PELVIC SUPPORTS

RELAXATION
AND
GENITAL PROLAPSE
BY
DR. 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.

TYPE
S OF GENITAL PROLAPSE
 1.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 are
outside the hymen. This
cystocoele is often part of the
third degree uterine or post
hysterectomy 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
the
Vaginal 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-fourth
of 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 large
cystocoele 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 voiding
ensures 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.

TREATMENT
Medical 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 stress
incontinence.
 COMPLICATION
S

-Acute urinary retention

-Recurrent UTI

PREVENTION
1. 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 the
posterior vaginal wall ;
frequently a flat, lacerated
perineal
body.
-examination is best
perfomed retrovaginally
with index finger
in the vaginal and the
middle finger in rectum.

DIAGNOSIS
-rectovaginal examination
confirms anterior
sacculation through the
posterior
vaginal 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).

TREAMEN
T

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
type
2. 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.

ENTEROCOE
LE
.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.

TREATMEN
T
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/Transvagin
al 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.

PREVENTIO
N
Neglected 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
MEASURES
Complete 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.

DIAGNOS
IS

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
vagina
before 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 uterus
or large leiomyomata.
In either approach, the
uterosacral and cardinal
ligaments are
Ligated and tied together
and the cul-de-sac
obliterated to
reduce 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 protruding
outside the intritus.
A portion of the cervix is
amputated and the uterus is
resuspended with the
divided 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 and
repair 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 morbidity
and a high success rate.
However, coital function is
limited,inspection of the
cervix
and uterus is impossible and
post operative urinary
incompetence can occur.

COMPLICATION
S
Leukorrhoea, abnormal
uterine bleeding and
abortion from
infection/disordered
uterine or ovarian
circulation in prolapse.
-Chronic decubitus
ulceration in procidentia.
 -UTI from cystocoele
and partial urethral
obstruction with
hydronephrosis
In 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 women
maintains 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 should
be avoided.
 DIFFERENTIAL
DIAGNOSIS
-Cervical elongation.
-Cervical tumours.

CONCLUTION

.Successful treatment of
cystocoeles require an
evaluation for both lateral
and central defects as
inadequate treatment of
either defect will lead to
reccurrences.
.The treatment of
rectocoeles is controversial.
Most clinicians would
certainly repair
symptomatic 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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