Prolapse of Uterus

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      • Cystocele (MCQ)
        • present when there is descent of the anterior vaginal wall
        • It is generally caused by
          • separation of the paravaginal attachment of the pubocervical fascia from the arcus tendineus fasciae pelvis (MCQ)
          • tearing of the pubocervical fascia, which results in herniation of the bladder. (MCQ)
      • Rectocele
        • caused by a defect in the rectovaginal septum . (MCQ)
        • results in herniation of the posterior wall of the vagina and the anterior wall of the rectum, so that they are in direct apposition to vaginal epithelium. . (MCQ)
      • Loss of perineal body integrity
        • occurs when the perineal body becomes detached from the rectovaginal septum and becomes mobile.
        • Loss of perineal body integrity can lead to an inferior rectocele and perineal descent.
      • Uterovaginal prolapse
        • occurs secondary to damage of the cardinal-uterosacral ligament complex and endopelvic fascia that normally support the uterus and upper vagina over the pelvic diaphragm.
      • Vaginal vault prolapse
        • refers to descent of the vaginal apex below its normal position in the pelvis after a woman has had a hysterectomy.
      • Enterocele
        • hernia in which the normal anatomic endopelvic fascia is absent so that small bowel fills the hernia sac . (MCQ)
        • peritoneum is in contact with vaginal mucosa
        • Enteroceles are the result of separation of the pubocervical and rectovaginal fasciae, which allows a peritoneal sac with its contents to protrude through the fascial defect.
      • Etiology of pelvic floor damage. . (MCQ)
        • Heavy lifting,
        • obesity, chronic coughing
        • chronic diseases, especially those accompanied by neuropathy, are associated with pelvic organ prolapse.
        • hypoestrogenic state of menopause
        • genetic predisposition
      • History.
        • Patients with vaginal prolapse commonly describe aching in the groin or lower back . (MCQ)
          • caused by traction on the uterosacral ligaments
          • discomfort typically resolves when the patient lies down
        • ulceration on the vaginal wall
        • The symptoms of urethral support are generally those of stress urinary incontinence. . (MCQ)
        • When patients have defective support of the upper anterior vaginal wall, they often complain of difficulty voiding and a sense of incomplete emptying.
        • Sometimes, these patients report that they must strain or perform a Valsalva maneuver to empty the bladder.
        • Patients with a rectocele complain of the
          • sensation of pelvic pressure
          • feeling that there is a mass or bulge in the vagina
          • inability to evacuate the distal rectum without straining
          • splinting (applying pressure between the vagina and the rectum to elevate the rectocele and facilitate defecation).
          • Unfortunately, as the woman bears down to empty the rectum, stool is pushed into the rectocele, and the harder she strains, the larger the rectocele becomes.
      • Physical examination.
        • When a patient with pelvic organ prolapse is being evaluated, there are four “compartments” that should be systematically assessed
          • anterior vaginal wall,
          • uterus and vaginal apex
          • posterior vaginal wall
          • presence or absence of an enterocele should be determined.
        • The physical examination should be performed with the patient in the lithotomy position.
        • Pelvic organ prolapse defects are best identified using a Sims speculum or the posterior blade of a Graves speculum
        • While the other compartments are supported, the patient is asked to strain forcefully or cough vigorously. During this time, descent of the pelvic organs is systematically observed.

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        • The Pelvic Organ Prolapse Quantitation system . (MCQ)
          • commonly used to quantify the degree of pelvic organ prolapse seen during the physical examination.
          • It describes nine measured segments of a patient’s pelvic organ support. The prolapse of each segment is evaluated and measured relative to the hymenal ring, which is a fixed anatomic landmark.

