GENITAL

PROLAPSE
Dr. Ashwini B
Assistant Professor
KIPT
Genital prolapse is the descent of one or more of the genital
organ (urethra, bladder, uterus, rectum or Douglas pouch or
rectouterine pouch) and is common clinical condition . It includes
descent of vaginal wall/uterus.
SUPPORTS OF UTERUS

 The uterus is normally anteverted , anteflexed and is placed

between bladder and rectum.
 It is grouped under three tier systems.
 The objective is to maintain the position and to prevent the
descent of uterus.
 UPPER TIER- it maintains the uterus in anteverted position
Structures include-
Endopelvic fascia covering uterus
Round ligament
Broad ligaments
 MIDDLE TIER- constitutes the strongest support of uterus
Structures include-
Pericervical ring
Pelvic cellular tissues
 INFERIOR TIER-it gives indirect support to uterus including
pelvic floor muscles endopelvic fascia levator plate perineal
body urogenital diaphragm.
SUPPORTS OF VAGINAL
WALL
 ANTERIOR WALL -positional support
pelvic cellular tissue

 POSTERIOR WALL-endopelvic fascia sheath

Attachment of uterosacral ligament
Levator ani muscle
Levator plate
ETIOLOGY OF PELVIC
ORGAN PROLAPSE
 ANATOMICAL FACTORS
 CLINICAL FACTORS-PREDISPOSING FACTORS
AGGRAVATING FACTORS
TYPES OF POP

 VAGINAL PROLAPSE
 UTERINE PROLAPSE
 TYPES OF GENITAL PROLAPSE

VAGINAL UTERINE

ANTERIOR POSTERIOR UTEROVAGINAL

CONGENITAL

CYSTOCELE
URETHROCELE
CYSTOURETHROCELE

RELAXED PERINEUM RECTOCELE VAULT PROLAPSE

PRIMARY SECONDARY

ENTEROCELE FOLLOWING

VAGINAL HYSTERECTOMY ABDOMINAL HYSTERECTOMY

TYPES OF PROLAPSE
Vaginal Prolapse:
1) Anterior vaginal wall prolapse:
a. cystocele – is formed by laxity and descent of upper two-third of anterior vaginal
wall.
b. Urethrocele – is formed where there is laxity of lower-third of anterior vaginal wall
the urethra herniates through it.
c) cysto-urethrocele- urethrocele when appears with cystocele is called
2) Posterior vaginal wall prolapse:
a) Rectocele- there is laxity of middle-third of the posterior
vaginal wall and adjacent rectovaginal septum.
b) Relaxed perineum- torn perineal body produces gaping
introitus with bulge of the lower part of the posterior vaginal
wall.
3) Vault prolapse:
Enterocele- laxity of upper-third of posterior vaginal wall
resulting in herniation of pouch of douglas.
Traction enterocele is secondary to uterovaginal prolapse
Pulsion enterocele is secondary to raised IAP
Secondary vault prolapse – can be seen in undetected enterocele
during initial operation or inadequate primary repair and may
occur following vaginal or abdominal hysterectomy
Uterine prolapse:
1)Utero-vaginal – is the prolapse of uterus, cervix and upper
vagina IAP has got a piston like action on uterus thereby
pushing it down into vagina.
2) Congenital – uterus herniates down along with the inverted
upper vagina and seen in nulliparous women so is also known
as nulliparous prolapse.
There are three degrees of uterine prolapse
 Degrees of uterine prolapse

1st degree:
The uterus descends down from its normal anatomical position
The external os of the cervix is at the level of the ischial spines but still remains inside
the vagina
2nd degree:
The external os protrudes from the vaginal introitus but the uterine body still remains
inside the vagina
3rd degree: (Complete prolapse, Procidentia) the uterine cervix and body descends
to lie outside the introitus
Procidentia involves prolapse of uterus with eversion of entire vagina
 Degrees of uterine prolapse

 1st degree-2nd degree-3rd degree

The pelvic organ prolapse
quantification system
Morbid factors
 Vaginal mucosa – becomes thick dry and with surface keratinization
 Decubitus ulcer – keratinization>cracks>infections>sloughing>ulcerations
 Cervix – vaginal part :hypertrophy and hyperplasia
blood stain discharge from ulceration
supravaginal part :pull of cardinal ligaments
weight of uterus
 Urinary system – bladder : incomplete emptying of bladder
hypertrophy of bladder
ureters : carried downwards
Symptoms

 Feeling of something coming down

 Backache and pelvic pain
 Dyspareunia
 Urinary symptoms
 Bowel symptoms
 White/blood stain discharge
 Clinical examination and
diagnosis
 Composite examination – rectal, vaginal ,rectovaginal

 General examination – BMI ,signs of neuropathy myopathy, abdominal mass

should be checked
 Pop is evaluated in dorsal and standing position
 Prolapse of one organ is associated with prolapse of adjacent organ
EXAMINATION
 Cystocele - bulging of anterior wall
bulge has got impulse with cough
 Cystourethrocele – bulging of lower third of anterior wall of
vagina
stress incontinence
 Relaxed perineum – gaping introitus
lower part of posterior vaginal wall is
visible
 Rectocele and enterocele – bulging of posterior vaginal wall
 Uterine prolapse according to grades 1 2 and 3
 Levator ani muscle tone
Management of prolapse

