prolapse (procidentia), the entire cervix and uterus protrude beyond the introitus and the vagina is inverted.

56. The principal components of the basin-like pelvic floor are the pelvic bones (including the coccyx), the endopelvic fascia, and the levator and perineal muscles.
The urogenital hiatus (“anterior levator muscle gap”), which permits the urethra, vagina, and anus to emerge from the pelvis, is a site of potential weakness.

57. Attenuation of the pubococcygeal and puborectal portions of the levator muscles, whether as the result of a traumatic delivery or of involutional changes, widens the levator gap and converts this potential weakness to an actual defect. If there has been a concomitant injury or attenuation of the endopelvic fascia (uterosacral and cardinal ligaments, rectovaginal and pubocervical fascia), heightened intra-abdominal pressure gradually leads to uterine prolapse along with cystocele, rectocele, and enterocele.
Anterior and posterior vaginal relaxation, as well as incompetence of the perineum, often accompanies prolapse of the uterus.
Prior to the menopause, the prolapsed uterus hypertrophies and is engorged and flabby. After the menopause, the uterus atrophies.
In procidentia, the vaginal mucosa thickens and cornifies, coming to resemble skin.

58. Clinical Findings
With mild prolapse (first-degree; cervix palpable as a firm mass in the lower third of the vagina), few symptoms can be attributed to the relaxation.
With moderate prolapse (second-degree; cervix visible and projecting into or through the vaginal introitus), the patient may experience a falling-out sensation or may report that she feels as if she is sitting on a ball; of less significance may be a sensation of heaviness in the pelvis, low backache, and lower abdominal and inguinal pulling discomfort.

59. In cases of severe prolapse (procidentia; third-degree), the cervix and entire uterus project through the introitus and the vagina is totally inverted. Frequently, this large mass has one or more areas of easily bleeding atrophic ulceration.
In premenopausal women with prolapse, leukorrhea or menometrorrhagia frequently develops as a result of uterine engorgement.
After the menopause, excessive vaginal mucus and bleeding may be due to atrophic ulceration and infection of the prolapse.
Compression, distortion, or herniation of the bladder by the displaced uterus and cervix may be responsible for accumulation of residual urine, which leads to urinary tract infection, frequency and urgency, and overflow voiding.
Incontinence is rare, but does occur.
Constipation and painful defecation occur with prolapse because of pressure and rectocele.

60. Pelvic examination:
With the patient bearing down or straining (perhaps in a standing position), pelvic examination reveals descent of the cervix. As the uterus progressively descends, some degree of cystocele and enterocele must develop concomitantly as a result of anatomic fixation of the bladder base and of the cul-de-sac to anterior and posterior uterocervical surfaces.
Uterine or adnexal neoplasms and ascites associated with uterine prolapse should be noted.
Rectovaginal examination may reveal a rectocele. An enterocele may be behind and perhaps below the cervix, but in front of a rectocele. Placement of a metal sound or firm catheter within the bladder may determine the extent of concomitant cystocele.

61. Differential Diagnosis
Cervical elongation
Cervical tumors—
Myomas or polyps may coexist with prolapse of the uterus and cause unusual symptoms.
Complications
Leukorrhea, abnormal uterine bleeding, and abortion may result from infection or from disordered uterine or ovarian circulation in prolapse.
Chronic decubitus ulceration of the vaginal epithelium may develop in procidentia. Urinary tract infection may occur with prolapse because of cystocele;
hydronephrosis may occur in procidentia.
Hemorrhoids result from straining to overcome constipation.
Prevention
Prenatal and postpartum Kegel exercises to strengthen the levator muscles may minimize prolapse.
Prolonged estrogen therapy for menopausal and postmenopausal women tends to maintain the vascularity and vitality of the endopelvic fascia and pelvic floor musculature.

62. Treatment
A. MEDICAL MEASURES
vaginal pessary.
In procidentia, reduction of the uterus followed by packing of the vagina to maintain uterine position may be necessary in the preoperative management of an ulcerated, infected prolapse.
In postmenopausal patients, the administration of estrogen (systemically or vaginally) will improve the tissue tone and facilitate correction of an atrophic, perhaps ulcerative, vaginitis.
Prescribe vaginal creams (eg, Aci-Jel), acetic acid douches, or topical estrogen for ulceration.
Treat urinary tract infection, diabetes mellitus, or cardiovascular complications appropriately.
Prescribe laxatives or enemas for constipation. Utilize a bowel preparation to evacuate distal sigmoid and rectum of feces to facilitate surgery of the vaginal compartment.

65. B. SURGICAL MEASURES
Uterine prolapse may remain constant for many years or may progress very slowly, depending somewhat on the patient's age and activity.
surgical treatment should be deferred until the prolapse gives rise to significant symptoms.
Selection of a surgical approach for uterine prolapse depends on:
patient's age.
desire for pregnancy or preservation of vaginal function.
degree of prolapse, and the presence of associated conditions (cystocele, stress incontinence, enterocele, rectocele).
Operations of the Manchester type were at one time recommended for the young patient with prolapse; but this procedure, which includes amputation of the cervix, has fallen into disfavor because it is associated with a high incidence of infertility and premature labor.

66. Vaginal hysterectomy with correction of hernial defects may be elected
Vaginal hysterectomy with correction of hernial defects may be elected. In addition to vaginal hysterectomy, the operation must include repair of actual or potential enterocele, careful anterior colporrhaphy to correct the cystocele and stress incontinence, and posterior colpoperineorrhaphy extending well up the posterior vaginal wall
Vaginal obliterative operations (Le Fort's operation or vaginectomy) are rarely indicated in elderly women who are poor surgical candidates and who no longer desire coital function.
Uterine prolapse can be managed by an abdominal approach that includes total abdominal hysterectomy and the obliteration of any associated enterocele. However, this method can be more morbid and time-consuming.
SUPPORTIVE MEASURES
If the patient is obese, she should be encouraged to lose weight.

67. TREATMENT OF COMPLICATIONS
Infection of the operative area or of the urinary tract may require antibiotic therapy. Prescribe a pessary or re operate for recurrence.
EMERGENCY MEASURES
Infrequently, pregnancy occur, the rapidly enlarging uterus may become incarcerated within the true pelvis or, in procidentia, even outside the pelvis. It is imperative that the uterus be replaced and that the patient remain in bed until the uterus is large enough to prevent recurrence of the prolapse. An incarcerated, edematous procidentia may lead to urethral (or even ureteral) obstruction, anuria, and uremia; therefore, prompt reduction of the prolapse is essential.

68. MALPOSITIONS OF THE UTERUS (“TIPPED UTERUS”)
Significant displacement of the uterus may cause signs or symptoms such as pelvic pain, backache, menstrual aberrations, and infertility. Virtually all women with symptoms that may be due to displacements are premenopausal. Almost all postpartum patients have a temporarily retro posed (tipped) uterus. Some retro displacements are secondary to defects in the supravaginal supports.
Retroversion implies that the axis of the body of the uterus is directed to the hollow of the sacrum, although the cervix remains in its normal axis.
If angulation of the corpus on the cervix is extreme, the term retro flexion is preferred.
Acute ante version probably does not cause either obstruction to uterine discharge or circulatory alteration or dysmenorrheal..