Transcript ppt - Liaquat University of Medical & Health Sciences

Uterovaginal Prolapse
Dr. Nusrat Nisar
Department of Obstetrics & Gynaecology
Liaquat University of Medical &
Health Sciences, Jamshoro
Uterovaginal prolapse is defined as protrusion
of uterus or vagina beyond their normal
anatomical confines
Incidence:
12 – 30% in multiparous women.
2% in nulliparous women.
Grading:
1st degree:
Descent with in vagina.
2nd degree:
Descent up to the introitus.
3rd degree:
Descent out side the introitus also known as
procidentia & usually accompanied by
cystourethrocele & Rectocele.
Classification
Anterior vaginal wall prolapse;
Urethrocele;
• Urethral descent.
Cystocele;
• Bladder descent.
Cystourethrocele;
• Descent of bladder & urethra.
Posterior vaginal wall prolapse;
Rectocele;
• Rectal descent.
Enterocele;
• Small bowel descent.
Apical vaginal prolapse;
Uterovaginal;
• Uterine descent with inversion of vaginal apex.
Vault prolapse;
Post hysterectomy inversion of vaginal apex.
Etiology
Extremely common in multiparous women.
Congenital;
2% symptomatic prolapse occur in nulliparous.
Congenital weakness of connective tissue.
Multiparity;
Multiple vaginal deliveries;
• Causes damage to major supports of
vagina,nerves,endopelvic fascia & levator ani.
Raised intra abdominal pressure;
Chronic cough.
Constipation.
Post menopausal;
Estrogen deficiency.
Post operative;
Vault prolapse.
Diagnosis
Diagnosis is made by clinical examination;
Clinical features;
Symptoms;
Non specific;
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Lump.
Local discomfort.
Backache.
Bleeding / infection if ulceration.
Dyspareunia or apareunia.
In sever cystourethrocele, uterovaginal or vault
prolapse renal failure may occur.
Specific;
Cystourethrocele;
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Urinary frequency.
Urgency.
Voiding difficulty.
Urinary tract infection.
Stress incontinence.
Rectocele;
• Incomplete bowel emptying.
• Digitation.
• Splinting.
Abdominal examination;
Should perform to exclude organomegaly or
abdomino-pelvic mass.
Vaginal examination;
Prolapse may be obvious.
Ulceration.
Pelvic examination to exclude pelvic mass.
Combine rectal & vaginal examination to
differentiate Rectocele from Enterocele.
Differential Diagnosis
Anterior wall prolapse;
Congenital or inclusion dermoid vaginal cyst.
Urethral diverticulm.
Uterovaginal prolapse;
Large uterine polyp.
Investigation;
No essential investigation.
If urinary symptoms present;
Urine microscopy.
Cystometry.
Cystoscopy.
If renal failure suspected;
B.Urea.
S.Creatinine.
U/s of renal areas.
Treatment
Depends upon patient`s wishes.
Correct obesity.
To treat chronic cough.
Constipation.
If ulceration then seven days course of local
estrogen.
Prevention;
Shortening the 2nd stage of labor.
Reducing traumatic delivery.
Use of episiotomy.
HRT in menopausal women.
Medical Treatment
Conservative therapy;
Silicon rubber based ring
pessaries.
Indications;
Patient`s wish.
As a therapeutic test.
Child bearing not complete.
Medically unfit for surgery.
During & after pregnancy.
While awaiting surgery.
Complications;
Vaginal ulceration & infection.
Surgical Treatment
Aim of surgical repair is to restore anatomy
& function.
Cystourethrocele;
Anterior repair or colporrhaphy.
Rectocele;
Posterior repair or colporrhaphy.
Enterocele;
Anterior & posterior repair & peritoneal sac
containing the small bowel should be excised.
Utero vaginal prolapse;
Vaginal hysterectomy;
• If patient completed her family.
Manchester repair;
• Involves partial amputation of cervix &
approximation of cardinal ligaments.
• Usually combined with anterior & posterior repair.
Sacrohysteropexy;
Abdominal procedure,
Attachment of synthetic mesh from the
utertocevical junction to the anterior
longitudinal ligament of the sacrum.
Vault prolapse;
Sacrocolopopexy;
• Similar to Sacrohysteropexy but the inverted
vaginal vault is attached to the sacrum.
• Sacrospinous ligament fixation.
Fascial defect repairs;
Fascial or muscle plication or attachment to
ligaments to support the vagina in its presumed
original position.