 Preventive
 Conservative
 surgical
PREVENTION
1. Ante-natal care (before delivery)
2. Post-natal care (after delivery)
3. Intra-natal care (during delivery)
To avoid strenuous activities , chronic cough , constipation and
heavy weight lifting
To avoid future pregnancy too soon and too many by
contraceptives
CONSERVATIVE

INDICATIONS ARE
Asymptomatic women
Mild degree prolapse
Pop in early pregnancy

Measures which can be taken are :

Estrogen replacement therapy
Pelvic floor exercises
Pessary treatment
Pessary treatment

 Indications to use it
Early pregnancy
Puerperium
Unfit for surgery
Improvement of urinary symptoms
Hodge-smith pessary is commonly used
It acts by stretching uterosacral ligaments to pull the cervix
backwards
 PESSARIES USED IN PROLAPSE

Ring pessaries: A pessary of suitable size is introduced in the vagina above the level
of the levator ani muscles. It stretches the redundant vaginal wall and prevents
descent of the uterus.
The "cup and stem" pessary : Is used if the patient's pelvic floor are so weak or
lacerated that a ring pessary cannot be retained in the vagina.

Whatever type of pessary is used, this method of treatment is at its best only a
temporary method to give relief of symptoms.
Precautions during wearing a pessary:
The patient is instructed to have a daily vaginal douche, and
every month the
pessary is removed, cleaned, the vagina examined for any signs
of pressure and
the pessary then reintroduced. If the pessary is made of rubber
it should be
changed every three months.
SURGICAL MANAGEMENT
Guidelines for prolapse operation

 Procedure may be
Restorative
Compensatory
Extirpative
Obliterative
 Corrects cystocele and urethrocele
 Excise portion of ant vaginal wall n pushes bladder upwards
 Bladder is supported by plicating endopelvic fascia and
pubocervical fascia under bladder neck
title Aim methodology Result

A 3–year follow‐up To compare the 1–year A total of 138 women, In total, 138 patients out
after anterior (previously published) of 55 years of age or of 160 (86.3%)
colporrhaphy compared and 3–year objective older, admitted for stage participated in the 3–
with collagen‐coated and subjective cure ≥2 anterior vaginal wall year follow‐up. POP–Q
transvaginal mesh for rates, and prolapse. The women revealed an objective
anterior vaginal wall complications, related to scheduled for primary anatomic cure for 88.1
prolapse: a randomised the use of a collagen‐ anterior vaginal wall and 91.4%, respectively,
controlled trial coated transvaginal prolapse surgery were in the mesh group at the
mesh for anterior randomised between 1‐ and 3–year follow‐
M Rudnicki et al vaginal wall prolapse conventional anterior ups, compared with 39.9
against a conventional colporrhaphy and and 41.2% in the
anterior repair. surgery with a collagen‐ colporrhaphy group.
coated prolene mesh. study demonstrates that
All patients were although the objective
evaluated using the outcome was superior in
Pelvic Organ Prolapse the mesh group, the use
Quantification (POP–Q) of mesh had no impact
assessment before and on the subjective
after surgery. Symptoms outcome.
related to pelvic organ
prolapse were evaluated
using the Pelvic Floor
Impact Questionnaire
(PFIQ–7) and the Pelvic
Floor Distress Inventory
title aim methodology result
Effect of pre- This study was This randomized There was no
colporrhaphic conducted to clinical trial was significant
physiotherapy on investigate the conducted on difference in age,
the outcomes of effects of pre- women aged 20-59 height, disease
women with pelvic colporrhaphic years with duration, and parity
organ prolapse physiotherapy on moderate to severe between the two
the outcomes of the POP. The subjects groups (p>0.05),
Mahnaz Yavangi et women with were but the difference in
al moderate to severe randomized to two weight was
POP candidates for groups of 35 each: statistically
colporrhaphy Controls and cases significant between
Three months later, the two groups
the two groups were (p<0.05). Pre-
examined for colporrhaphic
outcomes and the physiotherapy can
outcomes were improve quality of
recorded in a life and sexual
checklist. Data function in
analysis was candidates for
conducted by SPSS colporrhaphy
16.
Paravaginal defect repair
 Characteristics by presence of rugae on ant vaignal wall and
sulci on lateral wall
 This repair is done by reattaching the endopelvic fascia to the
tendinous fascia
 Perineorrhaphy-it is operated designed to repair prolapse of
post vaginal wall
McCall culdoplasty
 Depending upon the size of enterocele one or more then
McCall suture may be placed
 Operation is designed to correct uterine descent associated
with cystocele and rectocele and uterus is preserved.
Repair of vaginal vault
prolapse
Uterus without vaginal
walls
 Cervicopexy or sling (purandare’s) – indicated in
nulliparous prolapse without cystocele where is
cervix is pulled mechanically through abdominal
route
PHYSIOTHERAPY
MANAGEMENT