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Points and landmarks for POP–Q system examination. Aa, point A anterior, Ap, point A posterior, Ba, point B anterior; Bp, point B posterior; C, cervix or vaginal cuff; D, posterior fornix (if cervix is present); gh, genital hiatus; pb, perineal body; tvl, total vaginal length

 

 

          • Diagnostic studies.
            • if the patient has defecatory complaints, a dynamic MRI can be useful.
            • A defecating proctogram (quadruple-contrast study), which is performed under fluoroscopy, allows visualization of the small bowel, bladder, vagina, and rectum during defecation.
          • Treatment.
            • Nonsurgical
              • Hormone replacement therapy. . (MCQ)
                • Estrogen replacement therapy
                • affects postmenopausal urogenital symptoms
                • HRT alone will not relieve a patient’s prolapse.
                • However, HRT  before a surgical repair is performed is beneficial because it promotes vaginal cellular maturation and improves symptoms of atrophy.
              • Pelvic muscle exercises. -Kegel exercises. (MCQ)
                • aimed at improving muscle tone of levator ani , can alleviate the symptoms of prolapse
                • the bladder and other pelvic organs are supported by the levator ani muscles,.
              • Pessaries . (MCQ)
                • oldest effective treatment for prolapse.
                • one of the most commonly used for prolapse is the doughnut-shaped pessary.
                • Pessaries are placed in the vagina and are retained above the pelvic floor musculature, which prevents the smaller uterine cervix from passing through the introitus.
                • Having the patient remove the pessary at night minimizes the vaginal discharge that is commonly associated with pessary use.
                • In addition, treatment with estrogen, either locally or systemically, helps the vaginal mucosa tolerate the foreign body.
                • Because pessaries can cause erosion and ulceration, patients should be examined periodically.
          • Surgical
            • Abdominal
              • Enterocele repair. –  three techniques for the abdominal repair
                • Moschcowitz procedure. (MCQ)
                  • performed by placing concentric purse-string sutures around the cul-de-sac, including the posterior vaginal wall, right pelvic side wall, the serosa of the sigmoid, and the left pelvic side wall.
                • Halban procedure . (MCQ)
                  • obliterates the cul-de-sac using sutures placed sagittally between the uterosacral ligaments.
                • Transverse plication of the uterosacral ligaments
                  • used to obliterate the cul-de-sac.
                • In all three of these procedures, care must be taken to avoid kinking a ureter.
              • Abdominal sacral colpopexy . (MCQ)
                • a procedure used to suspend the vagina to the sacral promontory
                • used as a treatment for uterovaginal prolapse and vaginal eversion
                • It is the procedure of choice for patients who have other indications for abdominal surgery.
                • synthetic materials such as polypropylene or polytetrafluoroethylene mesh are most commonly used for the graft
              • Paravaginal repair.
                • This repair is performed for anterior vaginal wall prolapse
                • accomplished using an abdominal (retropubic) or vaginal approach
                • goal of this repair is to reattach the anterolateral attachments of the vagina, including the overlying endopelvic fascia, to the arcus tendineus fasciae pelvis.
            • Vaginal
              • Transvaginal hysterectomy with or without anteroposterior colporrhaphy . (MCQ)
                • the operation most commonly performed for the treatment of uterovaginal prolapse.
                • Each patient has different degrees of prolapse in the anterior and posterior compartments.
                • Should there be significant prolapse in either of these compartments, simply removing the uterus will not correct prolapse of the vaginal walls.
              • Anterior colporrhaphy. . (MCQ)
                • is performed to repair a cystocele and cystourethrocele.
                • The objective of anterior colporrhaphy is to reduce the protrusion of the bladder and vagina
                • In this procedure, the layers of the vaginal muscularis and adventitia overlying the bladder (pubocervical fascia) are plicated.
                • In women suffering from stress incontinence, a Kelly suture to plicate the bladder neck helps to correct stress incontinence
              • Posterior colporrhaphy . (MCQ)
                • done to correct a rectocele and repair a deficient perineum.
