PELVIC SUPPORTS RELAXATION ANDGENITAL PROLAPSEBYDR. E.O. OBI-THOMAS

. Introduction

. Definition

. Anatomy

. Epidemology

. Aetiology

. Types

. Classification

. Grading

. Clinical Features

. Investigations

. Diagnosis

. Treatment

. Complications

. Prevention

. Emergency measures

. Conclusion

INTRODUCTION_______________

-Genital prolapse (GP) conditions have posed a great challenge to the medical world over periods,of which women were expectedly at the receiving ends. -Safe and effective treatments were only developed in the 19th century.-The hallmark of these conditions is on the relaxation of the Pelvic Supports which can be

brought about by many factors.-Genital prolapse include cystocoele, rectocoele, enterocoele, and vaginal vault prolapse.-Genital prolapse does not include urethral prolapse through the meatus or rectal prolapse through the anus.

DEFINITION____________

. Uterovaginal prolapse –downward descent of uterus/vaginal towards or through the vaginal intritus. The vaginal can prolapse without the uterus but the uterus must prolapse with the vaginal.. Cystocoele-Descent of bladder bae towards the anterior vaginal wall. -anterior cystocoele concerns that part of the bladder base distal to the interureteric ridge.

-posterior cystocoele –part proximal to the interureteric ridge. Both types usually occur together.

. Uretherocoele-urethral displacement backwards and downwards towards the vaginal wall. -there is usually a resultant loss of the urethrovesical angle.. Enterocoele-apical vaginal wall herniation in which

bowels and occasionally omentum are contained in the prolapse segment. Important because of recurrence.. Rectocoele-defect in posterior vaginal wall in which rectum prolapses.

ANATOMY___________

. Levator ani

. Ligaments

Perineal muscles

EPIDEMIOLOGY_______________

. Difficult to determine

. Incidence 7.5 in 1000 (1997)

AETIOLOGY

Failure of the supports of the uterus and vagina.

-Congenital: occurs in nulliparous and multiparous woman, Ehlers –Danlos syndrome, spina bifida, bladder extrophy, shortness of vagina, deep uterovesical and uterorectal perineal pouches, uterine retrovertion, familial tendencies, marfan syndrome.-Trauma: Tears, prolonged labour, denervation, traction, (perineal and vaginal tears do not cause prolapse)

-Surgical injury: subtotal hysterectomy, vaginal hysterectomy, abdominoperineal excision of the rectum.-Conditions with increased intra abdominal pressure, e.g. chronic cough, pelvic tumours, Chronic constipation.-Hypoestrogenic state of menopause.

TYPES OF GENITAL PROLAPSE1. Anterior vaginal prolapse

-cystourethrocoele -urethrocoele

-cystocoele 2. Apical vaginal prolapse

-utero vaginal -vaginal vault (post

hysterectomy) 3. Posterior vaginal prolapse

-enterocoele -rectocoele

CLASSIFICATION

Cystocoele.

. First degree: The anterior vaginal wall, from the urethral meatus to the anterior fornix, descends halfway to the hymen. . Second degree: The anterior vaginal wall and

underlying bladder extend to the hymen. . Third degree: The anterior vaginal wall and underlying urethral and bladder areoutside the hymen. This cystocoele is often part of the third degree uterine or posthysterectomy vaginal vault prolapse.

Uterovaginal vault prolapse . .First degree: The cervix or vaginal apex

descends halfway to the hymen. .Second degree: The cervix or vaginal apex extends to the hymen or over the perineal body. .Third degree: The cervix and corpus uteri extend beyond the hymen or theVaginal vault is everted and protrudes beyond the hymen.

Rectocoele.

.First degree: The saccular protrusion of the rectovaginal wall descends halfway to the hymen. .Second degree: The sacculation descends to the hymen. .Third degree: The sacculation protrudes or extends beyond the hymen. Enterocoele. .First degree: Herniation of cul-de-sac to one-fourthof the distance to hymen.

