PROLAPSE Supports of uterus : Active Supports : Passive Supports : Pubocervical Fascia Rectovaginal Fascia Cardinal uterosacral ligament complex. Active Supports : Pelvic diaphragm made up of Levator Ani muscles.

INCIDENCE 10.20% AETIOLOGY : Atonicity & Aesthenia that follow menopause -> due to estrogen deficiency. - Birth injury of various kinds Home delivery Ventous extraction before full dilatation of cervix. Prolonged bearing down in the second stage. Delivery of big baby Crede’s method of extraction of placenta Rapid succession of pregnancies Raised intra abdominal pressure Nulliparous prolapse Previous surgeries – abdominoperineal excision of rectum, radical vulvectomy

Classification : Anterior vaginal wall – Cystourethrocele Upper 2/3 – cystocele Lower 1/3 – urethrocele Posterior vaginal wall _ Upper 1/3 – Enterocele Lower 2/3 – Rectocele

Uterine descent 1O – Descent of the cervix into the vagina 2O – Descent of the cervix upto the introitus 3O – Descent of the cervix outside the introitus Procidentia – All of the uterus outside the introitus.

Complications : Decubitus Ulcer : Caused by friction, congestion & circulating changes in the dependent part of the prolapse. It should be differentiated from Ca cervix. Elongation of cervix: Happens with IIo, IIIo, uv prolapse.

Changes in the urinary tract : Obstructive Uropathy – Due to huge cystocele. Hydroureter due to procidentia Hydronephrosis due to procidentia Urinary tract infection. Others – Incarceration of prolapse.

SYMPTOMS C/o something descending in the vagina or something protruding either at the vulva or externally. Vague midsacral discomfort or backache relived by rest. Vaginal discharge : Due to chronic cervicitis, vaginitis, decubitus ulcer.

-Micturition disturbances : stress incontinence frequency of Micturition : caused by chronic cystitis / incomplete emptying of bladder. -Difficulty in micturition : In severe degrees of cystocele . -Coital difficulties : with IIIO UV prolapse procidentia.

CLINICAL EXAMINATION : Per speculum examination : To determine vaginal prolpse Degree of uterine descent / conditions of cervix. Pervaginal Examination : Length of cervix Position & mobility of uterus.

INVESTIGATIONS HB Urine Microscopy Urine for culture & Sensitivity RBS Blood urea S. Creatinine High vaginal swab in case of vaginitis Cervical cytology Fitness for surgery CXR, ECG

DIFFERENTIAL DIAGNOSIS : Vulval cyst or tumor Cyst of anterior vaginal wall Urethral diverticula Congenital elongation of cervix Cervical fibroid polyp Chronic inversion Rectal prolapse

Prophylaxis : Antenatal physiotherapy,relaxation exercises. Attention to weight gain, anaemia. Proper management of 2nd stage A generous episiotomy Early postnatal ambulation Postnatal exercise & physiotherapy Adequate rest for 6m after delivery. Adequate spacing b/w pregnancies Avoid multiparity Prophylactic HRT in menopausal women.

TREATMENT : CONSERVATIVE TREATMENT - Pessary SURGERY Pessary treatment : Made up of polyvinyl chloride Indications : Young women planning a pregnancy During early pregnancy Puerperium For temporary use A women unfit for surgery A woman refusing surgery

LIMITATIONS : Only a paliative measure Doesn’t cure stress incontinence Can cause vaginitis Needs to be changed every 3 months. May cause dysperunia May not be retained in the patulous vagina A forgotten pessary can be the cause of ulcer, carcinoma of vagina, vesicovaginal fistula.

OPERATIVE TREATMENT : RADICAL CONSERVATIVE Radical : Ward Mayo’s operation Includes Anterior Colporaphy – to repair cystocele, cystourethrocele Posterior colporaphy & Colpoperineoraphy Vaginal Hysterectomy

CONSERVATIVE SURGERIES : FOTHERGILL’S REPAIR ( MANCHESTER OPERATION) Combines anterior colporaphy, posterior Colpoperineoraphy, amputation of cervix, suturing the cut ends of the MackenRodt’s infront of the cervix, covering the raw area. Advantages : Preserves menstrual & Child bearing function. Disadvantages : Incompetent OS cervical dystocia Hematometra Recurrence of Prolapse.

ANTERIOR REPAIR

ANTERIOR REPAIR

ANTERIOR REPAIR

POSTERIOR REPAIR

POSTERIOR REPAIR

POSTERIOR REPAIR

SHIRODHKAR’S Uteroscaral ligaments are crossed & Stitched in front of the cervix. LEFORT’S REPAIR : Ind : -Very elderly menopausal patient with advanced prolapse. - Women with medical risk factors. Procedure : Creation of raw area on the anterior & posterior vaginal wall & apposition with catgut. Limitation : Limits marital function. Some may develop stress incontinence. Contraindication : menstruating woman diseased cervix & uterus.

ABDOMINAL SLING OPERATION : For young women suffering from second or third degree UV prolapse. Aim : To buttress the weakened support by providing a substitute ( Nylon or dacron tape) ABDOMINO CERVICOPEXY : Elevation of two musculofascial lining from rectus sheath laterally & anchoring them infront of the uterine isthmus.

PURANDARE & MHATRE OPERATION : Attaching the tape posteriorly on the cervix close to the attachments of uterosacrals, anteriorly to the external oblique aponeurosis. KHANNA’S SLING OPERATION : Mersilene tape is fixed to the isthmus posteriorly & anterior superior iliac spine anteriorly.

OTHERS : Shirodkar’s abdominal sling operation Virkud’s sling operation Mangeshkar’s laparoscopic technique Neeta warty’s technique.

VAULT PROLAPSE Incidence : 3-6 per thousand. Aetiology : Weak supports Failure to identify enterocele Technical errors in previous surgery Age, parity, estrogen deficiency Obesity, chronic cough.

VAULT PROLAPSE

Treatment : Right transvaginal sacrospinous colpopexy. Transabdominal sacral colpopexy. Colpocleisis. Lefort’s repair Laparoscopic colpopexy Abdomino perineal surgery – If associated with rectal prolapse. Ring Pessary – for patient unfit for surgery. Posterior intravaginal sling.