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Pelvic organ prolapse gynaecology ppt

genital prolapse uterine prolapse cystocele rectocele urethrocele anterior middle posterior compartments management sacroclopopexy ward mayos repair fothergills repair urogynaecology vaginal hysterectomy perineorrhaphy anterior colpopexy mesh repair khannas sling procedure pessaries

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Pelvic organ prolapse gynaecology ppt

  1. 1. Pelvic organ prolapse
  2. 2. GENITAL PROLAPSE • Common complaint of elderly woman • Mostly in post menopausal and multiparous women • In prolapse straining causes protrusion of vaginal walls at vaginal orifices • Extreme cases uterus may be protrude
  3. 3. Normal axis Axis of the uterus and vagina: anteverted and anteflexed
  4. 4. PELVIC SUPPORTS • PELVIC FLOOR • Comprises Pelvic diaphragm Endopelvic fascia Perineal membrane Perineal body
  6. 6. Pelvic diaphragm
  7. 7. Perineal membrane
  8. 8. Uterine ligaments
  10. 10. • The pelvic structures are divided into 3 compartments : • Anterior : urethra /bladder • Middle : uterus/vault • Posterior : rectum/anus
  11. 11. Levels of support of uterus DeLancey's three levels of support • 3 levels
  12. 12. Level 1 (suspensory axis) • Level I- Uterosacral and cardinal ligaments • support the uterus and vaginal vault.
  13. 13. • Round ligament • (mackenrodts lig / transverse/lateral cevical cervical ligament at the base of broad lig with uterine A & V
  14. 14. • Defects in level 1 • Uterovaginal UV prolapse • Enterocele • Vault prolapse
  15. 15. Level 2 (attachment axis) • Level II- Pelvic fascias and paracolpos • Fascial septae connects mid vagina to the pelvic sidewalls • Anteriorly • Pubocervical • Posteriorly • Rectovaginal facia • which connects the vagina to the white line on the lateral pelvic wall through arcus tendinous
  16. 16. Level II and III detail. In level III, the vagina is fused to the medial surface of the levator ani muscles, urethra, and perineal body. The anterior surface of the vagina at its attachment to the arcus tendineus fascia pelvis forms the pubocervical fascia, while the posterior surface forms the rectovaginal fascia.
  17. 17. Defects in level2 • Paravaginal & para rectal defects
  18. 18. Level 3 (fusion axis ) • Level III-Levator ani muscle • supports the lower one-third of vagina. • Anteriorly • Urethra • Urogenital diaphragm • Pubis • laterally • Levator ani fascia • Posteriorly • Perineal body
  19. 19. Etiology • Menopause • birth injury • Prolonged bearing down in the second stage • Delivery of a big baby • Rapid succession of pregnancies • Lack of rest in peuperium • Peripheral nerve injury • raised intra-abdominal pressure • Surgeries • Congenital
  20. 20. Etiology • Menopause • prolapse are of menopausal age when the pelvic floor muscles • d/t oestrogen deficiency and decreased collagen content in fascias atonicity and asthenia that follow menopause
  21. 21. Causes related to child birth • Birth injury excessive stretching of the pelvic floor muscles and ligaments overstretching causes atonicity Perineal tear is less harmful than overstretching whereas torn muscle could be stitched or toned up
  22. 22. Causes related to child birth • Peripheral nerve injury such as pudendal nerve during childbirth • Delivery by untrained dais • This is because the patients are made to bear down before full dilatation of the cervix and when the bladder is not empty • Prolonged bearing down in the second stage • Lacerations of the perineal body during childbirth, unless sutured immediately, will widen the hiatus urogenitalis
  23. 23. Causes related to child birth • Delivery of a big baby • Lack of rest in peurperium • Lack of any pelvic exercises • Rapid succession of pregnancies
  24. 24. Raised intra abdominal pressure • chronic bronchitis, • large abdominal tumours or • obesity • Smoking, • chronic cough and • constipation
  25. 25. Prolapse in unmarried or nulliparous women • spina bifida occulta and • split pelvis • Collagen vascular diseases
  26. 26. congenital weakness of the pelvic floor muscles • in unmarried or nulliparous women • h/o precipitate labour • Family h/o uterine prolapse
  27. 27. Surgeries • Abdominoperineal excision of the rectum and • radical vulvectomy • Operations for stress incontinence such as Stamey and Pereyra operations
  28. 28. Classification of prolapse Upper two-third- Cystocele Lower one-third- Urethrocele Anterior vaginal wall(anterior compartment) Uterine descent Middle compartment Upper one-third- Enterocele (pouch of Douglas hernia) Lower two-third- Rectocele Posterior compartment
  29. 29. Cystocele the vesical and vaginal fasciae are thinned out and fail to support the bladder, so that the bladder prolapses with the anterior vaginal wall.
