1. Management Of Genital Prolapse
Associate Professor Semyatov S.M.
Department of Obstetrics and Gynecology
with course Perinatology
Peoples’ Friendship University of Russia, Moscow

2. DEFINITION
Prolapse/Procidentia is downward decent of uterus &/or vagina.
(Procidentia is from Latin procidere - to fall).
It is a state of pelvic relaxation due to a disorder of pelvic support structures that is, the endopelvic fascia.
It is not a disease but a disabling condition.

3. CAUSE WEAKNESS OF THE SUPPORTS OF THE UTERUS & VAGINA
Precipitating / Exaggerating / Unmasking Causes -
INCREASED INTRA ABDOMINAL PRESSURE
Chronic cough
Chronic Constipation
Heavy Wt.Lifting / domestic Work
Obesity, Ascitis
WEAKNESS OF THE SUPPORTS & MUSCLES
Chronic ill health, malnutrition dysentery, anemia
Inadequate rest during pureperium
Menopause

4. TYPES OF PROLAPSE Vaginal Anterior –cystocele & urethrocele
Posterior - Enterocele & Rectocele
Vault Prolapse - a special term applied to the prolapse of upper vagina
Uterine/Utero-vaginal- Acquired or Congenital.
First degree.
Second degree &.
Third degree-(total Prolapse / complete procidentia).
However Procidentia is often used only to denote third degree uterine prolapse.

5. EFFECTS OF PROLAPSE NO SYMPTOM- mild & moderate prolapse.
Discomfort & disability.
Sexual Dysfunction.
URINARY- Frequency, Dysuria, Stress incontinence, infection.
Incomplete emptying of rectum.
Discharge.
Backache.
Ulceration & Infection.

6. WHEN TO TREAT ?
Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse )
Interferes with the normal activity of the woman
The patient seeks treatment

7. HOW TO TREAT ? NON-SURGICAL Methods: -Limited Role
PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium).
HORMONE REPLACEMENT, both systemic and local.
PESSARY TREATMENT for temporary relief
During Pregnancy, Puerperium & Lactation
When Operation is Unsafe due to Extreme Senility/Debility and Diseases
Preoperatively
For therapeutic test

8. HOW TO TREAT ?
SURGICAL TREATMENT: -RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects.

9. SURGICAL TREATMENT
It is the definitive & curative treatment of Prolapse.
It is a cold operation. So complete investigation should be done & all existing diseases & disorders should be treated first.
Pre operative pessary/tampoon & or Hormone treatment should be given as indicated.
Meticulous and through examination under anaesthesia should be done before deciding the surgery.

10. SURGICAL TREATMENT
Depending on the type & extent of Prolapse, surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement.
Absolute haemostasis is mandatory. Diathermy should be liberally used.
Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable.
Catheter for more than 48 hrs should be exceptional.
Strict antibiotic prophylaxis is essential

11. VAGINAL OPERATIONS FOR PROLAPSE
Anterior colporrhaphy
Posterior colporrhapry- High / Low
Enterocele repair
Perineorrhaphy
Amputation of cervix
Paravaginal repair
Hysterectomy with or without Colporrhaphy / Perineorrhaphy

12. VAGINAL OPERATIONS FOR PROLAPSE
Manchester/ Fothergill’s operation & Shirodkar’s modification
Uterus/Cervix suspension/fixation
Vaginal vault suspension/fixation
Retro-rectal levatorplasty and post. anal repair for associated rectal prolapse
Vaginectomy ?
Colpocleisis ?

13. Anterior colporrhaphy & Urethroplasty
For correction of Cystocele & Urethrocele
Incision- Midline / Inv.T / Elliptical
Excision of vagina according to the size & site of laxity
Avoid shortening &/or narrowing of vagina
Closure with interrupted sutures

14. Posterior colporrhaphy & Enterocele repair
For correction of Enterocele & Rectocele
Enterocele repair can be done either by vaginal or abdominal route depending on the associated procedures.
Approximation of uterosacral ligaments for enterocele & prerectal fasciae and levator for rectocele with interrupted sutures is essential
Excision of vagina should be tailor made
Perineorrhapy to be done only if perineal body is torn

15. Perineorrhaphy
Not an Operation for prolapse, but Indicated only for associated old 2nd degree perineal tear
Performed along with posterior colporrhaphy
Aim-Reconstruction of the Perineal body and reduction of gaping introitus.
Can cause Dyspareunea
Essential steps - Excision of the scar tissue & approximation of levator ani & superficial perineal muscles

16. Vaginal Hysterectomy with/without Vaginal repair
Indicated when uterus needs removal, in old age & in total prolapse.
Patient’s consent is mandatory knowing that there are alternatives to hysterectomy.
Usually combined with Ant. & Posterior colporrhaphy.
Perineorrhaphy is not mandatory but case specific.
Vault suspension is an essential step.
If sexual function is not needed narrowing of vaginal canal should be done.

