Friday, April 18, 2014

Pelvic Organ Prolapse


Have no idea what it is called in Malay. I wished i had a dictionary specialised in medical terms in Malay. It would help a lot of  medical students and young doctors in Malaysia. What a horror for me to describe inflammation to malay and arguing wether its correct or not. I wished we could just teach laymen the proper medical terms instead of laymens term.

Ha, mungkin namanya rahim jatuh atau peranakan jatuh. Erm, betul kot...
























Classification of prolapse

Anterior vaginal wall-upper one third :cyctocoele
Posterior vaginal wall-Lower one third :Urethrocele
Posterior vaginal wall
Upper one third - Enterocele
Lower one third -Rectocele

Uterine descent
-Descent of cervix into vagina
-Descent of the cervix upto the introitus
-Descent of the cervix outside the introitus
-Procedentia:All Uterus outside the introitus

Management
It is divided into  >Preventive>conservative>surgery
Preventive care
  • Adequate antenatal anda intranatal care
  • Adequate postnatal care
  • General measures -avoid strenuous activities,chronic cough,constipation and heavy weight lifting,avoid too many and too soon pregnancies
Conservative
  • Improve general measures above
  • Oestrogen therapy replacement
  • Pelvic floor exercise : Kegel exercise
Pessary treatment
Pessary treatment does not cure uterine prolapse. It relieves the symptoms by steching the hiatus urogenitalis thus preventing vaginal and uterine descent.
It is used in patients with
  • Early pregnancy:placed upto 18 weeks when the uterus is sufficiently enlarge to sit on the brim of pelvis.
  • Puerperium: to facilitate involution.
  • Unfit for surgery
  • Unwillingness for surgery
  • While waiting for operation

Surgical Management of prolapse
-It is indicated when the conservative treatment has failed or not indicated.
-There is no single procedure for all types of prolapse.It depends on anatomical alteration of structures and the degree of prolapse.
-Age,reproductive abiliity and sexual functions should be considered before any specific surgery.

Types of operation



Anterior colporhaphy
  •    To correct cycstocele and urethrocele.
  • Sim's speculum is introduced, posterior lip of cervix is held by by multiple vulsellum and firmly brought down by assistant.
  • Metal catheter is introduced to know the lower limit of bladder.
  • Inverted T incision made to anterior vaginal wall.Horizontal incision is made below the bladder and the vertical incision is made starting from midpoint of the transverse incision upto a point abount 1.5cm below the external urethral meatus.
  • The triangular vaginal flaps including fascia on either sides are separated from the endopelvic fascia covering the bladder by knife and gauze dissection.
  • The bladder with the covering endopelvic fascia (pubocervical) is exposed as the edges of the vaginal wall are retracted  laterally.
  • The vesico cervical ligament is held up with Allis tissue forceps and divided. The bladder is then pushed up by gauze covered finger till the peritoneum of the uterovesical pouch is visible. The vesico-cervical space is now exposed.
  • The pubocervical fascia is plicated by interupted sutures with No "O" chromic catgut using round body needle.The lower one or two stiches include a bite on the cervix thus closing the hiatus through which the bladder herniates. The redudndant portion of the vaginal mucosa is cut on either side.
  • The cut margins of the vagina are apposed by interrupted sutures with No 'O' chromic catgut using cutting needle.
  • The catheter is reintroduced once more to be sure that the bladder is not injured.
  • Toileting of the vagina is done.
  • Vagina is tight packed with  roller gauze smeared with antiseptic cream.
  • A self retaining catheter is introduced.
Paravaginal defect repair
Cyctocele is repaired by anterior colporrhaphy and plicating the endopelvic fascia in the midline under the bladder neck. but anterior vaginal prolapse may be due to the detachment of the endopelvic fascia from the lateral pelvic side wall.In the case repair should be done by reattaching the endopelvic fascia to the arcus tendineus fascia(white line) of the pelvis. This may be done retropubically through the space of Retziusor vaginally. This is indicated in cases with recurrent cyctocele following repair.