  30. 30. Urethrocele When the urethra along with the lower one-third of the anterior wall prolapses (failure of pubocervical ligament Rare stress incontinence
  31. 31. Uterine prolapse
  32. 32. Uterine descent
  33. 33. • Uterine descent • - Descent of the cervix into the vagina • - Descent of the cervix up to the introitus • - Descent of the cervix outside the introitus • -Procidentia-All of the uterus outside the introitus
  34. 34. Symptoms • something protruding either at the vulva or externally • aggravated by straining and coughing, and by heavy work • reduces itself when she lies down • large prolapse, the external swelling  difficulty in walking or carrying out her everyday duties
  35. 35. Symptoms • Backache • uterosacral strain • Towards evening • relieved by rest
  36. 36. decubitus ulcer • benign and is present on dependant part. • d/t venous stasis  tissue anoxia. • treated by • keeping the prolapse reduced, which will restore circulation and help in healing. Prolapse can be kept in reduced position by packing.
  37. 37. micturition disturbances • imperfect control of micturition • Frequency of micturition • (diurnal or nocturnal) • (d/t chronic cystitis & incomplete emptying of the bladder) • Manual reduction of the cystocele into the vagina with their fingers • Straining to pass urine • Stress incontinence
  38. 38. • Ureteric obstruction and hydronephrosis } severe massive prolapse
  39. 39. Bowel symptoms • Urgency • Straining • Feeling of incomplete emptying • Pressure on vagina or perineum to start or complete defaecation
  40. 40. Discharge per vaginum • Mild vaginitis • Chronically inflamed lacerated cervix • Decubitus ulcer – discharge and bleeding
  41. 41. Coital difficulties • With third degree uterine prolapse and procidentia prevents penetration and orgasm due to a lax outlet.
  42. 42. Signs • Assessment of prolapse • In lithotomy position • Look for stress incontinence on a full bladder • patient is asked to strain / perform valsalva manoeuvre • Stress incontinence • Vulva examined for perineal laceration • Three compartments evaluated separately; • decubitus ulcer
  43. 43. Per speculum examination Anterior compartment • Sim’s speculum retracting posterior vaginal wall • Look for cystocele • Lateral cystocele or paravaginal defect • Urethrocele } stress incontinence Middle compartment • Degree of descent • Ulceration of cervix • Vagina may show keratinisation • Vaginal examination – length of cervix,position and mobility of uterus,any adnexal mass • Cervical cytology Posterior compartment • Sim’s speculum retracting anterior vaginal wall • Enterocele – bulge appears from above downwards • Rectal examination – impulse on • tip of finger- enterocele • pulp - rectocele • Bimanual examination-r/ o pelvic mass
  44. 44. Pelvic floor muscles • Pubococcygeus part of levator ani assessed at 4 and 8o’clock position • Perineal body • Rectal examination – tone of anal sphincter
  45. 45. Lab investigations • Hb • Urine examination,Urine culture,Xray,ECG • High vaginal swab in cases of vaginitis • RFT in long standing prolapse • Urodynamic investigations in case of incontinence • USG to r/o pelvic mass and hydronephrosis • IVP }massive prolapse • CT/MRI}
  46. 46. Differential diagnosis • Vulval cyst or tumour • Cysts of anterior vaginal wall • Urethral diverticula • Congenital elongation of cervix • vaginal portion of the cervix is elongated and • no vaginal prolapse. • deep fornices • Cervical fibroid polyp • Chronic inversion
  47. 47. COMPLICATIONS OF PROLAPSE • Kinking of ureter with resulting renal damage • Surgical injury to ureter • Urinary tract infection (chronic) in large cystocele with residual urine • decubitus ulcer and keratinisation pigmentation • if ring pessary is left in over a long period malignancy
  48. 48. Prophylaxis  Antenatal physiotherapy ,relaxation exercises,due attention to weight gain and anaemia  Proper supervision and management of second stage of labour  A generous episiotomy  Low forceps delivery if there is delay in second stage  Suture perineal tear  Postnatal exercises and physiotherapy  early postnatal ambulation  Adequate spacing of births  Avoid multiparity  Prophylatic HRT in postmenopausal women
