1. Anatomy of female genital tract

2. SUPPORTS OF UTERUS Primary Supports Fibromuscular supports-
a) Muscular supports- 1.Pelvic diaphragm
2.Perineal body
3.Urogenital diaphragm
b) Ligamentary supports- 1. Pubocervical ligament
2.Transverse cervical ligament
3. Uterosacral ligament
c) Fascial support – 1.endopelvic fascia
2.vesicovaginal fascia
3.rectovaginal fascia
Uterine axis
Round ligament

3. Secondary Supports – Broad ligament
Uterovesical fold
Rectovaginal fold
Mechanical Supports –
Bony supports- Lordosis of lumbosacral spine
Vertical orientation of inlet

5. Vagina H-shaped on cross section
It extends upwards and backwards (direction)making an angle 60 degree with the horizontal plane.
Upper 2/3rd is horizontal and lower 1/3rd is vertical
Anterior wall is 8 -9 cm and the posterior wall is cm.
4-5 cm at lower end & twice as wide at the upper end

7. Pericervical ring

8. Pubocervival /Rectovaginal septum

10. Urogenital diaphragm

12. Perineal Body Anatomical perineum/ Central tendon of perineum.
Pyramidal structure *4*4cm.
Base covered by skin. Apex attached to rectovaginal septum.
Confluence of 9 muscles-
1.Superficial transverse perinei
2.Deep transverse pernei
3.Levator ani
4.Bulbospongiosus
5. External anal sphincter

14. Levator Plate Also known as median raphe.
Strong connective tissue band formed by confluence of levator muscles in midline.
Vagina and rectum are suspended by endopelvic fascia over the levator plate.
Situated between coccyx & anus.
Horizontal in erect posture.
Descent occurs due to inherent loss of tone- enlarges urogenital hiatus & descent of upper 1/3 of vagina.

16. POP -Q
Approved by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons for the description of female pelvic organ prolapse
Ordinal staging system created to make comparative analyses and clinical communications more practical

17. Reduce the prolapse and mark Aa (3cm from external urinary meatus) and Ap (3cm from hymen on the posterior vaginal wall) points, measure TVL(forchette to posterior fornix) , GH (urethra to forchette) and PB (forchette to midpoint of anus)
At maximal excursion mark Ba, Bp, C and D points, now measure all 6 points from hymen

20. ICS CLASSIFICATION:POPQ System
Stage 0 – No prolapse
Stage 1 - Descent of most distal part of prolapse within 1cm above the level of hymen
Stage 2 – Descent between 1cm above and 1cm below the hymen
Stage 3 – Descent beyond stage 2 but not complete < (tvl-2)
Stage 4 – Total / Complete Vaginal Eversion ≥ (tvl -2)

21. Principles of genital prolapse surgeries

22. General prolapse All three supports are weak –
Ligaments – sling/mesh/SSF
Fascia – native tissue repair, attachment, mesh
Muscular - perineorrhaphy

23. UV prolapse 1st and 2nd degree – Ligaments are strong
Manchester operation
3rd and 4th degree – Ligaments are also weak
Sling/mesh/SSF

24. Congenital/Nulliparous prolapse
Severe weakness of connective tissue – congenital prolapse
Moderate weakness – Nulliparous prolapse
Mild weakness – Nulliparous prolapse after easy child birth

25. Case 1 Nulliparous prolapse 28 yr old P1L1 comes with mass per vagina
O/E – III Uterine descent without the descent of vaginal wall

26. Defect –
Ligamentary support is weak
Choice of surgery –
Sacrohysteropexy – fixing the uterus to the anterior longitudinal ligament at S2 S3 level (simulating Uterosacrals)

27. Sacral Hysteropexy

28. Sacral Hysteropexy

29. Sling surgeries
Modified Purandare – fixing the uterus to the anterior rectus sheath – dynamic sling – works only if tone of the rectus muscle is good

30. Purandhare’s sling

31. Shirodkar – uterus fixed to anterior longitudinal ligament at S2 S3 level (simulating Uterosacrals) (static sling)

32. Shirodkar’s abdominal posterior sling operation
Right side – retroperitoneal space created, tape fixed to posterior aspect of isthmus of uterus Left side – psoas loop, elevation of sigmoid colon, posterior aspect of isthmus of uterus

33. Virkud - uterus fixed to anterior longitudinal ligament at S2 S3 level on right side and to the anterior rectus sheath on left side (static and dynamic sling)
Khanna – Uterus fixed to anterior superior iliac spine (static sling)

34. Virkuds composite sling

35. Case 2
General prolapse
23 yr old nulliparous lady comes with mass per vagina
O/E – III degree uterine descent without supravaginal elongation and cystocele, enterocele, rectocele