                • It is commonly combined with an anterior colporrhphy, or a vaginal hysterectomy requiring pelvic floor repair, and as part of
              • Rectovaginal fascia defect . (MCQ)
                • a procedure in which isolated defects in the rectovaginal fascia are identified and reapproximated, so that normal anatomy is restored.
              • Perineorrhaphy
                • the identification and reconstruction of the elements of the perineal body.
              • Fothergill’s repair (Manchester operation) . (MCQ)
                • In this operation, the surgeon
                  • combines an anterior colporrhaphy with amputation of cervix
                  • sutures the cut ends of the Mackenrodt ligaments in front of the cervix
                    • covers the raw area on the amputated cervix with vaginal mucosa and follows it up with a colpoperineorrhaphy
                  • The operation preserves menstrual and childbearing functions. . (MCQ)
                  • However, fertility is somewhat reduced because of the-;amputation of the cervix causing loss of cervical mucus.
                  • It is suitable for women under 40 years who are desirous of retaining their menstrual and repro­ductive function. . (MCQ)
                  • Some include dilatation of cervix and endometrial cuRettage as a preliminary step in Fothergill repair.
                  • This is optional, but desirable in a woman complaining of men­strual disorder associated with prolapse.
                  • Obstetric complications of Fothergill operation. (MCQ)
                    • Cervical amputation may lead to
                      • Incompetent cervical os
                      • habitual abortions
                      • preterm deliveries.
                    • Excessive fibrosis may lead to cervical stenosis and dystocia during labour. Very rarely, it may cause haematometra.
                    • Recur­rence of prolapse may occur following vaginal delivery in some cases.
                • Shirodkar’s procedure
                  • To avoid the obstetric complications of Fothergill operation, Shirodkar modified this operation. (MCQ)
                  • The anterior colporrhaphy is performed as usual
                  • attachment of Mackenrodt ligaments to the cervix on each side is exposed.
                  • The vaginal incision is then extended posteriorly round the cervix
                  • pouch of Dou­glas is opened
                  • uterosacral ligaments identified and divided close to the cervix.
                  • The stumps of these ligaments are crossed and stitched together in front of the cervix.
                  • A high closure of the peritoneum of the pouch of Douglas is carried out. The cervix is not amputated and later pregnancy complications avoided.
                  • The rest of the opera­tion is similar to Fothergill’s operation.
                • Vaginal hysterectomy with pelvic floor repair
                  • suitable for . (MCQ)
                    • women over the age of 40 years
                    • those who have completed their families
                    • no longer keen on retaining their childbearing and menstrual functions.
                  • The age limit may be relaxed to 35 years for women who have . (MCQ)
                    • additional menstrual problems
                    • uterus is a seat of fibroids, adenomyosis.
                    • The operation relieves the woman of her prolapse and also of her menstrual problems.
                  • A Kelly stitch may be necessary to relieve her of stress incontinence, if this is present.
                  • Complications . (MCQ)
                    • haemorrhage, sepsis, anaesthesia risks
                    • urinary tract infection
                    • rarely trauma to the bladder and rectum may occur.
                    • Vault prolapse follows as a late sequela in a few cases.
                    • Dyspareunia is caused by a short vagina.
                  • LigaSure
                    • LigaSure vessel sealing system
                    • used to secure the pedicles in vaginal hysterectomy.
                    • device consists of bipolar radiofrequency generator, reusable hand-piece and disposable electrodes.
                    • The electrodes melt the col­lagen and elastin in the vessel wall to form a seal zone.
                    • The quick surgery with LigaSure is an advantage.
                    • Vaginal hysterectomy is mainly performed for major degree of uterine prolapse in the elderly woman.
                  • Vaginal hysterectomy is contraindicated if the uterus is: . (MCQ)
                    • Very bulky (more than 12-14 weeks)
                    • Fixed by abdominal adhesions  and inflammatory disease
