Genital prolapse
Dr. Rupak Bhattarai
Support to the Uterus Pubo-cervical

ligament:
The pubocervical ligament is a ligament connecting
the side of the cervix to the pubic symphysis.
 Transverse
ligament”)

cervical(“cardinal
Extend from cervix and lateral parts of the fornix to the
lateral walls of pelvis ( ischial spine).
 Uterosacral

ligament:
Pass superiorly and slightly posteriorly from sides (base)
of cervix to middle of sacrum; palpable during rectal
exam
 Round
ligament:
attaches anteroinferiorly to uterotubal junction

Broad ligament:

These are 2 layered folds of peritoneum which suspend the uterus
to the lateral pelvic wall
It has anterior & posterior layers. A free upper border, lower,
medial & lateral
Superiorly the 2 layers are continuous over the uterine tube
Inferiorly & laterally the 2 layers spread out to cover the pelvic floor



Genital prolapseIt refers to the downward displacement of the
uterus or vagina from its normal anatomical
position.
 Etiology of prolapse These are usually seen during vaginal delivery
with consequent injury to the supporting
structures.
 1.Premature bear down effort prior to the full
dilatation of the cervix.
 2.Application of the forceps or ventouse prior to
the full dilatation of cervix.
Precipitate labour.
 Early resumption of activites after delivery which
increases intra abdominal pressure before they
gain their normal tone.
 Repeated childbirth at frequent intervals.
 Increase in the intrabdomial pressure as in
chronic cough and constipation.

Clinical types
1.Vaginal prolapse:
 Anterior wall:
 A) Cystocele-is a medical condition that occurs when

the tough fibrous wall between a woman's bladder and
her vagina (the pubocervical fascia) is torn by childbirth,
allowing the bladder to herniate into the vagina.
Urethroceles often occur with cystoceles.
Cystocele

B) Urethrocele-is the prolapse of the female
urethra into the vagina. Weakening of the
tissues that hold the urethra in place cause it to
move and to put pressure on the vagina, leading
to the descent of the anterior distal wall of the
vagina.Urethroceles often occur with cystoceles,
(involving the bladder as well as the urethra).In
this case, the term used is a cystourethrocele.
Posterior wall:
 Rectocele:-results from a tear in the
rectovaginal septum (which is normally a tough,
fibrous, sheet-like divider between the rectum
and vagina). Rectal tissue bulges through this
tear and into the vagina as a hernia. There are
two main causes of this tear: childbirth, and
hysterectomy.


Enterocele:-Laxity of the upper third of
the posterior vaginal wall results in
herniation in the pouch of douglas and
contain omentum or even intestine.
Uterine prolapse

1.First degree-The uterus descend down
from the normal anatomical position (i.e
external os at the level of the ischial
spines) but external os still remains inside
the vagina.

2.Second degree-The external os protudes
outside the vaginal introitus but uterine
body still inside.

3.Third degree (Procidentia ,complete prolapse)The uterine body descends to lie outside the
introitus.
Predisposing factors







Congenital pelvic floor weakness
Difficult or traumatic labour
• Multiparity - trauma
• Chronic disorders – chronic obstructive
airway, constipations, straining
• Abdominal tumours
• Obesity, smoking, heavy lifting
• Steroids, menopause, pelvic surgery
Changes that may occur after
prolapse
 Vaginal
mucosa:
The vaginal mucosa becomes stretched
and if exposed to the air for long time
becomes thickened and dry with surface
keratinization.
Decibutis ulcer:
 Trophic ulcer always found at the dependent
part of the prolapsed mass lying outside the
introitus


There is initial surface keratinisation –cracksinfection-sloughing and ulceration.

There is diminished circulation due to the
constriction of the prolapsed mass by vaginal
opening and narrowing of the vessels by the
stretching effect.
 Cervix:
 The
supravaginal portion of the cervix becomes
Elongated due to the strain imposed by the pull.
 Obstruction
to the urinary tract due to the huge
cystocele which causes obstructive uropathy and
leads to hypertrophy of the bladder walls.
 The
kinking of distal ureter in procedentia leads
to hydronephrosis and hydroureter.

There may be infection of the bladder producing
pyelitis or pyelonephritis.

Incarceation: Infection of the paravaginal and
cervical tissues makes the entire prolapsed mass
odematous and congested and as a result the
mass is irreducible.

Peritonitis: The peritoneal infection may occur
through the posterior vaginal wall.
CLINICAL FEATURES
 Symptoms:
Feeling of something coming out per vagina .
 Initially it is reducible but later it becomes
irreducible.
 There may be variable discomfort that the mass
comes out when she walks.
 Backache or dragging pain in the pelvis.

 Urinary
symptoms like difficulty in passing
urine,incomplete evacuation .
 If
infection----- urgency ,frequency.
 Stress
incontinence i.e while doing
strenous work there is dribbling of urine.

Bowel symptom in presence of rectocele like
difficulty in passing stool and feeling of
incomplete evacuation of the faeces.

Excessive white or blood stained discharged per
vaginum if there is associated vaginits or
decibutis ulcer.
Signs

When you ask the patient to cough it raises the
intra-abdomial pressure leading to:

Bulge in anterior vaginal wall in case of
cystocele.

Bulging of the anterior and lower 1/3rd of vagina
in case of cystourethocele,

Bulging of the posterior vaginal wall in case o f
rectocele and enterocele.

Pinch Test:
Cough impulse in uterine prolapse leads to
the expulsion of the mass PV.
 In case of first degree prolapse
examination is made by introducing
speculum and one may see the cervical
descent below the level of ischial spines.


Treatment:
Conservative:
 In case if first degree uterine prolapse pelvic
floor exercise can be done.


In case of 2nd or 3rd degree ring
pessasary treatment can also be done if
the patient doesn’t want have any
operation.

For Incarceation:

For Ulcer:

Surgical operation :
Anterior colporaphy:
Surgical procedure to correct cystocele and
uretheocele.
 It involves making a cut in the front (anterior)
wall of the vagina so the bladder and/or urethra
can be pushed back into place.
 Once this is done, stitching together existing
tissues to provide a new support for the bladder
and urethra.



Colpoperinorraphy:
Surgical procedure to repair the prolapse of the
posterior part of vaginal wall i.e rectocele and
enterocele.
 The operation is done through the vagina. A cut
is then made in the back (posterior) wall of the
vagina and the rectum and/or small bowel is
pushed back into place stitching together the
existing tissues to create a new support for the
prolapsed organ(s) and then removes some of
the tissue from the vaginal wall to make it
stronger.



Pelvic floor repair(PFR):
It includes the combination of anterior
colporraphy or colpoperinorraphhy.


Fothergills operation:
To corect the uterine descent associated with
cystocele and urethrocele with preservation of
uterus is done.

Vaginal hystrectomy with PFR.