Muscle re-education
Is important as the patient lack awareness of the function of
the pubococcygeus muscle, it includes:
 Muscle re-education for pubococcygeus muscle
 Biofeedback Vibrance Kegel Device and EMG
biofeedback
 Mid-stream urine flow (stop test)
Resistive exercises for pubococcygeus muscle
 Vaginal cones
a)Muscle re-education of pubococcygeus muscle: Pelvic floor exercises
b)Biofeedback ( Vibrance Kegel Device and EMG biofeedback):
EMG biofeedback Provides the patient by sensory,
visible and auditory biofeedback
EMG biofeedback is useful in both increase the level
of pubococcygeal muscle activity and improving
the ability of the muscle to relax, EMG devices
and perineometers appears to be useful tools for
evaluation,& treatment of pelvic floor dysfunction.
Pelvic floor muscle training is given
Abdominal gymnastics – hypopressive abdominal gymnastics
title aim methodology result

Efficacy of To determine whether the databases of the Hypopressive

hypopressive hypopressive Cumulative Index to gymnastics is less
abdominal gymnastics abdominal gymnastics Nursing and Allied effective than pelvic
in rehabilitating the is more effective than Health Literature floor muscle training
pelvic floor of women: pelvic floor muscle (CINAHL), the for activating pelvic
A systematic review training or other Cochrane Library, floor muscles,
alternative conservative Latin American and achieving closure of
R. Ruiz de Viñaspre treatments for Caribbean Health the levator hiatus of the
Hernández et al rehabilitating the pelvic Sciences Literature anus and increasing
floor. (LILACS), Physiothera pelvic floor muscle
py Evidence Database thickness, strength and
(PEDro), PubMed, resistance.
Scopus, Trip Database There is a lack of
and Web of Science. quality clinical trials
The measured that have evaluated the
outcomes were the efficacy of
strengthening of the hypopressive
pelvic floor muscles, abdominal gymnastics.
the incidence of urine
incontinence or prolaps
e and
symptom remission.
title aim methodology result

Prevalence and risk to examine the A cross sectional A total of 1195

factors for pelvic prevalence and risk community based women were
organ prolapse in factors of POP study conducted in interviewed and
Kilimanjaro, among Tanzanian Hai, Rombo and invited for pelvic
Tanzania: A women by Same Districts, examination;
population based deploying the POP- Kilimanjaro 1063(89%) women
study in Tanzanian Q classification Region, Tanzania. presented at the
rural community system Women aged 18–90 clinic of whom
were recruited 1047(88%)
Gileard G. through multi-stage accepted a clinical
Masenga et al random sampling examination. Of
Home-based 1047 examined
questionnaire women, 64.6% had
interviews were an anatomical POP
performed stage II–IV and
6.7% had a severe
POP that descended
1 cm or more below
the hymen
title aim methodology result
PROPEL: To study the A Realist Study of the
implementation of evidence based Evaluation (RE) implementation of
an evidence based pelvic floor of implementation varying models of
pelvic floor muscle training and outcomes of service delivery of
muscle training intervention for PFMT delivery in PFMT across
intervention for women with contrasting NHS contrasting sites
women with pelvic organ settings will be combined with
pelvic organ prolapse conducted using outcomes data and
prolapse: a realist multiple case a cost
evaluation and study sites effectiveness
outcomes study Qualitative data analysis will
protocol will be collected at provide insight
four time-points into the
Margaret Maxwell across each site to implementation
et al understand local and value of
contexts and different models
decisions of PFMT service
regarding options delivery and the
for intervention cost benefits to the
delivery and to NHS in the longer
monitor term.
implementation,
uptake, adherence
title aim methodology Result
EMG-biofeedback The aim of the study All women with stress Four hundred and
assisted pelvic floor was to determine the or mixed urinary thirty four women
muscle training is an short- and long-term incontinence treated in attended our PFR-
effective therapy of efficacy of an the pelvic floor program in this 7-year
stress urinary or mixed intensive and EMG- reeducation program at period. All 390 women
incontinence biofeedback-assisted our clinic were with stress (80%) or
pelvic floor muscle included EMG- mixed (20%) urinary
Christian Dannecker training (PFMT) biofeedback assisted incontinence were
Et al program as a therapy PFMT was performed evaluated.
of female stress or Electric stimulation There was a
mixed urinary preceded PFMT if the statistically significant
incontinence. pelvic floor muscle improvement of the
contractions were stress provocation test
considered too weak (cough test) There
for active training was a significant
oxford score<2 increase in the Oxford-
Examinations included score by 1.2 points
among others: An intensive and
conventional EMG-biofeedback
urodynamic studies assisted PFMT is very
prior to therapy, a effective. Often,
stress provocation test avoidance of surgery
(cough test), and is possible.
determination of
maximal pelvic floor
muscle strength
(Oxford-grading and
 REFERENCE

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management of symptomatic pelvic organ prolapse in rural
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Douglas G Tincello, Eileen Calveley, Mary Macfarlane,
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pelvic organ prolapse: a realist evaluation and outcomes study
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Thank you