Perineorrhaphy/Colpoperineorrhaphy

Posterior vaginal wall prolapse is fixed by repairing
  • Relaxed perineum - The operation is extended to repair the torn perineal body.
  • Rectocele - The repair is extended to correct rectocele by tightening the pararectal fascia.
  • Enterocele - High perineorrhaphy is to be done right upto the cervicovaginal junction along with correction of enterocele.
*restoration of perineal body is essential with any form  of pelvic floor  repair. This maintains the normal vaginal  axis.

Step of operation
  • A pair of Allis tissue forceps is placed on each side at the lower end of labium minus and a third pair of  Allis is placed on the  posterior vaginal  wall in the midline  well above the rectocele bulge.
  • A horizontal incision is made on the mucocutaneous junction joining the two allis tissue  forceps.
  • Through the incision , with the help of perineorrhaphy scissors, the posterior vaginal wall is dissected off from the perineal body and rectum  upto third Allis forceps placed on the posterior vaginal wall.
  • A vertical incision is made from the apex to the  middle of the horizontal incision (inverted T shaped incision)
  • The two triangular flaps are now  dissected laterally to expose the rectum and musculofascial structures levators ani muscle.
  • Lax vaginal flaps are excised.
  • The rectocele is corrected by suturing the pararectal fascia with interupted sutures.
  • Two or three interrupted sutures are placed through  the levator ani  and fibro muscular  tissues  of the  perineal body  using No I catgut. The rectum should be  pressed back by finger while the sutures are placed.
  • The knots to be placed  at later stage.
  • The cut margins of the posterior vaginal wall are approximated ,starting  from the apex using  No 'O' catgut untill it reaches upto the perineal body.
  • The knots are now placed to the sutures passed through the perineal body.
  • The rest of the posterior vaginal wall and the skin margins are apposed by interrupted catgut sutures.
  • Toiletetting of the vagina is done.
  • tight vaginal pack is optional.



Repair of enterocele and vault prolapse
Enterocele is corrected transvaginally. The principles of correction are to obliterate the neck of the enterocele sac as high as possible by purse string suture, to  excise the excess peritoneal sac and approximation of the uterosacral ligaments.
step by step procedure.
  • An inverted T shaped incision is made with the vertical arm of the T extending up to the apex of the vaginal vault and the horizontal arm, along the mucocutaneous border.
  • Dissection is carried out to expose the enterocele sac.
  • The sac is opened the contents (bowel and omentum ) is pushed away.
  • The peritoneum of the posterior cul-de-sac is dissected off the anterior surface of the rectum and lower sigmoid and excised.
  • A purse string suture (2-0 vicryl)is placed high at the neck of the sac and tied. The excess peritoneum is resected off.
  • The cervix is pulled upwards. Two interupted sutures are now placed around the uterosacral ligaments. These sutures also pass through the posterior aspect of the cervix.These sutures are tied. rest of the steps are the same as that perineorrhaphy.
*AAbdominal repair of enterocele is done by obliterating the pouch of Douglas to prevent herniation of bowel. This is known as Moschowitz procedure. Generally three or four concentric sutures are placed incorporating the uterosacral ligaments and peritoneum over the rectosigmoid.

