1. Utero-Vaginal Prolapse

2. Background
The pelvis encloses organs that primarily function in storage, distension and evacuation. The pelvic viscera must maintain their normal anatomic relationships within this cavity so that these physiological functions can be sustained.

3. Background The uterus is normally anteverted, anteflexed
Version: is the angle between the longitudinal axis of cervix, and that of the vagina
Flexion: is the angle between the longitudinal axis of the uterus, and that of the cervix

4. Genital Prolapse
Genital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Pouch of Douglas or rectouterine pouch) through the fasciomuscular pelvic floor below their normal level
Vaginal prolapse can occur without uterine prolapse but the uterus cannot descend without carrying the vagina with it.

6. Supports of the uterus
DeLancey in 1994 defined three levels of vaginal support, reviving the importance of the connective tissue structures and giving a working basis for the present day understanding of the anatomy and surgical treatment.

8. Three level of Supports of Uterus
Level I: The cardinal uterosacral ligament complex
Level II: The pubo- cervical and recto-vaginal fascia
Level III: The pubo-urethral ligaments anteriorly & the perineal body posteriorly

9. Anterior vaginal wall prolapse
Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystocele
Prolapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele.
Complete anterior vaginal wall prolapse is called cysto-urethrocele.

10. Anterior vaginal wall prolapse
Weakness in the
Supports of the bladder neck
Urethero vesical junction
Proximal urethra
Caused by
Weakness of pubocervical fascia and pubourethral ligaments

12. Middle compartment defect
Enterocele and eversion of vagina
Enterocele (Herniation of POD)

13. Posterior compartment defect
Rectocele
Perineal body descent

15. Uterine descent
Utero-vaginal (the uterus descends first followed by the vagina): This usually occurs in cases of virginal and nulliparous prolapse due to congenital weakness of the cervical ligaments.
Vagino-uterine (the vagina descends first followed by the uterus):This usually occurs in cases of prolapse resulting from obstetric trauma.

16. Degree of uterine descent
1st degree: The cervix desends below its normal Ievel on straining but does not protrude from the vulva (The extemal os of the cervix is at the level of the ischial spines)
2nd degree: The cervix reaches upto the vulva on straining
3rd degree: The cervix protrudes from the vulva on straining
Procidentia- whole of the uterus is prolapsed outside the vulva and the vaginal wall becomes most completely inverted over it. Enterocele is usually present

19. Vault prolapse
Descent of the vaginal vault, where the top of the vagina descends )or inversion of the vagina) after hysterectomy

21. Pelvic organ prolapse quantitative (POPQ) exam
In 1996, by the ICS
POPQ system describes the location and severity of prolapse using segments of the vaginal wall and external genitalia, rather than the terms cystocele, rectocele, and enterocele

22. Aetiology
Erect posture causes increased stress on muscles, nerves and connective tissue
Acute and chronic trauma of vaginal delivery
Aging
Estrogen deprivation
Intrinsic collagen abnormalities
Debilitation
Iatrogenic

23. Precipitating factors
↑ intra abdominal pressure
↑ weight of the uterus
Traction of the uterus by vaginal prolapse or by a large cervical polyp
Obesity(40%--75%)
Smoking
Pulmonary disease (chronic coughing)
Constipation (chronic straining)
Recreational or occupational activities (frequent or heavy lifting)

24. Symptoms of Prolapse
Pelvic floor disorders become symptomatic through either of two mechanisms:
1. Mechanical difficulties produced by the actual prolapse,
2. Bladder or bowel dysfunction, disrupting either storage or emptying.

25. Clinical presentation
Before actual prolapse. the patient feels a sensation of weakness in the perineum. particularly towards the end of the day
Later the patient notices a mass which appears on straining. and disappears when she lies down
Urinary symptoms are common and trouble some even with slight prolapse:
a) Urgency and frequency by day
b) Stress incontinence
c) Inability to micturate unless the anterior vaginal wall is pushed upwards by the patient's fingers
d) Frequency when cystitis develops

26. Rectal symptoms are not so marked
Rectal symptoms are not so marked. The patient always feels heaviness in the rectum and a constant desire to defaecate. Piles develop from straining.
Backache, congestive dysmenorrhoea and menorrhagia are common.
Leucorrhoea is caused by the congestion and associated by chronic cervicitis.
Associated decubitus ulcer may result in discharge which may be purulent or blood stained

27. Diagnostic approach
Beginning with a careful inspection of the vulva and vagina to identify erosions, ulcerations, or other lesions
The extent of prolapse should be systematically assessed
Suspicious lesions should be biopsied

28. Examination Local examination Per speculum examination
Per vaginal/ Bimanual examination
Bonney’s stress test
Evaluation of tone of pelvic muscles
Recto vaginal examination
Position of patient for examination
- standing & straining
- dorsal lithotomy

29. Diagnostic approach
The maximal extent of prolapse is demonstrated with a standing straining examination when the bladder is empty
Pelvic muscle function should be assessed after the bimanual examination → palpate the pelvic muscles a few centimeters inside the hymen, along pelvic sidewalls at the 4 & 8 o’clock
Resting tone & voluntary contraction of the anal sphincters should be assessed during rectovaginal examination

30. Evaluation of pelvic floor tone
Place 1 or 2 fingers in the vagina and instruct the patient to contract her pelvic floor muscles (i.e., the levator ani muscles). Then gauge her ability to contract these muscles, as well as the strength, symmetry, and duration of the contraction.
The strength of the contraction can be subjectively graded with a modified Oxford scale (0 = no contraction, 1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 = strong).