  49. 49. Treatment • Surgical } • in women over 40 • C/I in pregnancy • Conservative management • mechanical devices and • pelvic floor muscle exercises ,abdominal massage, • in mild degrees of prolapse, • surgery not desired by patient , • in whom child bearing is not complete • Should be advised 3 to 4 months following delivery • Surgery Pregnancy – contraindication for surgery
  50. 50. Pessaries • Indications A young woman planning a pregnancy During early pregnancy (<18 weeks) Puerperium Temporary use while clearing infection and decubitus ulcer A woman unfit for surgery In case a woman refuses for surgery
  51. 51. pessaries Support Space filling eg:ring pessary stage 1 and 2 prolapse eg:gelhorn and cube pessaries for advanced stages soft plastic polyvinyl chloride material
  52. 52. Limitations • Never curative only palliative • Vaginitis • Needs to be changed every 3 months • Dyspareunia • Expulsion (if vaginal orifice is very patulous) • May cause ulcer,rarely Ca vagina and a vesico vaginal fistula • Does not cure urinary stress incontinence
  53. 53. SURGICAL APPROACHES • Ward-Mayo’s operation-vaginal hysterectomy with pelvic floor repair with or without: sacrospinous colpopexy –vault suspended from sacrospinous ligament • Fothergill’s or Manchester operation –uterus preserved and part of cervix is cut • Shirodkar’s Extended Manchester operation-both cervix and uterus preserved • Le Fort’s operation –obliterative procedure of anterior and posterior walls of vagina
  54. 54. Anterior colporrhaphy
  55. 55. Anterior colporrhaphy • performed to repair a cystocele and cystourethrocele
  56. 56. Anterior colporrhaphy • TOC for anterior cystocele • Procedure Lithotomy position Area cleansed and draped Bladder emptied Sim’s speculum introduced Anterior lip of cervix pulled down using volsellum forceps
  57. 57. Inverted T-shaped incision on anterior vaginal wall Vaginal flaps seperated from bladder Vesicocervical ligament boldly cut,bladder pushed up Bladder buttressing with delayed absorbable sutures In large defects, plication in two layers Excess vaginal mucosa trimmed and closed Bladder drained
  58. 58. • Complications Infection, bleeding, injury, recurrence, failure • Aftercare Avoid lifting weights, coughing, sneezing, straining at stools, sexual intercourse
  59. 59. • Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant. • Metal catheter is introduced to know the lower limit of bladder. • Inverted T incision made to anterior vaginal wall. • Horizontal incision is made below the bladder and • vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below the external urethral meatus. • The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection. • The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted laterally. • The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.
  60. 60. • The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side. • The cut margins of the vagina are apposed by interrupted sutures with No 'O' chromic catgut using cutting needle. • The catheter is reintroduced once more to be sure that the bladder is not injured. • Toileting of the vagina is done. • Vagina is tight packed with roller gauze smeared with antiseptic cream. • A self retaining catheter is introduced
  61. 61. Paravaginal repair • To correct lateral cystocele • Done abdominally, vaginally or laparoscopically • Repairing abdominally Involves entering retropubic space till arcus tendinous fascia pelvis seen  lateral vagina raised to arcus tendinous fascia Both are approximated with interrupted sutures
  62. 62. WARD-MAYO REPAIR • Commonest operation in case of utero vaginal prolapse in cases where child bearing is complete • Indication • In an elderly women who has completed her family
  63. 63. WARD-MAYO REPAIR • Vaginal hysterectomy + pelvic floor repair ± sacrospinous colpopexy • Combined with cystocele,enterocele or rectocele repair Cystocele-ant.colporrhaphy(AC) Enterocele-Mc Call’s culdoplasty Rectocele-posterior colporrhaphy(PC)
  64. 64. WARD-MAYO REPAIR VH PFR • anterior colporrhaphy and • colpoperineorrhaphy Sacrospinous colpopexy • procidentia with complete vaginal eversion • Vault prolapse.
