1. Genital Prolapse

2. 55 post-menopausal , multi parous lady came to your clinic complaining of a lump protruding from the introitus , worsen at the end of the day , suggesting of prolapse , she is a smoker and obese ……
What is the main cause of her prolapse ?
Multiparity ( child bearing )
What are other risk factors present in this lady ?
Post menopausal , increased intraabdominal pressure due to smoking and obesity.

3. During history taking , she was found to have stress incontinence, frequency , reccurent UTI , urgency , incomplete emptying of the bladder …
What type of prolapse do u suspect ?
Vaginal prolapse  Cystocele.
On inspecting the vulva, with coughing she was found to have stress incontinence supporting the diagnosis.

4. What other differentials u might suspect ?
Anterior vaginal wall prolapse – to be differentiated from congenital Gartner’s cyst, inclusion dermoid cyst & urethral diverticulum
What are the investigations u’ll need in this patient ?
MSU for analysis and culture .
Renal ultrasound and IVU in severe cystocele to exclude hydroureter & hydronephrosis which may occur as a result of kinking of the ureters
Cystometry in cases of incontinence , in order to exclude urge incontinence

5. What forms of advice u may consider in this patient ?
Avoiding and treating factors which increase the intra-abdominal pressure such as obesity , smoking, chronic cough
 Prevention of postmenopausal atrophy of pelvic support by balanced diet, exercise, calcium & by the increased use of HRT
Treating Urinary tract infections with proper antibiotics.

6. What forms of treatment u may offer this patient ?
Pessaries
Surgical treatment
The patient refused surgery , and chose the pessaries , what side effects u should warn ur patient about ?
Vaginal infection and discharge
Vaginal ulceration and bleeding
*What would you do to minimize these side effects ?
Use of silicon pessary - rubber pessary should not be used.
Change the pessary yearly - or earlier if infection or ulceration occurred .
Use of vaginal ostrogen cream in menopausal patients .

7. If she chose to have surgery , what type of surgery u’ll perform ?
Anterior repair, ie anterior colporrhaphy
After doing the operation , what is ur plan ?
Immediate postoperative care :
Vaginal pack –which to be removed within 24 hours.
Foley’s catheter ,which to be removed after 1- 2 days
Prophylactic antibiotics : Metronidazole and cephalosporin
Instructions after discharge - to minimize recurrence
Avoiding intercourse for 6 weeks .
Gradual return to normal activities over 2 months .
Avoiding smoking ,obesity ,constipation and lifting of heavy objects

8. What is the risk of recurrence of this condition ?
Recurrence occur in about 20-25%
Even with expert surgery and good postoperative care, recurrence can occur, especially in the presence of obesity, smoking and constipation .

9. In cases of vaginal prolapse : the previuos answers fits any case with some exceptions :
In case of rectocele in the history : Constipation , incomplete rectal evacuation and the patient may has to reduce the rectocele digitally to be able to empty her rectum.
Coital problems occur in vaginal and uterine prolapse.
In the examination of rectocele or enterocele :
Rectal examination, to differentiate between rectocele (finger goes through it) from enterocele ( finger goes high up) .

10. If the patient is in her child bearing age, additional point in the advice is added :
Prevention and limiting injury to pelvic support during childbirth by :
Avoiding of: prolonged labour , bearing down before full cervical dilatation and difficult instrumental delivery
Encouragment of postnatal pelvic floor exercises .
Family planning and smaller family size .

11. In the surgical treatment of vaginal prolapse :
Vaginal prolapse operations :
  i. Anterior repair ie anterior colporrhaphy - in Cystocele and Urethrocele.
ii. Posterior repair ie posterior colpoperineorrhaphy - in Rectocele
iii. Resection of enterocele sac - in Enterocele
iv. Abdominal sacrocolpopexy - in Vault prolapse

12. if the patient in her child bearing age , one point is added to post operative care after discharge :
Elective C.S. in the subsequent pregnancy.
At younger ages , and in nulliparous women having prolapse , we suspect genitic predisposition due to congenital reduction in the amount of collagen and weakness of connective tissue of the pelvic support
Also , race is an important risk factors for the predisposition of prolapse ,
Prolapse is common in Caucasian women , less common in Asians , and rare in Blacks .
This racial variation is explained by the variation in the amount of collagen and connective tissue in the pelvic support . ie greater in Blacks and lesser in Caucasian

13. What form of prolapse do you suspect ?
55 year old lady , came to your clinic complaining of a huge lump out side the introitus with Low backache, which is central, worse at the end of the day , increased on standing and relieved by lying down with Ulceration, blood stained and purulent vaginal discharge ?
What form of prolapse do you suspect ?
3rd degree uterine prolapse (procidentia)
What are your differentials ?
Uterine prolapse- to be differentiated from large cervical or endometrial polyp & chronic uterine inversion.

14. In this type of prolapse (3rd degree uterine) there is additional point in medical treatment
Reducing the procidentia and treatment of ulceration with oestrogen cream. The ulcer will usually heal within 7 days .
Risk factors are the same as vaginal
Advice  the same ( how to prevent )
Modes of treatment are also the same
Post op care also the same
Investigations are the same
Recurrence is the same

15. Methods of surgical treatment :
Uterine prolapse operations :
i. Vaginal hysterectomy – is the preferred operation in uterine prolapse
Indicated in young patients who complete the family and in menopausal patients .
ii. Manchester ( Fothergill ) operation.
Indicated in young patients who not complete the family.
Consisted of :
1. Partial amputation of the cervix
2. Shortening of the transverse cervical ligaments and suturing them to the front of cervical stump.
3. Anterior and posterior repair.
iii. Sacrohysteropexy
Indicated in patients who complete the family and wish to conserve the uterus

16. Le-Fort’s operation :
Rarely indicated in elderly and frail patients who are unfit for vaginal hysterectomy or pelvic floor repair .
Rectangular strips of vaginal epithelium are removed from the anterior and posterior vaginal walls in order to obtain a partial closure of the vagina . 

17. Incidence of prolapse :
Pessaries :
Indications :
Patient unfit for surgery .
Patient refuses surgery .
During pregnancy and after delivery .
During waiting time for surgery.
As a therapeutic test to confirm that surgery may help .
Incidence of prolapse :
Genital prolapse occurred in about 10-30% of multiparous women and in 2% of nulliparous women .

18. Types Uterine prolapse: 3 degrees of uterine prolapse
 First degree : is the descent of the cervix within the vagina .
Second degree :is the descent of the cervix through the introitus .
Third degree (Procidentia ): is the descent of the cervix and the whole uterus through the introitus. 18

19. Types Vaginal prolapse: mild , moderate or severe vaginal prolapse
Cystocele : is the prolapse of the upper 2/3 of the anterior vaginal wall and the bladder.
Urethrocele: is the prolapse of the lowest 1/3 of the anterior vaginal wall and the urethra .
Rectocele : is the prolapse of the posterior vaginal wall and the rectum.
Enterocele : is a true hernia of the pouch of Douglas through the posterior vaginal fornix - which may contain bowel or omentum.
Vault prolapse : is an inversion of the vaginal apex which occur after abdominal or vaginal hysterectomy. 19

20. cystocele

21. Uterine prolapse

22. rectocele

23. Vault prolapse