. Second degree: herniation to two-fourths of distance towards hymen..Third degree: herniation to three-fourths of distance towards hymen.. Fourth degree: herniation to hymen. The presence and depth of the enterocoele sac, relative to the hymen, should be described anatomically, with the patient in the supine and standing positions during valsalva maneuver.

STAGING_________Stage 0: No prolapse is demonstrated.Stage1: The most distal portion of the prolapse is > 1cm above level of the hymen.Stage11: The most distal portion of the prolapse is < 1cm proximal to or distal to the plane of the hymen.

Stage 111: The most distal of the prolapse is > 1cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters.Stage 1V: Essentially, complete eversion of the total length of the lower genital tract is demonstrated.

Cystocoele and Urethrocoele______________________ Clinical features:.Symptoms and signs

- Sensation of vaginal fullness, pressure-feeling she is sitting on a ball. - Feeling of incomplete emptying of the bladder, often stress incontinence, urinary frequency; perhaps a need to push the bladder up in order to void. - Presence of a soft, reducible mass bulging into the vaginal and distending through vaginal intritus. - Increased bulging and descent of the anterior

vaginal wall and urethra on straining or coughing.

DIAGNOSIS____________1. By physical examination. - Although urinary incontinence is most commonly demonstrated in cystocoele, does not as such cause incontinence and its repair does not correct stress incontinence. - Stress incontinence is an anatomic condition,

associated with relaxation of the musculofascial supporting tissues of the urethra. - Unless special attention is directed to urethral support, operative correct of a largecystocoele may cause rather than correct stress incontinence.

- Pressure of cystocoele on vagina is often mistaken as incomplete bladder emptying. -Also that cystocoele commonly cause cytstitis,

trigonitis, urethritis, urgency, frequency and dysuria. -Significant residual urine is seen in large cystocoele prejecting well outside the intritus. There could be bladder infection. -“double voiding” or manual reduction of cystocoele into vagina prior to voidingensures complete bladder emptying. -Unless patient has significant volumes of

residual urine as demonstrated by catheterization, cystocoele operation performed primarily to release symptoms of chronic inflammation of UT will be unsuccessful. -A smooth, relaxed, bulging thin anterior vaginal wall strongly suggests presence of cystocoele.2. Laboratory findings: -Evidence of infection in catheter specimen urine.

-Cystocoele is most likely not to cause UTI unless there is significant volume of residual urine.3. Imaging studies: -IVU -sonography -videocystourethrography(VCUG) -CT - poor resolution of soft tissues -MRI - capable to image in multiple plane.

DIFFERENTIAL DIAGNOSIS.Tumours of urthra and bladder.Large urethral diverticulum.True bladder diverticulum.Enterocoele of anterior vagina wall.

TREATMENTMedical and surgical.

1. medical measures: -pessary for elderly and patients with operative risk. -exercises provide more than partial relief for elderly. -estrogen mainly applicable to the post menopausal women to improve tone, quality and vascularity of the musculofascial supports.2. surgical measures: -anterior vaginal colporrhaphy is most common surgical treatment

for cystocoele. -obliterative vaginal operation(vaginectomy, Le Forts operation) used primarily for elderly with severe uterovaginal prolapse. -transabdominal repair of cystocoele( along with TAH) may be elected to correct cystocoele. -retropubic urethrovesical suspension( Burch/ Marshall-Marchetti-Krantz) combined with abdominal cystocoele

repair to correct or prevent the development of stressincontinence.

COMPLICATIONS

-Acute urinary retention-Recurrent UTI

PREVENTION1. Kegel’s exercise in ante- intra- and postpartum strengthens the levator ani

and perineal muscle groups.

2. obesity, chronic cough, straining and traumatic deliveries must be avoided.

3. oestrogen therapy for post menopausal women.

