‫سورة البقرة آيه ‪32‬‬

Genital prolapse
Definition:
Descend of the genital organs below its normal
position.
Types of prolapse:
1. Uterine prolapse.
2. Vaginal prolapse.
3. Combined prolapse: Either vagino-uterine or
utero-vaginal.
 Uterine prolapse
Degrees:
First degree:
The external os of the cervix descend below its
normal level at the ischeal spines, when the
patient stands or strains, but it does not
appears from the vulva.
Second degree:
The cervix but not the whole uterus appears from
vagina on standing or straining.
Third degree:
The whole uterus is prolapsed outside the vagina.
This is called complete procedentia.
Genital prolapse
 Vaginal prolapse
Anterior vaginal wall prolapse:
 Descend of the upper 2/3 of the vagina with the
bladder base  Cystocele
 Descend of the lower 1/3 of the vagina with the
urethra  Urethrocele
 Descend of the whole vagina with the bladder
and urethra  Urethro-cystocele
Vaginal prolapse
 Vaginal prolapse
Posterior vaginal wall prolapse:
 Descend of the upper 1/3 of the vagina 
Enterocele
 Descend of the middle 1/3 of the vagina with
the rectum  Rectocele
 Descend of the lower 1/3 of the vagina with the
anal canal  Rectocele
Vault prolapse:
Descend of the vaginal vault after hysterectomy
 Vaginal prolapse

Rectocele Vault prolapse

 Factors maintaining the uterus in
its normal position
1. The cervical ligaments.
2. Pelvic floor muscles (Levator ani muscles)
3. Anteverted anteflexed position of uterus
 Etiology of prolapse
(A) Primary causes:
1. Weakness of the cervical ligaments:
a. Congenital weakness:
Prolapse appears at an early age (Virginal or
nulliparous prolapse).
True congenital prolapse at birth is rare and usually
accompanied with spina bifida and generalized
viceroptosis.
 Etiology of prolapse
b. Obstetric causes: Commonest cause:
1. Delivery of large baby.
2. Bearing down before full cervical dilatation.
3. Forceps or breech extraction before fully
dilated cervix.
4. Obstructed labor
5. Inadequate puerperal rehabilitation.
6. Rapid succession of pregnancies.
c. Post menopausal causes:
Withdrawal of female sex steroid especially
estrogens after menopause, prolapse may
appear at this elder age group patients.
 Etiology of prolapse
2. Injury of the pelvic floor: This the result of
childbirth
Lacerations of the perineal body during childbirth
and unless the torned retracted muscles are
brought-in by immediate suturing, the
urogenital hiatus becomes patulous.
3. Retroversion of uterus:
When the uterus becomes retroverted, the increased
intra-abdominal pressure tends to push the
uterus downwards, so it lies along the
longitudinal axis of vagina.
 Etiology of prolapse
4. Hidden perineal tear:
It is due to over stretching or prolonged distension
of the perineum by the fetal head, lacerations
and weakness of the perineal muscles occurs
while the perineal skin remains intact.
 Etiology of prolapse
(B) Secondary causes:
Prolapse occurs when damage of the supports of
uterus has been already occurred.
1. Increased intra-abdominal pressure:
Due chronic coughs, chronic constipation, ascitis,
intra-abdominal tumors
2. Increased weight of uterus:
As in small uterine fibroid, and sub-involution of
uterus, if the size of uterus is large, the uterus
will be arrested on the pelvic brim.
3. Traction on the uterus:
By cervical fibroid or vaginal prolapse
 Complications of prolapse
(I) The vagina:
1. Vaginal wall becomes thickened due to
congestion and edema.
2. Vaginal mucosa becomes exposed to air  Dry
& kerateinized and pigmented.
3. Trophic ulcers in vaginal mucosa and portio-
vaginalis due to:
a. Congestion of tissues interfering with its
nutrition.
b. Friction with thigh and clothes.
c. Irritation by urine or feces.
d. Atrophy of vagina mucosa after menopause.
 Complications of prolapse
(II) The cervix:
1. Chronic hypertrophic cervicitis due to
congestion and edema.
2. Elongation of the supra-vaginal portion due to
traction on the lower portion of the Macenrodt`s
ligaments, while the upper part is strong
resisting traction and stretch.
3. Trophic ulcer
 Complications of prolapse
(III) Uterus:
1. Retro-version of uterus in second and third
degrees uterine prolapse
2. Congestion of endometrium.
(IV) Tubes and ovary:
Prolapsed ovary  chronic congestion which leads
to:
1. Dysparonia
2. Polymenorrhea  thick tunica albugenia and
anovulation
 Complications of prolapse
(V) Urinary tract:
1. Cystocele  Descend of bladder base 
Difficulty in micturation.
2. Chronic urine retention  Infection  Cystitis
with frequency and dysurea.
3. Stress incontinence due to injury of Lisso
sphincter
4. Third degree uterine prolapse may obstruct the
ureters  Hydroureters and hydronephrosis
 Symptoms
 Symptoms depend upon the type and degree
of prolapse and the presence of any
complications.
