UTERINE PROLAPSE MANAGEMENT

2. UTERINE PROLAPSE
MANAGEMENT
VISHNU AMBAREESH M S

3. PREVENTION

4. Genital prolapse is a preventable disease
1)Prevention and limiting injury to pelvic support during
childbirth by :
– Avoiding of: prolonged labour , bearing down before full
cervical dilatation and difficult instrumental delivery
– Encouragment of postnatal pelvic floor exercises .
– Family planning and smaller family size .
2) Avoiding and treating factors which increase the intra-abdominal
pressure such as obesity , smoking, chronic cough
and chronic constipation
3) Prevention of postmenopausal atrophy of pelvic support by
balanced diet, exercise, calcium & by the increased use of HRT.

5. WHEN TO TREAT ?
• Should be treated only when it is symptomatic
(Be certain symptoms are due to Prolapse )
• Interferes with the normal activity of the
woman
• The patient seeks treatment

6. MANAGEMENT

7. Choice of method - depends on the followings:
 Age, fitness and wish of the paitent
 Parity and wish for further pregnancy.
General measures :
• Treatment of urinary tract infection.
• Avoiding and treating factors which increase the intra-abdominal
pressure such as smoking, obesity, chronic cough and chronic
constipation .
• Use of HRT in menopausal patients .
• Reducing the procidentia and treatment of ulceration with oestrogen
cream. The ulcer will usually heal within 7 days .

8. • Mainly surgical
• Conservative management

9. CONSERVATIVE MANAGEMENT
limited role…
» PELVIC FLOOR REHABILITATION (pelvic muscle
exercises, galvanic stimulation, physiotherapy, rest
in the purperium).
» HORMONE REPLACEMENT, both systemic and local.
» PESSARIES

10. Pelvic floor training
• progressive resistive exercises for the pelvic floor
that are often titled Kegel exercises.
• improve urethral resistance and pelvic visceral
support by increasing the voluntary periurethral
muscles
• enhance the voluntary closing mechanisms.

12. OTHER METHODS
• Ben Wa balls, also known as Burmese
bells, Benoît balls, Venus balls or Geisha balls
• Vaginal Cones
• Colpexin Sphere

13. Pessaries
• Indications :
– Patient unfit for surgery .
– Patient refuses surgery .
– During pregnancy and after delivery .
– During waiting time for surgery.
– As a therapeutic test to confirm that surgery may
help .
• Types :
– SUPPORT - eg. Ring pessary – commonly used
pessary.
– SPACE FILLLING pessary – eg. Gelhorn & cube

14. • Side effects:
– Vaginal infection and discharge
– Vaginal ulceration and bleeding
• Precautions - to minimize side effects:
– Use of silicon pessary - rubber pessary should
not be used.
– Change the pessary yearly - or earlier if infection
or ulceration occurred .
– Use of vaginal ostrogen cream in menopausal
patients .

18. SURGICAL MANAGEMENT

19. RECONSTRUCTIVE SURGERY is invariably needed
and has to be a COMBINATION OF
PROCEDURES to correct the multiple defects
MOST COMMONLY PERFORMED
VAGINAL HYSTERECTOMY WITH
PELVIC FLOOR REPAIR

20. Route of surgery is mostly vaginal ….
also tried are abdominal & laproscopic
Surgical repair may be directed to
1. Anterior
2. Middle or apical
3. Posterior compartment

21. ANTERIOR COMPARTMENT
• USUALLY CYSTOCELES
• usual defect is a midline defect or anterior
cystocoele ( defect in the fibromuscular layer
of the vagina – ANTERIOR COLPORRHAPHY
• Lateral cystocele or paravaginal defect due to
vagina detaching from the arcus tendinous
fascia – PARAVAGINAL REPAIR

22. ANTERIOR COLPORRHAPHY
• Traction is given on the cervix to expose the
ant. Vaginal wall
• An inverted T shaped incision is made in the
anterior vaginal wall starting with a
transverse incision in the bladder sulcus and
through its midpoint a vertical incision
extended up to the urethral opening

23. • The vaginal walls are reflected to either side to
expose the bladder and vesicovaginal fascia
• The overlying vesicovaginal fascia is tightened,
and the excess vaginal wall is excised to
correct the laxity, and vaginal wall sutured

25. PARAVAGINAL REPAIR
• Method to correct a lateral defect or lateral
cystocele
• Adbominal method involves entering the
retropubic space and approximating the
detached vagina to the arcus tendinous fascia

27. Posterior compartment
POSTERIOR COLPORRAPHY &
COLPOPERINEORRHAPHY
• Done to correct a rectocele and repair a
deficient perineum
• Lax vagina over the rectocele is excised, and
rectovaginal fascia repaired after reducing the
rectocele
• Approximate the medial fibres of levator ani
• Usually combined with a perineorraphy if
there is defective perineal body.

29. Middle or apical compartment
The apical defects can be of three types:
• Uterine prolapse
• Enterocele
• Vault prolapse following hysterectomy
Vaginal route is usually preferred.

30. VAGINAL HYSTERECTOMY WITH PELVIC FLOOR
REPAIR( WARD-MAYO REPAIR )
• Commonest operation performed in cases of
uterovaginal prolapse in cases where
childbearing is complete
• usually combinedd with repair of an
associated cystocele, enterocele and rectocele

31. SACROSPINOUS COLPOPEXY
• in cases of procidentia with complete vaginal
eversion and in cases of vault prolapse
• Vault of vagina is attached to the sacrospinous
ligament
Acess via the retrovaginal spacce upto the
ischialspine

34. LEFORT’S REPAIR OR COLPOCLEISIS
• Obliterative procedure
• Very rarely employed
• Only in elderly women with meddical
problems making them unfit for repair
operation
Vaginal epithelium is removed followed by
suturing of the anterior and posterior walls of
vagina therby obliterating the vagina.

37. MANCHESTER OR FOTHERGILL’S OPERATION
• Not much used
• Useful in women who have completed their
families but wish to retain their uterus
• Option in lesser degrees of uterovaginal
prolapse with supravaginal elongation of
cervix.
• Recurrence more likely

38. • Procedure consists of anterior
colporrhaphy,isolation and ligation of the
cardinal ligaments, amputation of the
cervix,suturing the cardinal ligaments to the
front of the cervix( fothergill’s stitch) and
finally reforrming the lips of the cerrvvix using
the vagina(sturmdorf’s sutures)
• Best for young women who have completed
their families.

40. SHIRODHKAR’S EXTENDED MANCHESTER OR
VAGINAL SLING OPERATION
• Modification of fothergill’s
• Cervical amputation is avoided
• Here uterosacral ligaments are isolated to
form slings which are crossed and stitched
together in in front of the cervix.

42. USE OF MESH
Increasingly used in repeat surgery
purpose is to completely replace the patient’s
own weak tissues
Can be used while performing an ant or post
colporraphy
Main problem is mesh erosion

44. ENTEROCELE
• Must be looked for and corrected along with
with any repair procedure
• Important to do a prophylactic procedure
following hysterectomy even if no obvious
defect, as most enteroceles occur follows
hystrectomy.

45. VAGINAL CORRECTION
• CUL-DE-SAC is opened & peritoneum
dissected at its highest point
• Then peritoneal sac is ligated at its highest
point and peritoneum excised
• Defect closed by approximating the
uterosacral ligaments in the midline
• “McCall culdoplasty”

46. ABDOMINAL CORRECTION
• Vaginal vault after hysterectomy can be
suspended to the uterosacral ligaments on
either side to prevent an enterocele…
• Other procedures
1. Halban
2. Moscowitz procedures