Genital Prolapse
Definition:
When the genital organ descends from its normal position through the vagina is called genital prolapse.
Classification:
- Vaginal Prolapse
a) Anterior wall
- Upper (cystocele)
- Lower (Urethrocele)
b) Posterior wall
- Upper (Enterocele in Pouch of Douglas with or without intestine)
- Lower ( Rectocele)
- Prolapse of perineal body
- Uterine Prolapse: 10, 20, 30
Complaints
- Something coming out through vagina
- History of retention of urine which is overcome by manual reposition
- History of constipation
- Menopause for 4 years
- Duration of marriage 31 years
- Para: 4+2 abortion
- Age of last child – 15 years
Patient’s Profile:
- Age: Late reproductive age
- Parity: Multipara
- H/O: Difficult/ obstructed labor
Symptoms
- Something coming out through per vagina/ Fullness within the vagina
- Lower abdominal dragging pain during walking, working
- Frequency of micturition (Cystitis more common)
- Excessive whitish discharge (due to venous congestion)
- Decubitus ulcer in dependent part due to ischemia. (Rx by reposition)
- Keratinization
- 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
- Early-