My Clinical Notes

• Descent of the uterus and/or vaginal wall within the vagina
• Other organs may descend behind the vaginal walls producing a type of hernia

• The transverse cervical and uterosacral ligaments are the most important for pelvic support
• These attach to the cervix and suspend the uterus and upper vagina
• Levator ani muscle forms the pelvic floor and suspend the mid vagina, rectum and urethra. Weakness allows prolapse of the vaginal walls, bladder or rectum
• Affects half of all parous women
• Due to weakening of supporting structure eg following vaginal delivary. Oestrogen deficiency can also cause atropy of support structures and vaginal walls. Can be cause iatrogenically following hysterectomy or inadequate support of the vaginal vault. Genetic predisposition may be due to familial collagen weakness
• Obesity puts excess strain on pelvic supports. Extra strain can also be due to a chronic cough or pelvic masses

Types of Prolapse

Uterus

• Uterine prolapse is graded 1-3
• 1^st degree the cervix is still within the vagina
• 2^nd degree the cervix is at the introitus
• 3^rd degree (procidentia), entire uterus comes out of the vagina
• if the uterus has been removed the vault or top of the vagina can prolapse. This results in inversion of the vagina

Anterior Vaginal Wall

• Cystocoele is a prolapse of the bladder
• Urethrocoele is a bulging of the urethra into the lower anterior wall

Posterior Vaginal Wall

• Rectocoele is a prolapse of the rectum in the middle of the posterior wall
• Enterocoele is a prolapse of the pouch of Douglas (eg peritoneal cavity)

Clinical Symptoms

• Often asymptomatic
• Generally patient may feel a dragging sensation or a lump particularly at the end of the day
• Symptoms of a cystocoele may be urinary frequency, incomplete emptying of the bladder and incontinence
• Symptoms of a rectocoele may be difficulty in defecating

Management

• Weight reduction
• Physiotherapy
• Pessaries – these are placed in the vagina to stay behind the symphysis pubis and the front of the sacrum. May cause pain, urinary retention, vaginal ulceration or infection. Require to be changed every 9-12 months
• Surgical treatment

Hysterectomy produces best results.

Sacrohysteropexy is where the uterus is attached to the sacrum

Sacrospinous suspension – for a vaginal vault prolapse where it is stitched onto the sacrospinous ligament

Sacrocolpopexy – fixation to the sacrum using mesh

Burch colposuspension – for genuine stress incontinence

Tension free vaginal tape procedure – for genuine stress incontinence

This entry was posted on Saturday, September 29th, 2007 at 4:21 pm and is filed under Gynaecology/Obstetrics. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.