2. Genital support
I. Cervical ligaments (Main uterine support)
1. Cardinal: from supravaginal cervix & vaginal vault to
lateral pelvic wall
2. Uterosacral: to 3rd piece of the sacrum.
3. Pubocervical, pubourethral, puborectal ligaments: to
back of s. pubis
II. Pelvic floor muscles:
Mainly levator ani, iliococcygeus
III. Anteveresion of the uterus:
Longitudinal axis of the uterus is perpendicular to that of
the vagina Aboubakr Elnashar
3. a horizontal vaginal axis: The vaginal lies in a nearly
horizontal axis when the woman is standing. Hence
any intra-abdominal downward force will appose the
vagina on the pelvic floor muscles preventing
descent. This is aided by fascial and ligamentous
support around the vagina which hold it in place. This
support is divided into three levels:
a. upper vagina (vault) is supported by uterosacral and cardinal
ligaments,
b. middle vagina is supported by levator ani muscles via fascial
attachments to the arcus tendineus (“white line”), and
c. lower vagina (introitus) is supported by urogenital diaphragm
via pubourethral and pubocervical ligaments and posteriorly to
the perineal body.
Aboubakr Elnashar
8. DEFINITION
Prolapse: from the Latin prolapsus, a slipping
forth
falling or slipping out of place of a part or viscus.
Pelvic organ prolapse:
descent of the pelvic organs into the vagina, often
accompanied by urinary, bowel, sexual, or local
pelvic symptoms.
pelvic relaxation due to a disorder of pelvic
support structures that is, the endopelvic fascia
downward decent of uterus &/or vagina
Procidentia: from Latin procidere - to fall
Procidentia: third degree uterine prolapse.Aboubakr Elnashar
9. Incidence
Difficult to determine {many women do not seek
medical advice}.
half of parous women lose pelvic floor support,
resulting in some degree of prolapse, and that of
these women 1020% seek medical care.
The chance of a woman having a prolapse
increases with age. Therefore, the incidence of
prolapse will rise as life expectancy increases.
Aboubakr Elnashar
10. Causes and contributing factors
Congenital: nulliparous (virginal)
Bladder exstrophy
Collagen defects (type IV EhlersDanlos syndrome,
Marfan syndrome)
Race (white people have a higher risk)
Anatomy (congenitally short vagina)
Childbirth
Sucessive vaginal deliveries
Straining during 1st stage of labor
Forceps before full cevical dilatation
Prolonged 2nd stage of labor
•Trauma
Denervation
Aboubakr Elnashar
11. Raised intraabdominal pressure
Chronic obstructive airway disease
Straining, constipation, heavy lifting
Post menopause
Oestrogen deficiency: atrophy of cervical ligaments
Iatrogenic
Pelvic surgery (hysterectomy, colposuspension,
sacrospinous fixation)
Aboubakr Elnashar
12. TYPES
Vaginal
Anterior:
Cystocele: upper part containing
base of the bladder
Urethrocele: lower part containing
urethtera
Posterior:
Enterocele: upper part containing
peritoneum of D.P & loops of
intestine
Rectocele: lower part containing
aterior rectal wall
Vault: prolapse of upper vagina
after hysterectomy
Uterine:
First degree: external
os below ischial
spines but not
outside the vulva
Second degree:
cervix but not the
whole uterus
protrudes from the
vulva
Third degree:
complete
procidentia: whole
protrudes from the
vulvaAboubakr Elnashar
22. Pelvic Organ Prolapse Quantification (POPQ).
Diagram of reference points used in POPQ
measurements. Aa is the distance of 3 cm from
the anterior vaginal wall to the hymen.
Aboubakr Elnashar
23. Line and grid representation of
measurements obtained using POPQ.
Aboubakr Elnashar
24. The vagina
• Thickend wall: oedma
& congesion
• Keratinization:
exposure
• Trophic ulcer:
congestion, friction,
menopausal atrophy
The cervix
1. Hypertophy: congestion,
chronic cervicitis
2. Trophic ulcers
3. Elongation of supravaginal
cervix: in vagino uterine
prolapse: vagina descend: pulls
the cervix: supravaginal part
attached to the stronger upper
part of the cardinal ligament
resists
Pathological changes
Aboubakr Elnashar
25. Symptoms
often asymptomatic & clinical examination may not
necessarily correlate with symptoms.
Symptoms are often related to the site and type
Symptoms common to all types of prolapse are a feeling
of dragging, or a lump in the vagina, or something
coming down.