PROGNOSIS

-Af\ter anterior colporrhaphy is excellent.

RECTOCOELE

.symptoms and signs:

.a small rectocoele is usually asymptomatic- is demonstrated in virtually all multiparous patients..large rectocoele -sensation of vaginal & rectal fullness-difficulty in evacuation of faeses

-occasional reduction of mass before defaecation.-history of prolonged use of laxatives.-faecal and gas incontinence.. presence of a soft reducible mass bulging into the lower half of theposterior vaginal wall ; frequently a flat, lacerated perinealbody.

-examination is best perfomed retrovaginally with index fingerin the vaginal and the middle finger in rectum.

DIAGNOSIS-rectovaginal examination confirms anterior sacculation through the posteriorvaginal wall.

-lateral x-ray views after barium enema show rectocoele but this is not diagnostic.-dynamic cystoproctograghy and MRI can distinguish posterior vaginal wall defects from enterocoele-proctoscopy to exclude a concomitant lesion especially with haemorrhoidal bleeding.

DIFFERENTIAL DIAGNOSIS

-Enterocoele-Tumours (lipomas, fibromas sarcomas).

TREAMENT

medical and surgical.1. medical measures: –Is advisable until patient has completed child bearing

-Increased fluid intake and stool softeners -Laxatives and rectal suppositories -a large vaginal pessary; Gehrung/doughnut type2. Surgical measures: -Rectocoele alone seldom require surgical treatment -surgical measures when there is difficulty in faecal evacuation

-posterior colpoperinearlaphy .post-operative care -avoid straining,coughing and strenuous activity. -avoid constipation-causing diets. -Ensure increased fluid intake -Use of stool-softening, laxatives and lubricating suppositories.

ENTEROCOELE.An enterocoele is essentially a vaginal hernia in which the peritoneal sac containing a portion of the small bowel extends into the rectovaginal space between the posterior surface of the vagina and the anterior surface of the rectum. .After hysterectomy, an enterocoele occasionally may be found anterior between the posterior wall

of the bladder and anterior wall of vagina..Is categorized into four; based on its process of acquisition: congenital, iatrogenic,traction and pulsion.

-Congenital enterocoeles- are extremely rare -occur when incomplete fusion of the rectovaginal septum leaves an open cul-de-sac.

-Iatrogenic enterocoeles-occur following procedures that alter the vaginal axis as in the treatment of stress urinary incontinence (Burch procedure or a needle bladder neck suspension Mechanism-an anterior and vertical axis that allows the normally closed cul-de-sac to open and become unprotected. Incidence may be as much as 26 per cent after incontinence procedures and

6.3 per cent a year after hysterectomy.

-Traction enterocoeles-Relatively common. Found in conjunction with uterine prolapse, cystocoele and rectocoele.-Pulsion enterocoeles occur secondary to conditions that cause chronically raised intra-abdominal pressure, such as chronic cough or severe physical exertion.

SYMPTOMS AND SIGNS -Asymptomatic until they become so large that they descent to the hymenal level. -A pulling sensation or lower back pain aggravated by prolonged standing -uncomfortable pressure and a fall-out sensation in the vagina. -Associated with uterine prolapse or subsequent to hysterectomy.

-Demonstration of a mass bulging into the posterior furnix and upper posterior vaginal wall.

DIAGNOSIS Rectrovaginal examination with patient standing after retracting anterior vaginal wall with a Sims or single blade vaginal speculum.

Radiological examination: -lateral pelvic X-ray view during barium studies may reveal enterocoele. -MRI can facilitate distinction of high rectrocoele from an enterocoele.

TREATMENT Medical and surgical.1. medical measures: -pessaries

-vaginal pack with bacteriostatic or estrogen cream -weight reduction in obese patient.

2. Surgical measures: -Principle of management: (i) Identify the enterocoele and probable etiology by careful preoperative evacuation (ii) Mobilize or obliterate the enterocoele sac.