  65. 65. Vaginal hysterectomy A circular incision is made over the cervix below the bladder sulcus, and the vaginal mucosa dissected off the cervix all around.
  66. 66. To proceed as that of anterior colporraphy up to pushing up of bladder the UV fold of peritoneum incised The cervical incision is extended posteriorly along the cervicovaginal junction and the pouch of douglas is opened Uterus is delivered anteriorly First clamp on utero sacral and cardinal ligaments,tissues cut and ligated on both sides Second clamp involves uterinevessels which are cut and ligated Third clamp on round ligament,fallopian tube and ovarian ligament which are cut and ligated
  67. 67. Uterus removed Peritoniumclosed by purse string suture enterocele correction done by McCall’s culdoplasty Anterior colporrhaphy is completed Posterior colpoperineorrhaphy performed if there is rectocele.
  68. 68. SACROSPINOUS COLPOPEXY • Apical suspension procedure in  procidentia with complete vaginal eversion  Vault prolapse • Sacrospinous ligament is used to suspend the vault,by an approach through rectovaginal space
  69. 69. Abdominal sacrocolpopexy • Abdominal method of apical suspension • Used in Vault prolapse mainly • A mesh in the form of Y is used
  70. 70. • Long arm y  anterior longitudinal ligament of sacrum @ sacral promontory • Short arms  anterior & posterior vagina
  71. 71. Manchester/Fothergill’s operation • In a women who has completed her family • With lesser degrees of uterovaginal prolapse with supra vaginal elongation of cervix • but wishes to retain the uterus and opts for a vaginal procedure • it can be combined with AC , PC or enterocele repair
  72. 72. Manchester/Fothergill’s operation Dilatation of cervix Anterior colporrhaphy Isolation and ligation of cardinal ligaments Amputation of cervix Suturing the cardinal ligaments to the front of cervix Reforming the lips of cervix using the vagina
  73. 73. The patient is placed in the dorsal lithotomy position. Thorough examination of the pelvis is performed. The bladder is not catheterized because it can be identified and dissected with greater safety when partially filled than when empty.
  74. 74. Dilation & cuerettage
  75. 75. The labia may be tacked to the perineum for retraction if they are redundant. A Jacobs tenaculum is placed on the anterior lip of the cervix. Downward traction on the cervix exposes the junction of the vagina and cervix where a 360° circumcision incision is made. The bladder is sharply and bluntly dissected off the lower uterine segment up to the vesicouterine fold
  76. 76. A right-angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. This is picked up and opened.
  77. 77. The anterior cul-de-sac is opened, a finger is inserted, and the fundus and adnexa are explored.
  78. 78. A right-angle Heaney retractor is placed in the anterior cul-de-sac, allowing elevation of the bladder and ureter. The cervix is rotated anteriorly, and the posterior cul-de-sac is exposed. The peritoneum of the posterior cul-de-sac is picked up and opened. The posterior cul-de-sac is opened. A finger may be inserted into the cul-de-sac, and the uterus and adnexa explored.
  79. 79. the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament- >through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.