1. Urinary symptoms
Stress incontinence
Frequency (diurnal and nocturnal)
Urgency and urge incontinence
Hesitancy
Poor or prolonged urinary stream
Feeling of incomplete emptying
Manual reduction to start or complete emptying
Positional changes to start or complete emptyingAboubakr Elnashar
26. 2. Bowel symptoms
Difficulty in defecation
Incontinence of flatus, liquid stool, or solid stool
Urgency of defecation
Digitation or splinting of vagina, perineum, or anus to
complete defecation
Feeling of incomplete evacuation
Rectal protrusion during or after defecation (rectal
prolapse)
Aboubakr Elnashar
27. 3. Sexual symptoms
Inability to have or infrequent coitus
Dyspareunia
Lack of satisfaction or orgasm
Incontinence during sexual activity
Aboubakr Elnashar
28. 4. local symptoms
a. Feeling of pressure or heaviness in the vagina
b. Pain in the vagina or perineum
c. Sensation or awareness of protrusion from the
vagina
d. Low back pain, which is eased with lying down
e. Abdominal pressure or pain
f. Blood stained and purulent discharge
Aboubakr Elnashar
29. Signs
I. General:
1. Exclude anaemia
2. Chest: chronic bonchitis
II. Abdominal:
1. Renal angle: hydronephrosis or tenderness
2. Nulliparous prolapse: Spina bifida,
visceroptosis, hernia
Aboubakr Elnashar
30. III. Pelvic:
• Inspection & digital palpation:
a. Old perineal tear
b. Prolapsed structures: type of prolapse, degree
of uterine prolapse, changes in vagina &
cervix.
c. Stress incotinence
d. Tone of levator ani: 2 fingers in the vagina &
the thumb on the perineum while the patient is
asked to contract the muscles
e. Enterocele: impulse on cough & gurgling
sensation
Aboubakr Elnashar
31. 2. Bimanual Examination
Size & position of uterus & adenxa
3. Speculum Examination:
Cervical lesion
4. Sounding:
Detect supravaginal elongation of the cervix
5. P.R.:
In enterocele the rectum is not forming part of the
prolapse
Position: left lateral or standing position—with a Sims'
speculum, inserting it along the posterior vaginal
wall to assess the anterior wall and vault and vice versa.
Uterine descent can be assessed by traction with a
single toothed vulsellum.
Aboubakr Elnashar
32. D.D
Cystocele
1. Gartner cyst:
anterolateral in
vagina,
incomperessible,
catheter: normal
uretheral direction
2. Uretheral
diverticulum:
pressure on the
mass, urine from
external meatus
Rectocele
1. Dermoid cyst:
incompressible,
PR: rectum not
mass
2. Enterocele: arises
from upper part of
the posterior
vaginal wall,
gurgling & impulse
on cough, PR:
rectum not part of
mass, PR+PV: on
straining the
rectum is pushed
back
2nd & 3rd uterine
prolapse
1. Congenital
elongation of
portio-vaginalis:
vaginal vault is at
its normal level,
deep fornices
2. Fibroid polyp,
Chronic
inversion: absent
external os
Aboubakr Elnashar
33. 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
Aboubakr Elnashar
34. 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, Pureperium & Lactation
When Operation is Unsafe due to Extreme
Senility/Debility and Diseases
Preoperatively
For therapeutic test
Aboubakr Elnashar
35. SURGICAL TREATMENT: -
RECONSTRUCTIVE SURGERY is invariably needed
and has to be a COMBINATION OF PROCEDURES
to correct the multiple defects.
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.
Aboubakr Elnashar
36. 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
Aboubakr Elnashar
37. VAGINAL OPERATIONS FOR
PROLAPSE
Anterior colporrhaphy
Posterior colporrhapry- High / Low
Enterocele repair
Perineorrhaphy
Amputation of cervix
Paravaginal repair
Hysterectomy with or without
Colporrhaphy / Perineorrhaphy
Aboubakr Elnashar
38. 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 ?
Aboubakr Elnashar
39. 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
Aboubakr Elnashar
40. 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
Aboubakr Elnashar
41. Perineorrhaphy
Not an Operation for prolapse, but Indicated
only for associated old 2nd degree perineal
tear
Performed along with post. 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
Aboubakr Elnashar
42. 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.Aboubakr Elnashar
43. 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
Aboubakr Elnashar
44. 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
Aboubakr Elnashar
45. 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
Aboubakr Elnashar
46. ABDOMINAL OPERATIONS
FOR PROLAPSE
Sling operations
Closure or repair of enterocele
Sacrocolpopexy
Anterior Colpopexy
Colposuspension
Paravaginal repair
Aboubakr Elnashar
47. Abdominal Sling operations
Indicated when the ligaments are extremely weak as
in nulipara & 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.
Aboubakr Elnashar
48. 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.
Aboubakr Elnashar
49. Shirodkar’s sling
Tape is fixed to the post. Aspect of isthmus &
sacral promontory
Anatomically most correct but difficult to
perform
Risks of complication
Aboubakr Elnashar
50. Purandare’s cervicopexy
Tape is anchored to the ant.aspect of isthmus
and ant. abd. Wall
Easy to perform
Dynamic support
Aboubakr Elnashar
51. 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
Aboubakr Elnashar
52. 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
Aboubakr Elnashar
53. 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.Aboubakr Elnashar
54. 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
Aboubakr Elnashar
55. 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.
Aboubakr Elnashar
56. Vault / Colposuspension
Vault is fixed to the abdominal wall by a facial
strip or merseline tape
Aboubakr Elnashar
57. 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
Aboubakr Elnashar
59. 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
Aboubakr Elnashar
61. 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
Aboubakr Elnashar
62. 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
Aboubakr Elnashar
64. 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
Aboubakr Elnashar