 One or more of the following complaints may
be present:
1. Sensation of vaginal fullness or pelvic
heaviness by something coming out on
bearing down.
2. Menstrual symptoms:
a. Congestive dysmenorrhea
b. D.U.B. in the form of menorrhagia or
polymenorrhea
 Symptoms
3. Mass protrudes outside the vulva with the
following characteristics:
a. Painless
b. Compressible
c. Increase in bearing down or straining
d. Disappears on lying down
 Symptoms
4. Renal-symptoms (present in 40% of cases)
5. Frequency in micturation, firstly diurnal but
later it is diurnal and nocturnal.
6. Incomplete evacuation of bladder except with
elevation of the anterior vaginal wall.
7. Dysuria or sense of pain during micturation
caused by occurrence of infection.
8. Aggravation or development of stress
incontinence.
 Symptoms
8. Rectal symptoms (less common):
a. Sensation of heaviness in the rectum.
b. Constant desire for defecation.
c. Incomplete defecation except with elevation
of posterior vaginal wall.
d. Piles may develop from straining
 Symptoms
10. Infertility:
a. Change in the position of the cervix to the
seminal pool.
b. Anovulation due to congested ovaries.
c. Congested endometrium unsuitable for ova
implantation.
11. Leucorrhoea:
a. Congestion and hypertrophy of cervical
glands
b. Increased transudation from the vaginal
walls.
c. Infections and ulceration of the exposed
cervix and vaginal walls
 Symptoms
12. Pain:
a. Dragging pain in the loin due to traction on
round ligaments.
b. Low backache due to traction on the
uterosacral ligaments.
 Signs
A. Inspection of the vulva for:
1. Evidence of perineal lacerations or widening of
the vagina.
2. The prolapsed structure whether it is the vagina
or uterus appears after asking the patient to
strain maximally
3. The presence of any complication in the
prolapsed structure such as ulceration
4. Appearance of stress incontinence after
reducing the prolapse with full bladder
 Signs
B. Digital-palpation:
Determining the nature of the
structure:
1) Cystocele can be confirmed by
palpating the metal catheter
introduced through the urethra in
the prolapsed structure.
2) Rectocele is confirmed by P-R
examination
Determination of the tone of the
perineal body and levalor ani
muscles.
 Signs
C. Bimanual-examination:
1. Determination of the size, site and direction of
the uterus
2. Exclude any associated pathologic condition
3. Determine any suspected supra-vaginal
elongation by using a uterine sound to find out
the length of the cervix.
D. Speculum examination:
To expose the cervix (if not prolapsed) to determine
any infection or laceration.
 Differential diagnosis
A. Cystocele:
1. Cysts of anterior vaginal wall:
These are incompressible and passage of a metal
catheter through the urethra will show a normal
direction of urethra and the cyst is placed
between the catheter and the vaginal wall.
2. Urethral or bladder diverticulum:
Differentiated by urethrocystoscopic examination
because both are compressible like cystocele
and urethrocele
 Differential diagnosis
B. Rectocele:
1. Cysts of posterior vaginal wall
2. Enterocele (Hernia of Douglas pouch):
This is characterized by:
1. Swelling of upper 1/3 of the posterior
vaginal wall.
2. Gurgling sensation on palpating the mass.
3. Rectal examination shows that the rectum is
not included in the mass.
 Differential diagnosis
D. Uterine-prolapse
a. Congenital elongation of the portio-vaginalis
of the cervix:
This is characterized by:
1. Presence of vaginal fornices at their normal
levels above the ischeal spines although the
cervix is below it.
2. Uterine sounding reveals that the elongation
is in the vaginal and not in the supravaginal
part of the cervix.
b. Swelling protruding from the vulva:
1. Fibroid polyp.
2. Chronic uterine inversion
 A. Prophylactic treatment
1. During labor
1. Avoid prolongation of labor
2. Avoid straining in the first stage
3. Avoid forceps application or breech extraction
before full cervical dilatation
4. Emptying of the bladder at regular intervals.
5. Episiotomy should be performed routinely in all
primipara and in any multipara once the
perineum becomes over stretched and about to
be treated.
 A. Prophylactic treatment
2. During puerperium
1. Suturing any vaginal or perineal tear
immediately after labor
2. Post-natal exercises and physiotherapy to
strengthen the pelvic floor muscles.
3. Avoid early physical work
 A. Prophylactic treatment
3. During hysterectomy and vaginal repair
operations
At hysterectomy:
The cardinal and uterosacral ligaments should be
tied and included in the vaginal vault
During plastic vaginal operations:
Good choice for the type of repair and avoidance of
over or under correction will prevent recurrence
B. Palliative treatment (Pessary)
Indications
1. Prolapsed gravid uterus (before 16 weeks)
2. During puerperium and lactation
3. Permanent or temporary contra-indications for
surgery
4. Patient refuses surgery.
5. Temporary use to promote healing of a
decubitus ulcer
Precautions
1. Daily vaginal douche by antiseptic solution
2. Monthly removal of the pessary for cleaning
and re-insertion.
B. Palliative treatment (Pessary)
Types
A. Ring pessary:
It is made of rubber with a watch-spring core.