17. Amputation of cervix
Not for Prolapse.Indicated only for cervical elongation (Uterocervical length >12.5 Cm )
To be done only as a part of Fothergill’s repair/sling operations.
Adequate cervical dilatation - a prerequisite
Bladder displacement is a must
Excision of cervix should not exceed 2 cm
Likely to affect reproductive life
Long-term complications are real risks

18. Fothergill’s operation
It is the operation of choice in uncomplicated Utero-vaginal prolapse when uterus is to be preserved but NO future child bearing is required.
It is a combination of, Amp. of Cx., Fixation of the Meconrodt’s ligament to the anterior of Cx. & Ant. Colporrhaphy. D&C is a must.
Post. Colporrhaphy to be performed only if Ent/Rectocele is present
Perineorrhaphy is usually not required

19. Fothergill’s operation
Not useful if ligaments are weak & Uterus is of normal size. Purandare’s modification may help.
Technically difficult operation, requiring high degree of surgical skill.
Threat of short-term complications.
Real possibilities of long term complications.
Recurrence/Failure.
Sling operations are better alternatives
HAS A BLEAK FUTURE

20. ABDOMINAL OPERATIONS FOR PROLAPSE
Sling operations
Closure or repair of enterocele
Sacrocolpopexy
Anterior Colpopexy
Colposuspension
Paravaginal repair

21. Abdominal Sling operations
Indicated when the ligaments are extremely weak as in nullipara & young women.
Preserves reproductive function.
Principle - With a fascial strip / prosthetic material (Merselene tape or Dacron) the Cx is fixed to the abdominal wall / sacrum / pelvis.
Amp.of Cx should also be done if Utereocervical length >12.5cm.
Cystocele/Rectocele repair if needed can be done vaginally before or after.
Enterocele repair can also be done abdominally.

22. Abdominal Sling operations
It is a major abdominal operation & Synthetic material is costly & not widely available in India.
Types-.
Shirodkar’s posterior sling.
Purandare’s anterior cervicopexy.
Khanna’s sling.
Virkud’s composite sling.

23. Shirodkar’s sling
Tape is fixed to the post. Aspect of isthmus & sacral promontory
Anatomically most correct but difficult to perform
Risks of complication

24. Purandare’s cervicopexy
Tape is anchored to the ant.aspect of isthmus and ant. abd. Wall
Easy to perform
Dynamic support

25. Virkud’s composite sling operation
Tape is anchored from the post aspect of isthmus to sacral promontory on the Rt. side & ant. abd. Wall on the Lt. Side
Utrosacral ligament is plicated
Technically easy

26. Khanna’s sling operation
Tape is anchored to ant aspect of isthmus & ant. sup. Iliac spine
Easier to perform and safer
But tape is superficial
Risk of infection

27. Abdominal Colpopexy / Colposuspension
Indicated when vault prolapse occurs after hysterectomy or vaginal laxity is to be corrected at abdominal hysterectomy.
Major abdominal operation & technically difficult.
Sexual function is preserved.
Methods-.
Sacrocolpopexy.
Ant.Colpopexy.
Colposuspension.

28. Sacrocolpopexy
Vault is fixed to 3rd & 4th sacral vertebrae with a facial strip / proline mesh under the peritoneum to the right of rectum
Enterocele repair can be done if required

29. Ant.Colpopexy Corrects ant. vag laxity & stress inc.
Useful at abdominal hysterectomy / for vault prolapse.
Extra peritoneal supra pubic approach if done alone.
Enterocele repair if required.
Vagina stitched to the ileo-pectineal ligaments.

30. Vault / Colposuspension
Vault is fixed to the abdominal wall by a facial strip or merseline tape

31. LAPAROSCOPIC SURGERY PROLAPSE
Advantages of M I S-small incision, better view, haemostasis, no packing, minimal tissue & bowel handling, short recovery, less pain, insignificant scar
Can all types of prolapse be treated?- Yes.
Ant. / Post. Lower vaginal repairs if needed can also be done vaginally before or after lap.Surgery
However extended period of rest is essential
Expertise is needed
Presently cannot be widely practised
This is the surgery of the future today

32. LAPAROSCOPIC SURGERY PROLAPSE
PROCEDURES:-
Cervicopexy / Sling operations with/without Lap.Paravaginal repair / Vaginal repair
VH / LAVH / LH / TLH + Colposuspension
VH / LAVH /LH/TLH+ Lap.Pelvic reconstruction
Rectocele repair & levatorplasty
Enterocele repair with suturing of uterosacral ligaments
Colpopexy- Ant / Post

33. Laparoscopic Cervicopexy/sling Operations
All types of sling operations can be better performed by laparoscopy
Associated vaginal prolapse can also be repaired laparoscopically (Lap.Paravaginal repair)
Vaginal Ant./Post. colporrhaphy can be done before / after laparoscopy

34. Laparoscopic Vault suspension/ Culdoplasty)
Can be done with VH / LAVH / LH / TLH
Corrects mild laxity
Prevents vault prolapse

35. Laparoscopic Pelvic Reconstruction With VH / LAVH / LH / TLH
An alternative to Ward-Mayo’s operation
Before Hys., Lap.Ureteral dissection is done and suture placed in uterosacral ligament near sacrum & left long, for latter vaginal vault suspension
Lap. levator plication if needed
Enterocele repair and suturing of uterosacral ligaments if needed
Retro pubic Colposuspension (Bruch) if required

36. Laparoscopic Rectocele repair & Levatoroplasty
Rectovaginal space is opened & rectum dissected
Interrupted sutures given in the levator in the midline
Enterocele repair done if indicated
Vaginal vault suspension done

37. Laparoscopic Enterocele repair
Rectovaginal space is opened, sac excised and purse string suture given
Uterosacral ligament sutured

38. Laparoscopic Post Colpopexy / Sacrocolpopexy
Indicated for vault prolapse
Enterocele if present is first repaired
Prolene mesh is fixed to the vault & 3rd-4th sacral vertebrae, under the peritoneum in the Rt.para rectal space

39. Time has come for Laparoscopic Surgery for Prolapse So move with the times. Practice laparoscopy. This is the Surgery of the future today.
THANK YOU