uterine prolapse management

UTERINE PROLAPSEMANAGEMENT

VISHNU AMBAREESH M S

PREVENTION

Genital prolapse is a preventable disease 1)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 .

2) Avoiding and treating factors which increase the intra-abdominal pressure such as obesity , smoking, chronic cough and chronic constipation

3) Prevention of postmenopausal atrophy of pelvic support by balanced diet, exercise, calcium & by the increased use of HRT.

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

MANAGEMENT

Choice of method - depends on the followings: Age, fitness and wish of the paitent Parity and wish for further pregnancy.

General measures : • Treatment of urinary tract infection.• Avoiding and treating factors which increase the intra-abdominal

pressure such as smoking, obesity, chronic cough and chronic constipation .

• Use of HRT in menopausal patients .• Reducing the procidentia and treatment of ulceration with oestrogen

cream. The ulcer will usually heal within 7 days .

• Mainly surgical

• Conservative management

CONSERVATIVE MANAGEMENT limited role…» PELVIC FLOOR REHABILITATION (pelvic muscle

exercises, galvanic stimulation, physiotherapy, rest in the purperium).

» HORMONE REPLACEMENT, both systemic and local.» PESSARIES

Pelvic floor training

• progressive resistive exercises for the pelvic floor that are often titled Kegel exercises.

• improve urethral resistance and pelvic visceral support by increasing the voluntary periurethral muscles

• enhance the voluntary closing mechanisms.

OTHER METHODS

• Ben Wa balls, also known as Burmese bells, Benoît balls, Venus balls or Geisha balls

• Vaginal Cones

• Colpexin Sphere

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 .• Types :– SUPPORT - eg. Ring pessary – commonly used

pessary. – SPACE FILLLING pessary – eg. Gelhorn & cube

• Side effects:– Vaginal infection and discharge – Vaginal ulceration and bleeding

• Precautions - to minimize 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 .

SURGICAL MANAGEMENT

RECONSTRUCTIVE SURGERY is invariably needed and has to be a COMBINATION OF PROCEDURES to correct the multiple defects

MOST COMMONLY PERFORMED VAGINAL HYSTERECTOMY WITH

PELVIC FLOOR REPAIR

Route of surgery is mostly vaginal …. also tried are abdominal & laproscopic

Surgical repair may be directed to 1. Anterior2. Middle or apical 3. Posterior compartment

ANTERIOR COMPARTMENT

• USUALLY CYSTOCELES• usual defect is a midline defect or anterior

cystocoele ( defect in the fibromuscular layer of the vagina – ANTERIOR COLPORRHAPHY

• Lateral cystocele or paravaginal defect due to vagina detaching from the arcus tendinous fascia – PARAVAGINAL REPAIR

ANTERIOR COLPORRHAPHY

• Traction is given on the cervix to expose the ant. Vaginal wall

• An inverted T shaped incision is made in the anterior vaginal wall starting with a transverse incision in the bladder sulcus and through its midpoint a vertical incision extended up to the urethral opening

• The vaginal walls are reflected to either side to expose the bladder and vesicovaginal fascia

• The overlying vesicovaginal fascia is tightened, and the excess vaginal wall is excised to correct the laxity, and vaginal wall sutured

PARAVAGINAL REPAIR• Method to correct a lateral defect or lateral

cystocele• Adbominal method involves entering the

retropubic space and approximating the detached vagina to the arcus tendinous fascia

Posterior compartment

POSTERIOR COLPORRAPHY & COLPOPERINEORRHAPHY• Done to correct a rectocele and repair a

deficient perineum• Lax vagina over the rectocele is excised, and

rectovaginal fascia repaired after reducing the rectocele

• Approximate the medial fibres of levator ani • Usually combined with a perineorraphy if

there is defective perineal body.

Middle or apical compartment

The apical defects can be of three types:• Uterine prolapse• Enterocele • Vault prolapse following hysterectomy

Vaginal route is usually preferred.

VAGINAL HYSTERECTOMY WITH PELVIC FLOOR REPAIR( WARD-MAYO REPAIR )

• Commonest operation performed in cases of uterovaginal prolapse in cases where childbearing is complete

• usually combinedd with repair of an associated cystocele, enterocele and rectocele

SACROSPINOUS COLPOPEXY• in cases of procidentia with complete vaginal

eversion and in cases of vault prolapse• Vault of vagina is attached to the sacrospinous

ligamentAcess via the retrovaginal spacce upto the

ischialspine

LEFORT’S REPAIR OR COLPOCLEISIS• Obliterative procedure• Very rarely employed • Only in elderly women with meddical

problems making them unfit for repair operation

Vaginal epithelium is removed followed by suturing of the anterior and posterior walls of vagina therby obliterating the vagina.

MANCHESTER OR FOTHERGILL’S OPERATION• Not much used • Useful in women who have completed their

families but wish to retain their uterus• Option in lesser degrees of uterovaginal

prolapse with supravaginal elongation of cervix.

• Recurrence more likely

• Procedure consists of anterior colporrhaphy,isolation and ligation of the cardinal ligaments, amputation of the cervix,suturing the cardinal ligaments to the front of the cervix( fothergill’s stitch) and finally reforrming the lips of the cerrvvix using the vagina(sturmdorf’s sutures)

• Best for young women who have completed their families.

SHIRODHKAR’S EXTENDED MANCHESTER OR VAGINAL SLING OPERATION

• Modification of fothergill’s• Cervical amputation is avoided• Here uterosacral ligaments are isolated to

form slings which are crossed and stitched together in in front of the cervix.

USE OF MESHIncreasingly used in repeat surgerypurpose is to completely replace the patient’s

own weak tissues Can be used while performing an ant or post

colporraphyMain problem is mesh erosion

ENTEROCELE• Must be looked for and corrected along with

with any repair procedure• Important to do a prophylactic procedure

following hysterectomy even if no obvious defect, as most enteroceles occur follows hystrectomy.

VAGINAL CORRECTION• CUL-DE-SAC is opened & peritoneum

dissected at its highest point• Then peritoneal sac is ligated at its highest

point and peritoneum excised• Defect closed by approximating the

uterosacral ligaments in the midline• “McCall culdoplasty”

ABDOMINAL CORRECTION• Vaginal vault after hysterectomy can be

suspended to the uterosacral ligaments on either side to prevent an enterocele…

• Other procedures1. Halban2. Moscowitz procedures