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

1. Pelvic organ prolapse

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. Normal axis Axis of the uterus and vagina: anteverted and anteflexed

4. PELVIC SUPPORTS PELVIC FLOOR Comprises Pelvic diaphragm Endopelvic fascia Perineal membrane Perineal body

5. PELVIC DIAPHRAGM

6. Pelvic diaphragm

7. Perineal membrane

8. Uterine ligaments

9. PERINEAL BODY

10. The pelvic structures are divided into 3 compartments : Anterior : urethra /bladder Middle : uterus/vault Posterior : rectum/anus

11. Levels of support of uterus DeLancey's three levels of support 3 levels

12. Level 1 (suspensory axis) Level I- Uterosacral and cardinal ligaments support the uterus and vaginal vault.

13. Round ligament ( mackenrodts lig / transverse/lateral cevical cervical ligament at the base of broad lig with uterine A & V

14. Defects in level 1 Uterovaginal UV prolapse Enterocele Vault prolapse

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. 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. Defects in level2 Paravaginal & para rectal defects

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. 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. 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. Causes related to child birth Birth injury

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. 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. Raised intra abdominal pressure chronic bronchitis, large abdominal tumours or obesity Smoking, chronic cough and constipation

25. Prolapse in unmarried or nulliparous women spina bifida occulta and split pelvis Collagen vascular diseases

26. congenital weakness of the pelvic floor muscles in unmarried or nulliparous women h/o precipitate labour Family h/o uterine prolapse

27. Surgeries Abdominoperineal excision of the rectum and radical vulvectomy Operations for stress incontinence such as Stamey and Pereyra operations

28. Classification of prolapse

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. Urethrocele When the urethra along with the lower one-third of the anterior wall prolapses (failure of pubocervical ligament Rare stress incontinence

31. Uterine prolapse

32. Uterine descent

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. 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. Symptoms Backache uterosacral strain Towards evening relieved by rest

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. 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. Ureteric obstruction and hydronephrosis } severe massive prolapse

39. Bowel symptoms Urgency Straining Feeling of incomplete emptying Pressure on vagina or perineum to start or complete defaecation

40. Discharge per vaginum Mild vaginitis Chronically inflamed lacerated cervix Decubitus ulcer – discharge and bleeding

41. Coital difficulties With third degree uterine prolapse and procidentia prevents penetration and orgasm due to a lax outlet.

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. Per speculum examination

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. 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. 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. 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. 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. 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. 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. eg:ring pessary stage 1 and 2 prolapse eg:gelhorn and cube pessaries for advanced stages soft plastic polyvinyl chloride material

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. 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. Anterior colporrhaphy

55. Anterior colporrhaphy performed to repair a cystocele and cystourethrocele

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. 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. Complications Infection, bleeding, injury, recurrence, failure Aftercare Avoid lifting weights, coughing, sneezing, straining at stools, sexual intercourse

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. 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. 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. 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. 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. WARD-MAYO REPAIR

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. 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

67. Abdominal sacrocolpopexy Abdominal method of apical suspension Used in Vault prolapse mainly A mesh in the form of Y is used

68. Long arm y  anterior longitudinal ligament of sacrum @ sacral promontory Short arms  anterior & posterior vagina

69. 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

70. Manchester/Fothergill’s operation

71. 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.

72. Dilation & cuerettage

73. 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

74. A right-angle retractor is placed under the bladder to expose the vesicouterine peritoneal fold. This is picked up and opened.

75. The anterior cul-de-sac is opened, a finger is inserted, and the fundus and adnexa are explored.

76. 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.

77. 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.

78. 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

79. 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

80. 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

81. STEPS..

82. 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

83. Le Fort’s operation

84. 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

85. POSTERIOR COMPARTMENT Posterior colporrhaphy to correct rectocele

86. 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

87. 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

88. 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

89. 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

90. Mc call culdoplasty for enterocele repair

91. VAULT PROLAPSE Enterocele Secondary vault prolapse

92. 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

93. 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

94. 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

95. 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

96. 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

97. 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

98. MANAGEMENT Abdominal sacrohysteropexy Teflon or mersilene mesh Purander’s sling operation or cervicopexy Shirodkar’s sling operation Khanna’s posterior sling