Genital Prolapse: Def, Type, Cause, Treatment, Complications

Genital Prolapse

 

Definition:

When the genital organ descends from its normal position through the vagina is called genital prolapse.

 

Classification:

 

1. Vaginal Prolapse

a)      Anterior wall

1. Upper (cystocele)
2. Lower (Urethrocele)

 

b)      Posterior wall

1. Upper (Enterocele  in Pouch of Douglas with or without intestine)
2. Lower ( Rectocele)
3. Prolapse of perineal body

 

1. Uterine Prolapse: 1⁰, 2⁰, 3⁰

 

Complaints

1. Something coming out through vagina
2. History of retention of urine which is overcome by manual reposition
3. History of constipation
4. Menopause for 4 years
5. Duration of marriage 31 years
6. Para: 4+2 abortion
7. Age of last child – 15 years

 

Patient’s Profile:

• Age: Late reproductive age
• Parity: Multipara
• H/O: Difficult/ obstructed labor

 

Symptoms

1. Something coming out through per vagina/ Fullness within the vagina
2. Lower abdominal dragging pain during walking, working
3. Frequency of micturition (Cystitis more common)
4. Excessive whitish discharge (due to venous congestion)
5. Decubitus ulcer in dependent part due to ischemia. (Rx by reposition)
6. Keratinization
7. Constipation – In rectocele

 

 

A. On examination

• Appearance- Normal
• Anaemia may present
• Malnutrition may present

 

B. Per Vaginal Examination:

 

Inspection:

• Protruding part
• Leading part cervix (through external os is outside the introitus and decubitus ulcer is seen)
• Cystic swelling (on coughing)
• Rectocele may be present

[Anterior vaginal wall- base of bladder

Posterior vaginal wall- Urethra]

 

 

Palpation:

1⁰ – Cervix descends below ischial spine but remains within the introitus

2⁰ – Get up the swelling –ve/ Cervix crosses the introitus but uterine body remains within the vagina.

[Outside the introitus during working

On rest- Spontaneous correction]

3⁰ – Get up the swelling +ve / the whole uterus crosses outside the introitus. Fundus is outside the intoritus.

 

Normal Uterus- Anteverted and ante-flexed

 

Cause

Precipitation factor

 

v  Weakness of supports of uterus (congenital)

• Macendort’s ligament
• Uterosacral ligament
• Broad ligament

v  Repeated child birth

v  After surgery (Hysterectomy) : vaginal vault prolapse

v  Climetric (After menopause): Menopausal atrophy of supportive ligament.

 

Aggravating Factor:

v  ↑ Intra-abdominal pressure (cough, ascites, constipation)

v  ↑ Weight of uterus: Large fundal fibroid

 

 

C. Bimanual examination:

• Uterus size: Normal in size, mobile and fornices are free, No mass present.
• Associated condition
• Uterine consistence
• Mass of fornix
• No adnexal mass

 

Differential Diagnosis:

i)        Gartner’s duct cyst (Remnant of Wolffian duct)

• Present on anterolateral wall of vagina
• No cough impulse transmit
• Non reducible

ii)      Fibroid polyp

On p/V mass present but no opening

Bimanual: Mass is fixed to cervix by peduncle

iii)    Congenital elongation of cervix

• Vaginal part up to 5 cm (but uterus in normal position)

iv)    Chronic inversion of uterus- Inversion inside

Inversion – Two types: Acute and Chronic (It is said chronic when there is fundal fibroid)

In chronic inversion:

• Rough irregular shaggy mass- Endometrial friable
• Irregular vaginal bleeding
• Fundus is not found bimanually
• (On DRE)A cup like depression will be felt
• Cervical rim will be found on the top around the mass (P/V)

Investigation:

• Hb%, TC, DC, ESR
• Blood grouping, Rh typing
• Urine R/E, Culture and sensitivity
• FBS
• S-creatinine
• ECG, chest x-ray
• USE- Gall stone, Kidney status

 

 

Treatment:

If age 60 years with prolapse:

 

A. Vaginal Hysterectomy (Total) with pelvic floor repair.

• Vaginal wall:
  • Anterior wall: Anterior colporraphy
  • Posterior wall: Posterior colporraphy

B. If patient preserve reproductive function then: Manchester/ Fother+ Gilli’s (when uterus remain i abdomen)

• Dilatation and curettage
• Amputation or cervix
• Tightening and cutting Mackenrodt’s ligament in front of the cervix.(cutting , shortening and tightening of Mackenrodt’s ligament)
• Anterior colporraphy
• Posterior colporraphy (Perineorraphy)
• Reposition of bladder

[ Only in cystocele- Colporraphy (ant.)]

Rectal prolapse- Post. colporraphy

 

Intermediate management after operation:

 

• Continuous catheterization (Folley’s) – 3-5 days
• Tight vaginal pack to prevent reactionary haemorrhage

 

Complications:

• Keratinization of vaginal wall
• Pigmentation of vaginal wall
• Decubitus ulcer

[Blood stained discharge present, present on depending part due to decease vascularity  (blood vessel twisting→ Ischemia→ slough out→ ulcer]

 

Ulcer must be treated before operation- otherwise

• Difficulty in incision
• Post-operative healing slowed
• ↑ Bleeding
• Post-operative infection

 

● so, reposition of prolapse part by –

• Packing
• Bed rest

 

● Infection (indicated by foul smell) – Oral antibiotic- 7-14 days- healing

• Elongation of supra vaginal part of cervix (Mackenrodt’s ligament)
• Cervical gland hypertrophy (↑ white discharge)
• Cystitis→ Pyelonephritis→ Renal failure
• Obstructive uropathy→ Hydroureter→, Hydronephrosis, Incarcination

 

Complication of Vaginal Hysterectomy:

• During Operation:
  • Primary Haemorrhage
  • Injury to bladder and rectum
  • Anesthetic− cardiac arrest
  • Post-operative:
    • Early-
      • Secondary Haemorrhage
      • Reactionary Haemorrhage (Within 24 hours)
      • Vault hematoma− Abscess cystitis
      • Late
        • Vault granuloma (excess healing)
        • vault prolapse
        • Dyspareunia (if very tight pack)
        • Pregnancy related Complication: See guide