Transcript Genital prolapse DISPLACEMENTS OF THE UTERUS The uterus is normally anteverted,anteflexed Version: is the angle between the longitudinal axis of cervix, and that of.

Genital prolapse
DISPLACEMENTS OF THE
UTERUS
The uterus is normally anteverted,anteflexed
Version: is the angle between the
longitudinal axis of cervix, and that of the
vagina.
Flexion: is the angle between the
longitudinal axis of the uterus, and that of
the cervix.
Downwards Displacement
(Genital Prolapse)
Genital prolapse is the descent of one or
more of the genital organ (urethra,
bladder, uterus, rectum or Douglas pouch
or rectouterine pouch”) through the
fasciomuscular pelvic floor below their
normal level.
Vaginal prolapse can occur without uterine
prolapse but the uterus cannot desent
without carrying the vagina with it.
Varieties of prolapse:
Vaginal Prolapse:
1) Anterior vaginal wall prolapse:
a. Prolapse of the upper part of the anterior vaginal
wall with the base of the bladder is called
cystocele
b. Prolapse of the lower part of the anterior vaginal
wall with the urethra is called urethrocele.
c) Complete anterior vaginal wall prolapse is called
cysto-urethrocele.
2) Posterior vaginal wall prolapse:
a) It is called rectocele if the anterior wall of
the rectum is also prolapsed with the
middle third of the posterior vaginal wall.
b) It is called entrocele (hernia of the pouch
of Douglas) if the upper third of the
posterior vaginal wall descends lined by
the peritoneum of the Douglas pouch and
containing loops of the intestine
3) Vault prolapse:
(descent of the vaginal vault, where the top
of the vagina descends )or inversion of the
vagina) after hysterectomy.
* Vault prolapse is more likely to occur after
subtotal than after total hysterectomy.
II) Uterine prolapse:
1)Utero-vaginal (the uterus descends first
followed by the vagina): This usually occurs in
cases of virginal and nulliparous prolapse due to
congenital weakness of the cervical ligaments.
2) Vagino-uterine (the vagina descends first
followed by the uterus):This usually occurs in
cases of prolapse resulting from obstetric
trauma.
Degrees of uterine prolapse
1st degree:
The cervix desent below its normal Ievel on straining but
does not protrude from the vulva.
N.B.: The extemal os of the cervix is at the level of the
ischial spines.
2nd degree:
The cervix protrudes from the vulva on straining
3rd degree: (Complete procidentia) the whole uterus is
completely prolapsed outside the vulva and the vaginal
wall becomes most completely inverted over it.
Enterocele is usually present.
Degrees of uterine prolapse
• 1st degree-2nd degree-3rd degree
Etiology of prolapse
The primary cause of prolapse
is weakness of the supporting structures of
the uterus and vagina, usually as a result
of the trauma of childbirth
Predisposing Factors:
1. Weakness of the pelvic cellular tissue:
The cervical ligaments which act as the main
support for the uterus may become weakened
by the following:
a) Obstetric trauma
b) Congenital weakness
c) Postmenopausal atrophy
2)Injury of the pelvic floor
Symptoms of prolapse:
1. Before actual prolapse. the patient feels a sensation
of weakness in the perineum. particularly towards
the end of the day.
2. Later the patient notices a mass which appears on
straining. and disappears when she lies down.
3. Urinary symptoms are common and trouble some
even with slight prolapse:
a) Urgency and frequency by day.
b) Stress incontinence.
c) Inability to micturate unless the anterior vaginal wall
is pushed upwards by the patient's fingers.
d) Frequency and scalding day and night when cystitis
develops
.
4. Rectal symptoms are not so marked.
The patient always feels heaviness in the
rectum and a constant desire to defoecate.
Piles develop from straining.
5. Backache, congestive dysmenorrhoea
and menorrhagia are common.
6. Leucorrhoea is caused by the congestion
and associated by chronic cervicitis.
Treatment of Prolapse
A) Prophylactic treatment for Obstetric
prolapse:
1. Proper ante-natal care (before delivery):The
pelvic floor should be both strong and elastic. It
is strong to help internal rotation of the fetal
head in the second stage of labour (Gutter like
action) and is elastic, so that the baby can pass
through painlessly causing the least amount of
trauma to the pelvic floor.
