MANAGEMENT OF
PROLAPSE
BY SHILPA BIJU
MANAGEMENT OF VAGINAL PROLAPSE
• Anterior Colporrhaphy
Performed to repair Anterior vaginal wall prolapse i.e, Cystocele and Urethrocele.
Steps- Traction is given to cervix to expose the AVW.
Inverted T- shaped incision is made in AVW.
Vaginal mucosal flaps are reflected on either side to expose the bladder and
vesicovaginal fascia.
Overlying VVF is tightened and excess vaginal wall is excised .
Intermittent suturing of vaginal flaps.
• Posterior colpoperineorrhaphy
It is done to correct a Rectocele and repair a deficient perineum.
The laxed vagina over the Rectocele is excised and the Recatovaginal fascia is repaired
after reducing the Rectocele.
It is commonly combined with Anterior Colporrhaphy or Vaginal hysterectomy.
Disadvantages- high cost
Dysparunia
Infection (in case mesh is used.)
sinus formation
• Mc Call Culdoplasty
Done to correct Enterocele.
Pouch of Douglas is obliterated and sutured with the vaginal wall.
MANAGEMENT OF UTERINE PROLAPSE
CONSERVATIVE MANAGEMENT
•KEGEL’S EXERCISES
Perineal/Pelvic floor exercises
Prevent Prolapse and it’s progression.
Done in first degree prolapse.
Indicated in Pregnant females.
•PESSARY TREATMENT
Pessary is a space occupying device made up of soft plastic polyvinyl chloride and available in different sizes.
Most common types are Ring, Gellhorn and Doughnut pessaries.
It doesn’t allow the uterus to prolapse.
Indications- Young woman who is desirous of further childbearing.
Pregnancy (first trimester)
Postpartum period
Unfit for surgery
Patient’s choice
Temporary use while treating infection and Decubitus ulcer.
•Limitations- Needs to be changed every 3 months
Cause vaginitis, Vaginal ulcers and Dysparunia.
Get expelled spontaneously in a squatting position, if vaginal orifice is patulous.
Not helpful for symptoms of Stress Urinary Incontinence.
SURGICAL MANAGEMENT
• Main mode of treatment of uterine prolapse.
• Done in second and third degree prolapse.
• Type of surgery depends on age and parity of woman.
VAGINAL HYSTERECTOMY WITH PELVIC FLOOR REPAIR
It is a surgical procedure to remove uterus through vagina.
Indications- Woman older than 40 years
Woman who had completed her family
Postmenopausal woman
• Complications - Hemorrhage
Sepsis
Anaesthesia risks
UTI
Trauma to bladder and rectum
Vault prolapse
Dysparunia ( short vagina)
• Contraindications – Bulky Uterus
If Uterus is fixed by Abdominal adhesions and Inflammatory disease
Endometriosis
Ovarian tumors
In such cases, Proper Laparotomy is indicated.
ABDOMINAL SLING OPERATIONS
• Also called as Colpocleisis
• Artificial slings are used to support the uterus and strengthens the weak support of uterus.
• Material used are Mersilene tape or Nylon mesh.
• They are strong and non tissue reactive.
• The operations in common use are as follows:
Abdominal wall cervicopexy
Shirodkar’s sling op.
Khanna’s sling op.
• Indications – Nulliparous females (treatment of choice)
Congenital prolapse
Woman who are desirous of childbearing.
MANCHESTER’S OPERATION (FOTHERGILL’S REPAIR)
• Done in female of Reproductive age with increased Uterocervical length and childbearing is complete.
• It includes 2 steps:
Cervical Amputation- Circumcision of cervix and the bladder is dissected from cervical neck.
Plication of Cardinal ligament- The cut ends of Cardinal ligament are sutured in front of cervix to suppor the uterus
Complications of Fothergill’s repair
• Cervical incompetence
• Cervical stenosis and dystocia
MANAGEMENT OF VAULT PROLAPSE
SACROCOLPOPEXY
• Best method for the treatment of vault prolapse.
• A synthetic sling (Mersilene mesh) is used to fix the vault to the sacrospinous ligament.
UTEROSACRAL SUSPENSION
• Attaching Uterosacral ligament to the apex of the vagina.
• Prevent vault prolapse
• Can be done abdominally and vaginally.
SACROSPINAL FIXATION
• Vault is sutured to the Sacrospinous ligament.
Le FORT’s COLPOCLEISIS
• Approximation of Anterior and Posterior wall of vagina
