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

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

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

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

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

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

Descent of cervix Hypertrophy and ulcerations Keratinisation Supravaginal elongation of cervix

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

Complications Decubitus ulcer Obstructions in the urinary tract Incarceration

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

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

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

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

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

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

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

Treatment Pelvic floor exercise Pessary treatment Surgical treatment

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

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

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

Postoperative complications Haemorrhage Infection Stress incontinence

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