2. Proper intra-natal care (during
delivery):Avoid aetiological factors as
straining during the first stage(before full
cervical dilatation); avoid the application of
forceps before full cervical dilatation;
episiotomy should be done when indicated
to avoid hidden perineal lacerations; and
avoid fundal pressure to deliver the
placenta.
3. Proper post-natal care (after delivery):
Accurate repair of perineal tears or episiotomies,
avoidance of occurrence of R.V.F. by postural treatment
(daily time rest, relaxation on face, knee chest position)
correction of retroversion during the puerperium with the
use of knee chest position or pessaries, encourage
pelvic floor exercises and other postnatal ex's, prevent
puerperal constipation in order to avoid strong bearing
down efforts while the supporting ligaments of the uterus
are slack, and care of general health to prevent debility
and bad general health.
B) Palliative treatment:
palliative treatment by wearing a pessary is indicated in the
following conditions:
1)Slight degrees of prolapse in young patients. Operation should
be postponed until the woman has had a sufficient number of
children as long as the symptoms are mild.
2) Prolapse of the uterus in early pregnancy. The pessary is worn
until the end of the fourth month until size of the uterus will be
sufficient to prevent its descent.
3) Contraindications to operations as lactation, severe cough , or
patients refusing surgical repair.
4) Bad surgical risks as old patient with advanced diabetes or
severe hypertension.
Pessaries used in prolapse
Ring pessaries: A pessary of suitable size is introduced in
the vagina above the level of the levator anie muscies. 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. There is always the drawback of a
foreign body in the vagina, which is liable to cause
leucorrhoea and if neglected may even ulcerate into the
wall of the vagina.
A pessary is a device which is inserted into the upper part of the
vagina to provide support to the pelvic structures. The majority of
pessaries are made of silicone and come in a number of shapes
and sizes. A pessary needs to be inserted by a medical professional
and can be kept in place for 3-4 months, after which it will require
changing. When inserted properly, a woman should not be able to
feel a pessary. Pessaries provide a temporary solution to prolapse
symptoms for pregnant women, women who have recently given
birth or for women who are awaiting surgery. Pessaries can also be
used permanently by women who do not wish to have surgery or
who are unsuitable candidates
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.
c)Actual treatment:
Physiotherapeutic lines: indicated in:
1. Early and mild cases.
2. As a prophylactic measure after delivery.
3. Alleviation in more severe cases (pre-and post
operative treatment).
Aims out of P.T. treatment
• To establish the awareness of the function
pubococcygeus and pelvic supports & To
strength the pubococcygeus muscle.
Physical therapy treatment: Is
divided into two phases:
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 [Kegel perineometer and EMG biofeedback
.Mid-stream urine flow (stop test)
.Cyriax method
Resistive exercises for pubococcygeus muscle:
• An inflated cuffed catheter
• Vaginal cones
a)Muscle re-education of pubococcygeus
muscle: Pelvic floor exercises
b)Biofeedback (Kegel perineometer and EMG
biofeedback):
Kegel perineometer provides the patient by
powerful sensory and visible biofeedback, is
able to measure pubococcygeus muscle up to
100 mmhg so that changes in pelvic floor
strength can be measured.,
EMG biofeedback Provides the
patient by sensory, visible and
auditory biofeedback
EMG biofeedback is useful in both
increase the level of pubococcygeu
muscle activity and improving the
ability of the muscle to relax on
volition ,EMG devices and
perineometers appears to be useful
tools for evaluation,& treatment) of
pelvic floor dysfunction.
* Cyriax method
Cyriax method of treatment for stress incontinence is also
suitable for early cases of genital prolapse. This method
aims to strength: pubococcygeus, gluteal, anal, and
abdominal muscles.
. The patient is asked to lie in crock-lying position, to
breathe in deeply from her nose, and at the same time
contract pubococcygeus, gluteal, anal and abdominal
muscles, this is associated with drawing all internal
viscera up towards the diaphragm, then she will asked to
relax and expire air from her mouth with a sigh .