It is introduced in the vagina above the level of the
levator ani muscle to stretch the redundant
vaginal walls and prevent descent of the uterus.
It is only used for women with intact pelvic floor
muscles.
 C. Surgical treatment
Pre-operative measures:
Investigations:
Routine investigations such as blood grouping,
complete blood picture and Hb determination
Specific investigations for urinary tract such as
complete urine analysis, pyelography and kidney
function tests (serum creatinine, urea clearance)
are needed to exclude infections and to assess the
kidney function.
 C. Surgical treatment
Treatment of any trophic ulceration: by
1. Reposition of the prolapse.
2. Vaginal packs soaked with antiseptic solution
and keeping the patient in flat position to
diminish congestion
3. Painting the ulcer with silver nitrate solution or
microchrome solution to help healing
4. Estrogen either in systemic or local forms can
be given to postmenopausal women.
5. Correction of the general health:
Such as anemia, malnutrition, chronic cough or
constipation and control hypertension or
diabetes
 C. Surgical treatment
Time of operation
All operations to correct prolapse should be done in
the post-menstrual period to give the wound a
chance to heal before the next period and to
minimize the amount of blood lost during the
operation.
At least 6 months should be passed from any
pregnancy and labor to operate on completely
involuted tissues.
 The choice of the operation
depends upon
1. Age of the patient.
2. Degree and type of prolapse
3. Desire for future fertility
4. Presence of elongated cervix or enterocele
5. Coitus is still practiced or not
 (A) Child-bearing period
1. Anterior colporraphy:
Indicated for patients with cystocele or
urethrocele
2. Posterior colpoperineorrhaphy:
Repair of posterior vaginal wall and perineal
muscles is indicated for cases of rectocele.
It is preferred to do posterior colpoperineorrhaphy
as an adjuvant procedure for any operation to
prolapse.
 (A) Child-bearing period
3. Classical repair
Cystorectocele with or without first or second
degree uterine prolapse
Not associated with elongation of the cervix.
It consists of:
a. Anterior colporrhaphy
b. Shortening of Mackenrodt's ligament
c. Posterior colpoperineorrhaphy
 (A) Child-bearing period
4. Fathergill's operation:
It is indicated for cases of cystorectocele with first
or second-degree uterine prolapse associated
with supra-vaginal elongation of the cervix. It
consists of:
a. Dilatation and Curettage
b. Anterior colporrhaphy
c. Amputation of the cervix
d. Shortening of Mackenrodt's ligaments
e. Posterior colpoperineorrhaphy
 (B) Post-menopausal patients
1. Vaginal hysterectomy with anterior
colporrhaphy and Posterior
colpoperineorrhaphy
It is particularly indicated for prolapse in pre- or
postmenopausal women, especially those with
complete procedentia orcomplicated by some
uterine diseases such as uterine fibroid,
adenomyosis or endometrial hyperplasia.
 (B) Post-menopausal patients
2. Le Fort's operation
It consists of partial longitudinal closure of the
vagina to prevent descent of the uterus.
It is indicated for prolapse in postmenopausal
unmarried women whose general condition
cannot stand hysterectomy.
 (B) Post-menopausal patients
Vault Prolapse:
1. Anterior colporrhaphy and posterior
colpoperineorrhaphy with special attention for
repair of tissues at the apex
2. Colpo-suspension operations in which the vault
may be slinged to the anterior abdominal wall
or to the sacrum using either natural fascia
(fascia from external oblique or fascia lata) or
synthetic materials as a sling.
 (B) Post-menopausal patients
Hernia of Douglas pouch:
Through a vaginal or abdominal approach, the
peritoneal sac is excised and the uterosacral
ligaments are implicated to obliterate the cul-de-
sac
 Causes of recurrent prolapse
Pre-operative:
1. Weakness of the genital support.
2. Poor general conditions of the patient: e.g.
Anemia and malnutrition.
3. Persistent causes of increased intra-abdominal
pressure.
4. Local conditions: e.g. vaginitis and ulceration.
5. Bad choice of timing of operation.
 Causes of recurrent prolapse
Operative:
1. Unrecognized hernia of the Douglas pouch.
2. Neglected cervical elongation.
3. Poor choice of operation.
4. Poor surgical technique
Post-operative:
1. Post-operative complications e.g. hematoma or
infections.
2. Early post-operative ampulation.
3. Subsequent pregnancy soon after operation or
repeated pregnancies.
 Causes of recurrent prolapse
Pre-operative:
1. Weakness of the genital support.
2. Poor general conditions of the patient: e.g.
Anemia and malnutrition.
3. Persistent causes of increased intra-abdominal
pressure.
4. Local conditions: e.g. vaginitis and ulceration.
5. Bad choice of timing of operation.
 Causes of recurrent prolapse
Operative:
1. Unrecognized hernia of the Douglas pouch.
2. Neglected cervical elongation.
3. Poor choice of operation.
4. Poor surgical technique
Post-operative:
1. Post-operative complications e.g. hematoma or
infections.
2. Early post-operative ampulation.
3. Subsequent pregnancy soon after operation or
repeated pregnancies.