Uterine prolapse management

UTERINE PROLAPSE MANAGEMENT

1. UTERINE PROLAPSE MANAGEMENT VISHNU AMBAREESH M S

2. PREVENTION

3. 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.

4. 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

5. MANAGEMENT

6. 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 .

7. Mainly surgical Conservative management

8. CONSERVATIVE MANAGEMENT limited role… PELVIC FLOOR REHABILITATION (pelvic muscle exercises, galvanic stimulation, physiotherapy, rest in the purperium ). HORMONE REPLACEMENT, both systemic and local. PESSARIES

9.   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.

10. OTHER METHODS Ben Wa balls , also known as  Burmese bells ,  Benoît balls ,  Venus balls  or  Geisha balls Vaginal Cones Colpexin Sphere

11. 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

12. 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 .

13. SURGICAL MANAGEMENT

14. 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

15. Route of surgery is mostly vaginal …. also tried are abdominal & laproscopic Surgical repair may be directed to Anterior Middle or apical Posterior compartment

16. 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

17. 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

18. 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

19. 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

20. Posterior compartment POSTERIOR COLPORRAPHY & COLPOPERINEORRHAPHY Done to correct a recto cele 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.

21. Middle or apical compartment The apical defects can be of three types: Uterine prolapse Enterocele Vault prolapse following hysterectomy Vaginal route is usually preferred.

22. 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

23. SACROSPINOUS COLPOPEXY in cases of procidentia with complete vaginal eversion and in cases of vault prolapse Vault of vagina is attached to the sacrospinous ligament Acess via the retrovaginal spacce upto the ischialspine

24. 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.

25. 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

26. 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.

27. 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.

28. USE OF MESH Increasingly used in repeat surgery purpose is to completely replace the patient’s own weak tissues Can be used while performing an ant or post colporraphy Main problem is mesh erosion

29. 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 .

30. 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 ”

31. ABDOMINAL CORRECTION Vaginal vault after hysterectomy can be suspended to the uterosacral ligaments on either side to prevent an enterocele … Other procedures Halban Moscowitz procedures