Pelvic Floor Repair (PFR)
PFR includes anterior colporrhaphy and colpoperineorrhaphy. It should be emphasized that the pelvic floor repair is not the operation for uterine descent. but as the uterine descent is most frequently associated with prolapse of the vaginal wall, pelvic floor repair has to be done along with operation for uterine descent.
Fothergill's or Manchester Operation
The operation is designed to correct uterine descent associated with cyctocele and rectocele where preservation of the uterus  is desireble.
The indications are :
  • Preservation of reproductive  functin
  • when the symptoms are due to vaginal prolapse associated with elongation of the (supravaginal) cervix.
Principles steps of the operation are:
  1. Preliminary dilatation and curretage
  2. Amputation of the cervix
  3. Plication of the mackenrodt's ligaments in front of the cervix.
  4. Anterior colporrhaphy
  5. Colpoperineorrhaphy
If family is completed vaginal sterilisation is to be done.
Steps of operation
  • D & C
  • Anterior colporrhaphy upto pushing the bladder
  • The posterior lip of the cervix is to be held with vulsellum and the cervix is drawn upwards.
  • A pair Allis forceps is placed in midpoint of the posterior cervicovaginal junction.
  • The anterior transverse incision is now extended posteriorly across the posterior cervicovaginal junction. The lateral and posterior vaginal wall is dissected off from the cervixby scissors and finger dissection.
  • The Mackenrodt's ligament with descending cervical artery of either side is clamped at higher level of amputation , cut and replaced by ligature(chromic catgut No 1)
  • The presence of enterocele should be searched for and if detected, to be repaired.
  • The cervix is now amputated at the calculated level.
  • Anterior lip of the amputated cervix is now held with single-toothed vulsellum.
  • The posterior lip of amputated cervix is covered by the vaginal flap using a Sturmdoff sutur or by Bonney's method.
  • The cut ends of Mackenrodt's ligament are sutured to the anterior surface of the cervix. alternatively, the ligaments are fixed using Fothergill's stitch. Fothergill's stitch is used to make the uterus anteverted. The stitch passes through the following tissues in sequence. Vaginal skin at the level of Fothergill's lateral point->Mackenrodt's ligament->through the cervical tissue from outside inwards->cervical tissue from inside outwards->Mackenrodt's ligament of the other side -> vaginal skin(Fothergill's lateral point) of the other side.
  • Pubocervical fascia is approximated as in anterior colporrhaphy.
  • Redundant portion of the vaginal mucosa is excised.
  • The cut margins of the vagina are apposed by interuppted sutures.
  • Posterior colpoperineorrhaphy is performed.
  • Toiletting the vagina is done.
  • Vaginal pack is given.
  • Self retaining catheter is introduced.

Vaginal Hysterectomy with Pelvic Floor Repair
-Also called as Ward Mayo's operation.
-Indications:
  • Uterovaginal prolapse in postmenopausal women.
  • Genital prolapse in perimenopausal age group along with the diseased uterus like DUB, unhealthy cervix or small submucuous fibroid requiring hysterectomy.
  • As alternative to Fothergill's operation where family is completed.
  • As an alternative to abdominal hysterectomyin undescended uterus either as a routine or in selected cases where abdominal approach is unsafe.PFR is not done in such cases.
  • As an alternative to laparoscopic assisted vaginal hysterectomy (LAVH)in selected cases of undescended uterus. Compared to LAVH vaginal hysterectomy is less expensive and the perioperative morbidity is no different.
Principles of the operation in prolapse
  • Removal of the uterus through vaginal route.
  • Correction of the enterocele, if any.
  • Approximation of the pedicles in the midline to have a good buttress.
  • Fixation of the uterosacral ligaments to the vault to prevent vault prolapse.
  • Bladder support is reconstituted utilising the broad ligaments and round ligaments as buttress.
  • Repair of cyctocele.
  • Reconstuction of the perineum.




Steps of operation for vaginal hysterectomy (indication -genital prolapse)


  • Anterior colporrhaphy procedure same, up till pushing the bladder.
  • The uterovesical peritoneum is  cut open.Landon's retractor is introduced and to be held by an assistant.
  • The posterior vaginal wall along the cervico vaginal  juncton is cut  as  in Fothergills operation.The vaginal wall is dissected down till the pouch of Douglas is reached. The peritoneum is cut open.
  • First clamp is placed which includes uterosacral ligament,Mackendrodt's ligament and descending cervical artery. The tissue are cut as close to the cervix and replaced by vicryl No 1 .Simmilar procedures the followed on the other side.
  • Second clamp includes uterine artery and base of the broad ligment. The structures are cut as close to the uterus and and replaced by ligature (vicryl No 1) .Same procedures are done other side.
  • The fundus is now brought out through the anterior pouch by a pair of Allis tissue forceps.
  • The third clamp includes round ligament , fallopian tube, mesosalphinx and ligament of the ovary.The structures are cut and replaced by transfixing suture (Vicryl No 1). Same done the other side.The uterus is removed.
  • Correction of enterocele is to be done at this stage.
  • Peritoneum is closed by purse string suture.
  • The sutures of the uppermost pedicles on either side are tied. The excess suturesof the uterien artery pedicle on each side are cut.The sutures of the pedicle containing the uterosacral and Mackenrodt's ligaments are passed throughthe vault crosswise and are to be held temporarily.
  • As in anterior colporrhaphy , the pubocervical fascia is approximated and fixed to thhe uppermost tied broad ligament pedicles to close the hiatus.
  • Redundant portions of the vaginal flaps are excised and the margins approximated by interupted sutures(Vicryl No 0)
  • Crosswise passed sutures of the lowermost pedicles are tied, thus fixing the ligaments with the vaults.
  • Perineorrhaphy is done.
  • Vaginal packing is optional.
  • Self retaining catheter is introduced.