36. Defect –
ligamentary and fascial support weakness
Surgery –
Sling surgeries with site specific repair of fascial defects
Extended Manchester – cervix not amputated , uterus is anteflexed by fixing the Mackenrodts and uterosacrals anteriorly, conventional anterior and posterior colporrhaphy

37. Case 3 Uterovaginal prolapse
A 28 yr old P2L2 comes with mass per vagina
O/E – III degree uterine descent with supravaginal elongation, cystocele enterocele and deficient perineum

38. Defect –
All three supports ligamentary, fascial and muscular support
Surgery –
Modified Fothergill’s - cervix amputated , uterus is anteflexed by fixing the Mackenrodts and uterosacrals anteriorly, conventional anterior and posterior colpoperineorrhaphy
Sling surgeries with site specific repair of fascial defects

39. Manchester operation (Fothergill’s operation)
Fothergill’s points – 1 sub urethral , 2 on either side of the cervix
1 on posterior vaginal wall

40. Case 4 Uterovaginal prolapse in peri and postmenopausal age group
Defect –
All three supports ligamentary, fascial and muscular support
Surgery –
Vaginal hysterectomy with site specific repair of fascial defects, perineorrhaphy and SSF

41. Site specific repair Reconstruction of pericervical ring
Anchor vesicovaginal fascia and rectovaginal fascia to the pericervical ring
plication of vesicovaginal fascia will detach the fascia from its lateral attachment

42. Vaginal hysterectomy

43. Vaginal hysterectomy

44. Vaginal hysterectomy

45. Vaginal hysterectomy

46. Vaginal hysterectomy

47. Vaginal hysterectomy

48. Cystocele repair –
- Central – defects in the fascia are closed and vesicovaginal fascia is attached to uterosacrals
- Lateral – vesicovaginal fascia is attached laterally to ATFP(Arcus tendinous fascia pelvis) and proximally to uterosacrals

49. Cystocele repair

50. Enterocele repair – rectovaginal fascia is fixed proximally to the uterosacrals

51. Enterocele correction
Abdominal
Moschowitz procedure
Halban’s
Vaginal
McCaul culdoplasty

52. Suture inserted into the pouch of Douglas peritoneum including serosa of the colon and both uterosacral ligaments.

53. Three successive sutures in place to obliterate the pouch of Douglas.

54. Halban’s Technique - antero posterior plication

55. Internal Culdoplasty
External Culdoplasty

56. Principles:
Obliterates cul de sac
supports vaginal apex
Directs it to hollow of sacrum
lengthens posterior vaginal wall
Attaches rectovaginal fascia to uterosacrals

57. Rectocele Central defects in the rectovaginal septum are repaired
Rectovaginal fascia is attched proximally to uterosacrals
Laterally to ATRV
Distally to PB

58. Rectocele repair

59. Rectocele repair

60. Perineorrhaphy – approximation of bulbospongiosus and transverse perinnei muscles (distal attachment of rectovaginal septum, narrowing of genital hiatus and horizontal orientation of levator plate)

61. Perineorrhaphy Essential because it prevents vault prolapse by
Anchoring rectovaginal fascia to PB
Making levator plate horizontal
Narrowing the genital hiatus
Levator myorrhaphy in selected cases
Dumble shaped vagina

62. Perineal body reconstruction / Perineorraphy

63. Levator Myorraphy and High Perineorraphy

64. Case 5 General prolapse in postmenopausal women Defects –
All three supports ligamentary, fascial and muscular support
Surgery –
Vaginal hysterectomy with site specific repair of fascial defects and perineorrhaphy
Sacrospinous fixation
Iliococcygeous fixation – easy and safe

65. Case 6 Recurrent vaginal wall prolapse Defect – Fascial support
Management
Prolift / Perigie / customised mesh repair of cystocele
Apogie for rectocele repair

66. Needle passes through the groin to enable connection of the anterior wall graft to the pelvic sidewalls.
Final positioning of the Perigee system

67. Apogee needle passage
Final positioning of the Apogee system

68. Posterior intravaginal slingoplasty (Infracoccygeal sacropexy)

69. Case 7 Vault prolapse Defect – Ligamentary support Surgery –
Abdominal sacrocolpopexy
Vaginal sacrospinous / iliococcygeous fixation of the vault

70. Vault Prolapse Sacrocolpopexy Sacrospinous fixation
Green-top Guideline No. 46 RCOG/BSUG Joint Guideline | July 2015

71. Surgery? Who?
Surgical treatment should be offered to women with symptomatic PHVP after appropriate counselling.
PHVP surgery should be performed by an urogynaecologist or gynaecologists who can demonstrate an equivalent level of training or experience.

72. Postop result
Pelvic Organ Prolapse Quantifiation (POP-Q) stage of I or 0 in the apical compartment seems to be acceptable and widely used as the optimum postoperative result.

