GENITAL PROLAPSE

DR. IQBAL TURKISTANI Asst. Prof. & Consultant

 The pelvic floor, closing the outlet of the pelvis is made up of a number of muscular and facial structures the most important of which is the LEVATOR ANI.
These structures are pierced by the RECTUM, VAGINA & URETHRA. passing through the exterior of the body These structures are supported in place by: ligaments condensation of facia

 A relaxed vaginal outlet is usually a sequel to mere OVERSTRETCHING of the perineal supporting tissues as a result of previous parturition Muscular atony and loss of elastic tissue in later life lack of hormone DENERVATION due to damage to perineal or pelvic nerves delivery and pelvic surgery

TYPES OF GENITAL PROLAPSE

PELVIC ORGAN PROLAPSE (POP)
1. CYSTOCELE = As a result of defect in the pubo-cervical facial plane which support the bladder anteriorly = it tends to permit the bladder to sag down below and beyond the uterus URETHROCELE: = when the defective facia involves the urethra RECTOCELE = due to attenuation in the pararectal facia permits the rectum to bulge through ENTEROCELE: = Peritoneal hernial sac along the anterior surface of the rectum = Often contains loops of small intestine

2. 3.

4.

DIAGNOSIS OF POP
SYMPTOMS:
Often symptomless Complaints of : Pressure and heaviness in the vaginal region Sensation of everything dropping out Bearing down discomfort in the lower abdomen Backache

 Other associated problems:

Fecal incontinence (e.g. with complete perineal laceration) and often with loose stools. Difficulty in emptying the bladder with marked cyctocele Cystitis due to residual urine ascending UTI frequency of micturition Urinary incontinence stress incont. Difficulty of defection and constipation with rectocele haemorrhoids

Lump/mass protruding through is marked prolapse

SIGNS / EXAMINATION:

Inspection Gaping introitus Perineal scars Visible cystocele and rectocele / urethral Uterine prolapse Cx. Ulceration (contact) = Decubitus ulcer

Degree of prolapse

TREATMENT
Incontinence
Objective:
To provide cure or improvement Treatment options, risks, benefits and outcomes should be discussed.

POP

Treatment Options:
Can be divided into:
Pharmacologal Conservative Measures Surgical intenvention

I. CONSERVATIVE TREATMENT:
Life style interventions Physical therapy (PFMT) / Kegels Exercise Bladder training Electrical stimulation Behavioral strategies Anti- incontinence devices

II.

PHARMACOLOGICAL TREATMENT: A. Drug used for Urgency Incont. and OAB.

i. Antimuscarinic (anticholinergic) agents - Muscanic receptors (M2 & M3) are predominant in the bladder. - These can be blocked by antimuscarinic which act by competing with ACH on the muscarinic receptors mainly during the storage phase e.g. Oxybutinin Tolterodine Solifenacin Darifanacin Propiverine

Tertiary amines Quarternary amines

- Very good efficacy profile - Side effects: Dry mouth Constipation Blurred Vision & Cardiovascular effect palpitations / tachycardia - Contraindication: , Narrow angle glucoma

ii.

Botulinum Toxin (BTX) - types A & B

- local intravesical injection - Blocks the release of Ach from parasympathetic nerve endings at the myo-neuronal junction redution in muscle contractility

B.

DRUGS FOR SUI:

Duloxetine
= combined norepinephrine and serotonin re-uptake inhibitor sphincter muscle activity during filling phase of micturition significant in incont. episode frequency (IEF) >50% from baseline ---> improvement in quality of life

SIDE EFFECTS:
- Nausea - Others fatigue, dry mouth, headache, dizzines

C.

ESTROGENS
= Controversiial little effect in the management of SUI

SURGICAL TREATMENT FOR INCON.

I. SURGERY FOR SUI:
1. 2. 3. Intra-urethral injection therapy Cysto-urethropexies Low-tension vaginal tape TVT TOT Classical sling procedures Artificial sphincters

4. 5.

II.

SURGERY FOR URGNECY INCONT. (UUI)

1. 2. 3. Augmentation cystoplasty Auto-augmentation Sacral nerve stimulation