4.Management of pelvic organ prolapse-Mathew john.ppt

Management of pelvis organ prolapse

1. Management of Pelvic Organ Management of Pelvic Organ
ProlapseProlapse

2. What is the problem?
Boat in the Dock analogy!Boat in the Dock analogy!
Pelvic organs : Boat
Levator muscles : Water
Endopelvic fascial ligaments :Moorings
PROBLEM!PROBLEM!

3. Treatment
options
Conservative Surgical

4. Treatment Guidelines
Choice of treatment :
Age of the patient
Desire to conserve the uterus
Menstrual function
General condition of the patient
Degree of pelvic organ prolapse

5. Conservative management
Kegel Exercise
Improve tone in pubococcygeus and other
muscles of the pelvic floor
Alternate contraction and relaxation

6. Conservative management

7. Conservative management
•Advanced Techniques : barbells, springs,
and rubber bulbs
Reference:http://www.nlm.nih.gov/medlineplus/ency/article/003975.html

8. Pessaries
Devices inserted intravaginally – symptomatic relief
Types:
Supportive
Ring
Gehrung
Lever
Space filling
Donut
Cube
Gellhorn
Reference: Rony A Adam, Te linde oper gyn,10th edition 2009 , pg936-941

9. Pessaries
Advantages
Non invasive (non surgical)
Indications
Elderly patients
Patients at high operative/anesthetic risk
Pregnant women with prolapse
May also treat incontinence (continence
pessaries)
Reference: Rony A Adam, Te linde oper gyn,2009 10
th
edition, pg936-941

10. Pessaries
Disadvantages
Requires constant handling
(removal/cleaning/replacement)
Risk for vaginal abrasion/ulceration/fistula
formation
Routine pelvic exams and topical estrogen cream
mandatory
Reference: Rony A Adam, Te linde oper gyn,2009 10th edition, pg936-941

11. Surgical management
Aims :
Relieve symptoms
(of POP, Urinary
tract, Bowel)
Restore anatomy
Restore sexual
function
Approaches:
Vaginal
Abdominal
Laparoscopic

12. Site Specific Repair
Anterior compartment defects
Anterior fascial repair
Paravaginal repair
Posterior compartment defects
Posterior fascial repair
Perineoplasty & Perineal body reconstruction

13. Restoratory Compensatory Obliterative
Ligament
fixations
Uterosacral
Illiococcygeus
Sacrospinous
Sacral
colpoplexy
Colpocleisis

14. Anterior Fascial Repair

15. Paravaginal Repair

16. Posterior fascial repair

17. Restorative procedures for apical
defects
Use native support structures to anchor
the vaginal vault
SACROSPINOUS SUSPENSION

18. Illiococcygeal
fixation

19. Compensatory Procedures
Add a graft for increased strength and
anchorage of the vaginal wall
Abdominal sacrocolpopexyAbdominal sacrocolpopexy Hysteropexy (Uterine sparing)Hysteropexy (Uterine sparing)

20. Obliterative Procedures
Principle: Closure of the vaginal lumen
Procedure: ColpocleisisColpocleisis

Indications:
Partial (Le Fort)
Total
Elderly menopausal
patients
Medical risks
Unfit for surgery
Reference: Thomas L Wheeler et al,Oster-Gardt uro-gyn,chapter 31,2008, pg 513-515

21. Le fort Operation
Alan S Evans,oper for
genital prolapse,Rob
& Smith oper surgery
4
th
edition pg103-105

22. Obliterative Procedures
Principle: Closure of the vaginal lumen
Procedure: ColpocleisisColpocleisis

Indications:
Partial (Le Fort)
Total
Reference: Thomas L Wheeler et al,Oster-Gardt uro-gyn,chapter 31, 2008, pg 513-515
Women whose
uterus has been
removed

23. Total colpocleisis

24. Manchester Fothergill procedure
Historical (though still done in some parts)
Indications:
Women in the reproductive age group who want to have
children
Steps
Anterior fascial repair
Cervical amputation
Mackenrodt ligament ligation
Perineal body reconstruction

25. Manchester Fothergill procedure
Advantages:
preservation of menstrual and child bearing function
Limitations
Impaired fertility
Incompetent cervical os
Abortions
Dystocias (due to fibrosis)-
Cervical stenosis
Reference:Kris Strohoben et al, Danforth’s ob& gyn,10
th

edition,2008 ,pg850-852

26. Manchester Fothergill procedure
Shirodkar’s modification:
no amputation of cervix is doneno amputation of cervix is done
Reference: Kris Strohoben et al, Danforth’s ob& gyn,10th
edition,2008,pg850-852

27. Abdominal Sling Operation
Indicated:
nulliparous women
when the ligaments are extremely weak
Preserves reproductive function.
Principle: With a fascial strip / prosthetic
material the cervix is fixed to the abdominal
wall / sacrum / pelvis.
Cystocele / Rectocele repair if needed can be done
vaginally before or after.

28. Abdominal Sling Operation
Types:
Shirodkar’s posterior sling.
Purandare’s anterior cervicopexy.
Khanna’s sling.
Virkud’s composite sling.
Joshi’s sling
Sacrocervicopexy
Abdominocervicopexy

29. Vaginal hysterectomy with pelvic floor
repair
Indications:
Women >40yrs  completed their families
Women >35yrs  with added menstrual
abnormalities, fibroids, adenomyosis

30. Vaginal hysterectomy with pelvic floor
repair
Steps
Vagina is stretched and kept open
Make an internal incision at the top of the vagina around
the cervix.
The uterus and cervix are cut free, and the connecting blood
vessels are tied off.
The uterus and cervix are removed through the vagina
This area is then closed to prevent infection and to keep the
intestines from dropping down.

31. Prevention of pelvic organ prolapse
Ante-natal
Adequate attention to weight
gain
Relaxation & stress limitation

32. Prevention of pelvic organ prolapse
Intra-natal
Supervision of 2nd stage labour
Generous episiotomy(??)
Proper suture techniques

33. Prevention of pelvic
organ prolapse
Post-natal
Physiotherapy
Early ambulation
Avoid strenuous work
Family planning & spacing

34. Bibliography
1.Rony A Adam, Te linde oper gyn,10th edition
2.Urogynaecology & reconstructive pelvic surgery ,Mickey M
Karram,3
rd
edition
3.Chris zimmerman,Te linde oper gyn,10th edition
4.Bobby Schull,Te linde oper gyn,10th edition
5.Thomas L Wheeler et al,Oster-Gardt uro-gyn,chapter 31
6.Kris Strohoben et al, Danforth’s ob& gyn,10th edition
7.Alan S Evans,oper for genital prolapse,Rob & Smith oper
surgery 4th edition