73. Which surgery? Tailored to the individual patient’s circumstances.
Both ASC and SSF are effective treatments for primary PHVP. ASC is associated with signifiantly lower rates of recurrent vault prolapse, dyspareunia and postoperative stress urinary incontinence (SUI) when compared with SSF.

74. ASC Vs SSF
However, reoperation rates or higher patient satisfaction remain the same.
SSF is associated with earlier recovery compared with ASC.
SSF may not be appropriate in women with short vaginal length and should be carefully considered in women with pre-existing dyspareunia.

75. Lap Vs Abdominal
LSC can be equally effective as ASC in selected women with primary PHVP.
LSC can include mesh extension or be combined with other vaginal procedures to correct other compartment prolapse.
There is limited evidence on the effectiveness of RSC.

76. High uterosacral ligament suspension (HUSLS)
HUSLS - risk of ureteric injury, especially in the laparoscopic approach.

77. Transvaginal mesh (TVM) kits/grafts?
The limited evidence on TVM kits does not support their use as fist-line treatment of PHVP.

78. When should colpocleisis be used?
Colpocleisis is a safe and effective procedure that can be considered for frail women and/or women who do not wish to retain sexual function.

79. Concomitant surgery for occult SUI?
Colposuspension performed at the time of sacrocolpopexy is an effective measure to reduce postoperative symptomatic SUI in previously continent women.

80. Concomitant surgery for PHVP and overt SUI?
Colposuspension at the time of ASC does not appear to be effective treatment for SUI.
Concomitant mid-urethral sling surgery may be considered when vaginal surgical approaches are used for the treatment of PHVP.

81. Sacrocolpopexy

82. Suspension of the vaginal vault to the sacrospinous ligament.

83. Case 10
A 85 yr old C/o mass per vagina. K/C/o HTN, old IHD. ECHO – LVEF – 48%
O/E:
General prolapse with grade 3 cystocele, enterocele, deficient perineum
Management –
If muscular support is good - pessary
Pt not fit for hysterectomy – Le Fort’s repair

84. Partial colpoclesis

85. Total colpoclesis

86. Partial colpocleisis/ Le Fort’s
Total colpocleisis/ Goodall’s modification
Partial colpocleisis/ Le Fort’s
Pt medically unfit/ sexually not active
Pap smear/ endometrial biopsy- must
Aggressive perineorraphy to narrow introitus
Plication of the bladder neck routinely done
Done in sexually active young menstruating women
Triangular flaps removed
Single vagina in lower 2/3 and double vagina in upper 1/3
- Channels on sides permit egress of menstrual blood

87. LeFort’s / Partial colpocleisis : Indications
Are very old or infirm women
Do not desire coital function
Have medical contra-indications for major procedures.
Post menopausal women

88. Introital tightening / Dani’s stitch :
Based on principle of thiersch stitch for rectal prolapse.
Alternative for LeFort’s
Technique :
-Cerclage of the introitus

89. Kelly

90. Fothegill surgery

91. Wards modification (cystocele, enterocele repair):
Purse string suture is passed through UV fold of peritoneum, upper pedicle, Mackenrodt’s uterosacral complex, & highest point on posterior peritoneum
United uterosacral and cardinal ligaments are tied

92. Drawbacks Broad ligaments are drawn into distorted position
Vagina is shortened
Due to interposition all sutures are under tension

93. Laparoscopy/Robotics
Better anatomical delineation – better repair
Subjective and objective cure?
Morbidity ?
Cost?
Further research needed

94. Case 8 A 24 yr old G3P2L2 with 12 wks gestation with mass per vagina
O/E: III uterine descent +
Treatment
Ring pessary, used until 16 weeks of gestation.

95. Treatment of edematous and congested prolapsed cervix with pregnancy
Foot end elevation atleast by 25cms
Cover the prolapsed cervix by soaked guage with glycerine MgSO4.
All these measures continued till 18 weeks of gestation.
Once replaced patient is allowed is ambulate.

96. Management of incarcerated pregnant uterus
Once it is diagnosed , pregnancy has to terminated, irrespective of period of gestation
During labour:
A close watch on cervical dilatation needed
Generally most of delivery go on spontaneously, if cervical dilatation fails then,
At <4cms inspite of good contraction  Consider Em LSCS

97. At>7cm with good contraction 
DUHRSSEN INCISION
(2’0 and 10’0 clock) ↓
Delivery by vacuum and forceps.
Hyaluronidase injected at multiple points on the cervical rim helps in cervical dilatation.

98. Case 9 Post Natal Day 3 . P2L2 had FTVD. C/o mass per vagina
O/E- III uterine descent
Management
Consider physiotherapy
Use pessaries till corrective repair surgery done
Corrective repair surgery after 3 to 6 month

99. Challenge
Challenges in the management of pelvic organ prolapse still remains……
High recurrence rates
Lack of randomized control trials
Poorly defined success and failure rates