(iii) Occlude the sac with suture ligation as high as possible. (iv) Close the hernia defect by providing support below the hernia sac and restore the normal vaginal axis.

Transabdominal/Transvaginal repair: Transabdominal repair-rarely necessary unless performed with other abdominal procedures.

The cul-de-sac can be closed in one of two ways.

1.Halban approach-placing permanent sutures in a continuous sagittal fashion just beneath the peritoneum, starting at the posterior wall of the vagina, proceeding to the cul-de-sac, and then continuing to the anterior wall of the rectum. The lateral sutures approximate 1 cm medical to the ureters, to maximize angulation. This approach is often preferred

because the course of the ureters is affected minimally.

2. Moschowitz repair-the enterocoele sac is obliterated and the utero-sacral ligaments and endopelvic fascia are approximated with concentric purse-string sutures. -For symptomatic enterocoele which almost invariably is associated with uterine prolapse, cystocoele, and rectocoele, a transvaginal

operation may provide the best route of repair and offer the greatest likelihood of permanent correction of the enterocoele. -This procedure includes excision and high ligation of the enterocoele sac (a cardinal principle of any hernia repair) and approximation of the uterosacral ligaments and endopelvic fascia anterior to the rectum.

-Concomitant VAH, anterior and posterior colponhaphy and perinearhaphy may greatly augument the support. -Posthysterectomy enterocoele with prolapse of the vaginal vault is also best managed by the transvaginal route. Mc Call enterocoele repair (after VAH and repair) – includes among others colpocleisis, sacrospinuos ligament suspension,

endopelvic fascia vaginal vault fixation, iliococcygeal fixation, and high uterosacral ligament suspension using non-absorbable sutures. -Avoid techniques that suspend the vaginal vault from the anterior abdominal wall as this promotes recurrence of the enterocoele. -Abdominal sacro colpety is an excellent primary procedure for vaginal vault prolapse enterocoele and is the

procedure of choice for patients with recurrent vaginal prolapse or patients who are already having an abdominal approach for another indication. -Vaginal obliterative procedures (Le Fort’s operation, colpectomy) may be beneficial to patients who do not require preservation of vaginal function and hernia sac is obliterated or removed to avoid recurrence of enterocoele.

-Care must be taken to avoid obstructing the ureters or entering the rectum. -When an enterocoele co-exists with a cystocoele, rectocoele or vault prolapse, the enterocoele is usually repaired first. -Colposcopy be performed after IV indigo carmine to ensure urethral patency. -It is important not to foreshorten the vagina:

otherwise dysparaeunia may occur.

PREVENTIONNeglected obstructed labour and traumatic delivery should be avoided. Factors that increase intra-abdominal pressure (obesity, chronic cough, straining, ascites, large pelvic tumours) should be corrected promptly.At hysterectomy efforts must be made to detect and

repair any potential or actual enterocoele.

EMERGECY MEASURESComplete eversion of the vagina by the enterocoele may occur and be complicated by trophic ulceration, edema, and fibrosis of the vaginal walls such that prolapsing enterocoele becomes irreducible.

-managementincludes bed rest with foot of bed elevated and wet packs applied to reduce edema and enhance reduction.

PROGNOSIS- excellent after proper enterocoele repair.

UTERINE PROLAPSE

Is the descent of the uterus/ cervix through the vaginal canal.Defects in the uterosacral, the cardinal ligament and connective tissue of the urogenital membrane.Occurs commonly in multi parous women. Occurs also as; .Systemic – obesity, asthma, chronic bronchitis and bronchiectasis. .Local – ascitis, large uterine and ovarian tumours

.Others – sacral nerve disorder as in spinal bifida, diabetic neuropathy, caudal anaesthesia accidents, and presacral tumours. .Congenital weakness of pelvic fascial supports. SYMPTOMS AND SIGNS .moderate degree of prolapse –associated with a feeling of pelvic heaviness or fullness or low back pain. Worsen

with exertion and ease with bed rest. .Severe degree of prolapse – a “mass” is protruding from the vagina. Bleeding from mucosal ulcerations or from cervical os may occur due to rubbing of the prolapsed tissue against the patient’s clothing. Associated problems of cystcoele and

recocoeles lead to difficulty in voiding, recurrent UTI, and /or ‘splinting’ to defaecate.