  80. 80. Both Mackenrodt's ligaments have now been ligated and the cervix almost completely amputated. A vulsellum is attached to the anterior lip of the cervix above the amputation
  81. 81. A covering for the posterior lip of the cervix has been fashioned from the mobilized vaginal skin of the posterior fornix and this has been secured to the new cervix by deep sutures. Fothergill's stitch is illustrated and it should be noticed that it passes through vaginal skin in the region of Fothergill's lateral point, through Mackenrodt's ligament and through the anterior lip of the cervix into the cervical canal, and thence out to the other side and through Mackenrodt's ligament and vaginal sk
  82. 82. Shirodkar’s Extended Manchester operation • Shirodkar’s Extended Manchester operation- in a women who wants to conceive • Vaginal sling operation • Uterus and cervix are preserved • Strenghthening of uterosacral ligaments • Best for women with strong uterosacrals
  83. 83. STEPS.. AC done Vaginal incision extended posteriorly around the cervix The pouch oh Douglas is then opened The uterosacral ligaments identified and divided close to cervix They are isolated to form slings They are crossed and stitched together infront of the cervix
  84. 84. Le Fort’s operation • Le Fort’s operation In very elderly women who is medically unfit for a repair procedure and not desirous of vaginal intercourse. • Colpocleisis • Obliterative procedure • Total colpocleisis-total obliteration of cavity • Partial colpocleisis-some part of vaginal epithelium is left unsutured to provide drainage tract ,useful in women with uterus to drain cervical secretions
  85. 85. Le Fort’s operation Vaginal epithelium is removed Suturing of anterior and posterior wall of the denuded vagina
  86. 86. • Repairing vaginally More difficult More risk of hemorrhage If a paravaginal defect is present,retropubic space can be reached readily vaginally 4-6 permanent sutures between arcus tendineus and lateral edge of fibromuscular layer
  87. 87. POSTERIOR COMPARTMENT • Posterior colporrhaphy to correct rectocele
  88. 88. Posterior colporrhaphy • Procedure Pair of Allis forceps at lower end of labium minus and a third one on posterior vaginal wall above rectocele Incision put joining first two forceps Vaginal mucosa dissected from prerectal fascia(Denonvillier’s fascia) upto third forceps Vertical incision put from middle of this incision to the apex
  89. 89. Prerectal fascia approximated in the midline with delayed absorbable sutures If defect identified, better to do a defect repair Usually anterior plication of pubococcygeus part of levator ani also performed across the rectum Then vaginal mucosa trimmed and closed Combined with perineorrhaphy when defective perineal body Superficial perineal muscles are plicated in the midline and skin closed
  90. 90. Mesh repair In repeat sx Replace patients own weak tissue • 4 types • Type 1 monofilament mesh preferred(pore size >75 micrometre) • Mesh of choice : Monofilament macroporous light weight polypropylene mesh (eg : Gynemesh) • Main problem with use of mesh is mesh erosion
  91. 91. Postoperative care • Parental fluids until bowel sounds return. • Early oral fluids are now advocated. • Antibiotics, sedatives, metronidazole for 24 hours IV. • Indwelling catheter for 48 hours. • Vaginal pack for 28 hours. • Early ambulation • DVT prophylaxis
  92. 92. Mc call culdoplasty for enterocele repair
  93. 93. VAULT PROLAPSE Enterocele Secondary vault prolapse
  94. 94. ENTEROCELE • Herniation of upper third of posterior vaginal wall • Contain omentum or even loop of small bowel • Always look for and correct during prolapse repair • Prophylactic correction during vaginal or abdominal hyterectomy
  95. 95. MANAGEMENT • VAGINAL CORRECTION • STEPS  Inverted T shaped incision Dissect and expose sac Sac opened and contents pushed away Peritoneum dissected and excised Purse string suture – neck of the sac Cervix pulled up ,interrupted suture around uterosaral ligaments
  96. 96. • VAGINAL CORRECTION OF POST HYSTERECTOMY ENTEROCELE • Uterus absent • internal Mc call suture • ABDOMINAL CORRECTION • Vaginal vault – suspend to uterosacral ligament • Other procedure  HALBAN PROCEDURE MOSCOWITZ PROCEDURE
  97. 97. SECONDARY VAULT PROLAPSE  Prolapse of vaginal vault following hysterectomy  Due to failure to recognise and correct – enterocele- during hyserectomy  Can be Vaginal eversion – vault suspension Cystocele Anterior and posterior Rectocele colporrhaphy
  98. 98. MANAGEMENT  Vaginal approach Sacrospinous colpopexy + anterior and posterior colporrhaphy Preferred in old and less healthy women • Abdominal approach Sacrocolpopexy + Halban procedure Preffered in young women bcoz resultant vagina is longer
  99. 99. NULLIPAROUS PROLAPSE • More likely to have spina bifida or connective tissue disorder • Uterine +vaginal prolapse , may include complete vaginal inversion • Mesh required for repair • Following repair- aviod vaginal delivery – perform elective caesarean section
  100. 100. MANAGEMENT • Abdominal sacrohysteropexy • Teflon or mersilene mesh • Purander’s sling operation or cervicopexy • Shirodkar’s sling operation • Khanna’s posterior sling