31. Bladder evaluation
For all patients with prolapse following information should be obtained
Screening for urinary tract infection
Postvoid residual urine volume
Presence or absence of bladder sensation
Bonney’s stress test performed following reduction of prolapse
If test positive incontinence surgery should be performed at the time of prolapse surgery

32. Testing for Integrity of anal sphincter
Should be assessed for resting tone and voluntary squeeze and sensation around the vulva with the bulbo-cavernous reflex and crude sensory testing for evidence of pudendal neuropathy

33. Prevention During labour &puerperium Avoid premature bearing down
Avoid long second stage
Repairs all tears &incisions accurately in layers
Use delayed absorbable suture
Do not express the uterus when attempting to deliver placenta
Encourage pelvic floor exercise
Avoid puerperal constipation-decreases bearing down

34. Prevention At hysterectomy
Vault suspension with uterosacral and cardinal ligaments
Obliteration of deep cul-de –sac by Moschowitz sutures
Sacropexy in high risk situations like collagen disorders
Increase acceptability of estrogen replacement therapy

35. Treatment Physiotherapy Kegel’s pelvic floor exercise
Kegel’s perineometer
Influence only the voluntary muscles
No action to the fascial supporting system
Vaginal cones of increasing weight .

36. Associated decubitus ulcer
To relieve congestion, the prolapse can be reposited in the vagina with the help of tompoons ar pessary and this helps in healing of the ulcer
Hygroscopic agents like acriflavin-glycerine can help reduce the congestion further

37. Pessary During pregnancy Immediately after pregnancy, during lactation
When future childbearing is intended in near future
Refusal to operation by patient
As a therapeutic test
To promote healing in a decubital ulcer

39. Pessary in situ

40. Complications of pessary
Constipation
Urinary incontinance
B.vaginitis, ulceration of vaginal wall
Cervicitis
Carcinoma of vaginal wall
Impaction of pessary
Strangulation of prolapsed tissue

41. Principles of Management
Physical examination must not be used in isolation to develop treatment strategy.
Any decision for surgical intervention should take account of how prolapse is affecting lifestyle.

42. Aim of pelvic reconstructive surgery
To restore anatomy, maintain or restore visceral function, and maintain or restore normal sexual function

43. Uterine descent- surgeries
Vaginal hysterectomy
Sling surgeries
Shirodkar
Khanna’s
Purandares
Fothergill’s surgery

44. Vault prolapse
Separation of the rectovaginal fascia from pubocervical fascia.
In post hysterectomy patients it is important to reattach the rectovaginal fascia to the pubocervical fascia and to provide good support to the vaginal apex by reattaching the vaginal cuff to the uterosacral cardinal ligament complex.

45. Surgery for prolapsed vaginal vault
Vaginal surgery
Decreased operative time
Decreased incidence of adhesion formation
Quicker recovery time
Abdominal surgery.
Failed previous vaginal approach
Have foreshortened vagina
Young patients with advanced prolapse
With other co existing conditions
Obliterative procedures

46. Vaginal surgery Mc Call culdoplasty Sacrospinous ligament fixation
Internal
external
Sacrospinous ligament fixation
High uterosacral ligament suspension with fascial reconstruction
Iliococcygeus fascia suspension

47. Abdominal repairs Abdominal sacral colpopexy
High uterosacral ligament suspension
Laparoscopic approach

48. Obliterative procedures
Le forte partial colpocleisis
Colpectomy and colpocleisis

49. Diagnosis of Stress Incontinence with Pelvic Organ Prolapse
Loss of urine during coughing, sneezing, laughing or lifting something heavy
These activities cause an increase in "belly pressure” → forces the urine out of the bladder
Stress incontinence occurs almost exclusively in women & thought to be due to "pelvic (vaginal) relaxation" from childbirth or aging

50. Treatment of Stress Incontinence with Pelvic Organ Prolapse
Conservative therapy
- Pelvic floor exercises
- Urinary meatel occlusion devices
- Collagen injections
 Urinary incontinence surgery
- Ant repair & Kelly’s plication
- Pubo-vaginal sling procedure
- TVT sling procedure
- Burch Urethropexy    

51. Thank you