Uterovaginal prolapse

Uterovaginal prolapse

Pelvic organ prolapse refers to the protrusion or displacement of the pelvic organs from their normal anatomical position into or through the vagina to varying degrees ( Figure 87.23 ). It is said to a ff ect up to 40% of women at some point in their lifetime. A prolapse can have a detrimental impact on normal organ performance, including anorectal, urinary and sexual function. A prolapse is more common in certain groups, including: /uni25CF older women; /uni25CF parous women, increased parity , prolonged labours, vagi - nal deliveries; /uni25CF obese women; /uni25CF women who have chronic constipation; /uni25CF women with occupations that involve heavy lifting; /uni25CF women with oestrogen deficiency; /uni25CF women with a family history or genetic risk; /uni25CF women with connective tissue disorders, e.g. Ehlers–Danlos syndrome, Marfan syndrome. (a) (c) (e) Women with minor prolapses may be asymptomatic, but those with more significant degrees may present with a sensation of ‘something coming down’. A cystocele (bladder prolapse) and a cystourethrocele (prolapse of the bladder and urethra) can lead to the sensation of a lump in the vagina and may be associated with urinary urgency (OAB symptoms) and recurrent urinary tract infections. Uterine descent can lead to a lump in the vagina or a dragging sensation; with complete prolapse of the uterus (procidentia) there may be associated vaginal discharge, ulceration of the vaginal mucosa and bleeding. A rectocele (prolapse of the rectum into the vagina) may cause di ffi culties with defecation or a sensation of incomplete emptying, which can be relieved by digital reduction of the prolapse. The degree of prolapse is graded in terms of descent. Cur rently , the commonly used grading system is the Pelvic Organ Prolapse Quantification System (POP-Q): /uni25CF grade 0: no prolapse is demonstrated; /uni25CF grade 1: the most distal portion of the prolapse is >1 /uni00A0 cm above the level of the hymen; /uni25CF grade 2: the most distal portion of the prolapse is ≤ 1 /uni00A0 cm (b) above or below the level of the hymen; /uni25CF grade 3: the most distal portion of the prolapse is >1 /uni00A0 cm below the level of the hymen but 2 /uni00A0 cm less than the total vaginal length; /uni25CF grade 4: maximal descent. Non-surgical management of a uterovaginal prolapse includes: lifestyle changes (avoidance of constipation); physio - therapy to help strengthen the pelvic floor muscles for at least 16 weeks for those with grade 1 or 2 organ pr olapse; topi - cal oestrogen replacement for oestrogen deficiency to help increase tissue strength and elasticity; and vaginal pessaries . There are a number of di ff erent pessaries a vailable and they are replaced every 3–6 months, with the ring pessary being the most frequently used. It is inserted between the posterior fornix - and the pubic bone. The main complications are of vaginal ulceration and infection leading to discharge and bleeding; it is advisable, therefore, to replace the ring frequently . Surgical management aims to correct the prolapse. The surgical procedures are intended to restore the uterovaginal anatomy and position. They may be carried out using a vaginal or abdominal (open or laparoscopic) appr oach ( Table 87.12 ).

(c) (e) (d) Figure 87.23 Uterovaginal prolapse: (a) urethrocele/cystocele (arrow); (b) uterine prolapse (arrow); (c) enterocele (arrow); (d) vaginal vault prolapse (arrow); (e) rectocele (arrow).

/uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF Approximately 30% of women in their lifetime report a recurrence of their symptoms following surgical treatment. This figure increases with subsequent procedures.

Condition Treatment Urethrocele/cystocele An anterior vaginal wall repair (anterior colporrhaphy) ( Figure 87.23a) without the use of mesh Uterine prolapse If the patient’s family is complete, a vaginal ( Figure 87.23b ) hysterectomy with or without vaginal sacrospinous /f_i xation can be performed Uterus-preserving surgery includes: amputation of the cervix with suturing of the transverse cervical ligaments vaginally (Manchester repair); laparoscopic plication of the uterosacral ligaments (McCall suture); or hysteropexy, which may be vaginal (attaching the cervix to the sacrospinous ligaments using non- absorbable sutures) or laparoscopic/abdominal (sacrohysteropexy using a polypropylene mesh to suspend the uterus to the sacral promontory) A colpocleisis can be considered in women who no longer wish to have penetrative intercourse Enterocele A similar technique to repair of a hernia is used. The ( Figure 87.23c ) vaginal mucosa is opened and the hernial sac repaired Vaginal vault prolapse Sacrospinous /f_i xation performed vaginally: the ( Figure 87.23d ) vault is attached to the right sacrospinous ligament using a non-absorbable suture/mesh, avoiding the rectosigmoid colon on the left Sacrocolpopexy performed abdominally or laparoscopically: the vaginal vault is attached to the sacral promontory using a mesh A colpocleisis can be considered in women who no longer wish to have penetrative intercourse Posterior colpoperineorrhaphy without mesh: the Rectocele posterior vaginal wall is opened, the rectum returned ( Figure 87.23e ) to its normal position and redundant vaginal mucosa excised SUI, stress urinary incontinence.