                    • Abdominal   adhesions   are   likely   to   be present   if  the   woman   had   previous   abdominal surgery or caesarean section.
                    • Other pelvic pathology exists such as endometriosis and    ovarian    tumour.    In    such cases, proper laparotomy is indicated.
                • Abdominal sling operations
                  • designed  for young women . (MCQ)
                    • suffering from second- or third-degree terine prolapse,
                    • who are desirous of retaining their childbearing and menstrual functions.
                  • The objective of these operations is to buttress the weakened supports (Mackenrodt and uterosacral ligaments) of the uterus by providing a substitute in the form of nylon or Dacron tapes, used as slings to support the uterus. . (MCQ)
                  • The advantage of the synthetic tapes is that they are strong and non-tissue reactive.
                  • The sling operations are best suited to nulliparous prolapse
                  • The operations in common practice include: . (MCQ)
                    • Abdominocervicopexy.
                    • Shirodkar’s abdominal sling operation.
                    • Khanna’s abdominal sling operation.
                  • Abdominocervicopexy
                    • Presently, the surgeon uses a 12 inch long Mersilene/nylon tape to provide the new artificial supports for the uterus
                    • Purandare and Mhatre improved on the original opera­tion by attaching the tape posteriorly on the cervix close to the attachments of the uterosacral ligaments, and then the ends of the tape were brought forward retroperitone­ally, and attached to the external oblique aponeurosis.
                    • Abdominocervicopexy can be combined with a . (MCQ)
                      • Moschcowitz’s repair to obliterate an enterocele
                      • anterior colpor-rhaphy and colpoperineorrhaphy to correct additional genital laxity of the vagina.
                  • Indian gynaecologists that  contributed signifi­cantly to the operative repair of genital prolapse.
                    • Virkud’s sling operation
                    • Mangeshkar’s laparoscopic tech­nique,
                    • Neeta Warty’s laparoscopic modification of Shirodkar’s operation.
                • Shirodkar’s abdominal sling operation for uterine prolapse. (MCQ)
                    • designed to meet the special needs of the case of a nulliparous prolapse having inherently weak supports.
                • Khanna’s sling operation
                    • In this operation the Mersilene tape is fixed to the isthmus posteriorly, and the two free ends brought out retroperitoneally to emerge out at the lateral margin of the rectus abdominis muscle on either side, and anchored to the anterosuperior iliac spine on either side.
              • Enterocele repair.
                • McCall culdoplasty procedure
                  • an enterocele is surgically corrected at the time of a vaginal hysterectomy
                  • The advantage of this procedure is that it not only repairs the enterocele, but it provides apical support for the vagina
                  • Some have recommended performing this procedure with every vaginal hysterectomy to prevent future enterocele formation and vaginal vault prolapse.
              • A LeFort partial colpocleisis . (MCQ)
                • performed to obliterate the vagina.
                • performed to reduce uterovaginal prolapse
                • apposes the anterior and posterior vaginal walls.
                • It is considered to be an operation of last resort, and the patient should understand that she will not have a functional vagina.
                • Advantages are that the procedure can be performed quickly and under regional anesthesia.
                • This procedure is commonly used in elderly patients who are poor surgical candidates.


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Sacrohysteropexy is a surgical procedure to correct uterine prolapse. It involves a resuspension of the prolapsed uterus using a thin strip of synthetic mesh to lift the uterus and hold it in place. It allows for normal sexual function and preserves child bearing function. It is routinely performed via laparoscopy.
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Showing vaginal hysterectomy and pelvic floor repair for stage 3 uterine prolapse.
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wow!! prolapse of uterus of a cow
another great(dirty) work by a veterinary surgeon!!!!. inside out postpartum (soon after calving)prolapse of uterus of cow is getting corrected by dr.jomon angamaly. veterinary work is a very challenging one.please rate this amazing video
Total prolapse of uterus,procidentia,vaginal hysterectomy,mesh,pelvic floor repair,dr c v hegde,mumbai,india