DIAGNOSIS The history and physical findings are so characteristic. Pelvic examination while patient is bearing down or straining revealed the descent and degree of prolapse.

Rectovaginal examination may reveal a rectocoele. Placement of metal sound/firm catheter within bladder may reveal extent of co-existing cystocoele.

TREATMENT

Medical and Surgical. .Medical measures: -pessaries - multitude of sizes and shapes.

The uterus and cervix are repositioned within the vaginabefore the pessary can be sized and placed.Supine position during pessary insertion. -hormone replacement therapy – strengthens the vaginal Mucosa in the elderly patient..Surgical measures: Vaginal and abdominal approaches.

-Vaginal – if the uterus is small.-Abdominal – in younger females who may have a larger uterusor large leiomyomata. In either approach, the uterosacral and cardinal ligaments areLigated and tied together and the cul-de-sac obliterated toreduce the risk of subsequent enterocoele and suspend the vaginal vault.

Selection of surgical approach depends on: *Age *Desire for pregnancy *Preservation of vaginal function *The degree of prolapse *Presence of associated conditions.Patients who want to maintain fertility have 3 options; a Manchester

procedure, an abdominal suspension, or a transvaginal suspension . Manchester procedure – uterine prolapse with a long cervix protrudingoutside the intritus. A portion of the cervix is amputated and the uterus is resuspended with thedivided cardinal ligaments. An anterior and posterior colporrhaphy should also be performed.

No longer popular because of the potential complications: *cervical incompetenence *cervical Os stenosis *post-operative pelvic prolapse requiring subsequent hysterectomy.Trans abdominal suspensions using mesh or fascia -relative morbidity procedures

-results are comparable to those of transvaginal procedure. -reserved for young patients with anomalies such as myelomeningocoele who desire to maintain fertility but have severe uterine prolapse. .In postmenopausals who are sexually active – vaginal hysterectomy andrepair of associated vaginal defect.

.In older women who are no longer sexually active – a partial colpocleisis can be performed. This procedure partially closes the vagina over the uterine cervix. -is advantageous in that it is a simple procedure with minimal morbidityand a high success rate. However, coital function is limited,inspection of the cervix

and uterus is impossible and post operative urinary incompetence can occur.

COMPLICATIONSLeukorrhoea, abnormal uterine bleeding and abortion from infection/disordereduterine or ovarian circulation in prolapse. -Chronic decubitus ulceration in procidentia.

-UTI from cystocoele and partial urethral obstruction with hydronephrosisIn procidentia. -Haemorrhoids from straining to overcome constipation.

PREVENTION-Kegel’s exercises – prenatal and postpartum strengthening of the levator ani muscles.

-Prolonged estrogen therapy for menopausal and postmenopausal womenmaintains the vascularity and vitality of endopelvic fascia and pelvic floor musculature.-Obese encouraged to lose weight-Tight girdles and garments that increased intra-abdominal pressure shouldbe avoided.

DIFFERENTIAL DIAGNOSIS-Cervical elongation.-Cervical tumours.

CONCLUTION

.Successful treatment of cystocoeles require an evaluation for both lateraland central defects as inadequate treatment of either defect will lead to reccurrences.

.The treatment of rectocoeles is controversial. Most clinicians would certainly repairsymptomatic rectocoeles, the need for treating asymptomatic rectocoeles is not clear. .Small asymptomatic enterocoeles in elderly patients can be treated conservatively using a pessary; however, most patients will require surgical intervention.

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