Vault prolapse . Post hysterectomy (vaginal or abdominal )vault prolapse is usually accompanied by an enterocele ( 70%). However, cyctocele and or rectocele may be present. The vault prolapse in such cases may be effectively repaired transvaginally mantaining the same  principle of repair of enterocelealong with anterior colporrhaphy and colpoperineorrhaphy.

Conservative Rx: Pessary generally not recommended.

Surgical Rx: 

Transvaginal approach : 
  • Repair of enterocele along with pelvic floor repair.
  • Le fort operation
  • Colpocleisis (cases following hysterectoy)
  • Sacrospinious colpopexy.
Abdominal approach
  • Vault suspension (sacral colpopexy)
Le Fort operation
The procedur is almost obsolete. It may be done in old agevwith procidentioa he the patient is unfit for longer duration of surgery as vaginal hysterectomy with PFR. There should not be any uterine or pelvic pathology.Cervical cytology (pap smear) should be normal.The operation can be done under local anaesthesia.

Step b ystep
  • Denudation of rectangular vaginal flap from the anterior and posterior vaginal walls.
  • Apposition of the denuded anterior and posterior vaginal walls by chromic catgut. Two small channels are left in the vagina one on either side or drainage.
  • The comlications include -pyometra and urinary stress incontinence.
Colpocleisis (after hysterectomy)
Denudation of vaginal mucosa is done all around. Successive purse string absorbable sutures are placed from above downwards to appose the vagina walls.It is simple , safe and effective opertion for a woman who is no longer interested in coital function.

*sacrospinous colpopexy is done by fixing the vaginal vault to the sacrospinous ligamenton the right side. This procedure may cause damage to the bowel ,ureter or the pudendal vessels.It has higher failure rates.

Abdominal approach

Vault suspension (sacralcolpopexy):principle of the operation is to suspense the vaginal vault to be anterior longitudinal ligament in front of the 3rd sacral vertebra. Non absorbable suture material (Mersilene or Gore-tex mesh) is used.
Step by step
  • Abdomen is opened by vertical or transverse incision.
  • A verticle incision is made on the posterior peritoneum over the sacral hollow while the rectosigmoid is pulled up laterally.
  • Lateral angles of the vagina are identified and grasped with Allis tissue forceps.
  • Two strips or Mersilene or Gore-Tex mesh(1.5cm wide ) are fixed to the vaginal angles and are pulled up in the midline.The other ends are fixed to the anterior longitudinal ligament in front of 3rd sacral vertebra with proper tension.
  • Posterior peritoneum is sewn over the strips to make them retroperitoneal .
  • Complications: Stress urinary incontinene is important one.
*Laparoscopic sacrocolpopexy is found to be effective with similar result to open sacrocolpopexy.


Cervicopexy or Sling operation (Purandare's operation)

The operation is indicated in congenital or nulliparous prolapse without cyctocele where the cervix is pulled mechanically through abdominal route.Strips of rectus sheath of either side passed extraperitoneally are stiched to the anterior surface of the cervix by silk.

Step by step
  • A transverse abdominal incision is made through the skin and fat.
  • Two facial strips (retus sheath) of 1.5c wide are dissected off,keeping its lateral attachment at the lateral border of the rectus muscle intact.
  • The peritoneal cavity is opened in midline. Bladder peritoneum is dissected off and the uterine isthmus is exposed mobilising the bladder.
  • The medial ends of the facial strips are now brought down between the leaves of the broad ligament to this site of uterine isthmus.
  • The free edges of the facial strips are now fixed at the uterine isthmus  with a sturdy bite using silk. This is done after adjusting the correct position of the uterus.
  • Bladder peritoneum is repaired and abdomen is closed in layers. This operation may be combined with Moschowitz procedure.Instead of facial strips , currently non-absorbable(Marlex or Gore Tex) tape is used for this purpose.


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