Prolapse Notes

Prolapse

Prolapse is the herniation of contents from their normal anatomical position. In gynecology, it can be:

• Utero-cervical prolapse: Uterus and cervix prolapse from their normal position.

• Vaginal prolapse: Prolapse of the vagina.

Utero-cervical Prolapse

The uterus and cervix make an angle with the vagina, known as the angle of anteversion. There is also an angle between the cervix and the uterus, called the angle of antiflexion. Normally, the uterus is in an anteverted and antiflexed position.

• Angle of anteversion: $90$ degrees.

• Angle of antiflexion: $120$ degrees.

This positioning, along with the bladder, prevents the uterus from easily prolapsing into the vagina.

Classification

Shaw Classification (Older)

Reference point: Introitus (external opening of the vagina).

• Grade 1: Uterus and cervix come into the vagina but do not reach the level of the introitus.

• Grade 2: Uterus and cervix come up to the level of the introitus.

• Grade 3: Uterus and cervix come outside the introitus.

• Procidentia: Entire uterus and cervix are hanging out from the vagina.

POPQ Classification (Newer)

Reference point: Hymen.

• Second degree prolapse: Prolapse happens $1$ cm on either side of the hymen.

• First-degree prolapse: Prolapsed part is more than $1$ cm above the hymen.

• Third-degree prolapse: Prolapsed part is more than $1$ cm below the hymen.

• Procidentia: Entire uterus and cervix have come out.

Full form of POPQ classification: Pelvic Organ Prolapse Quantification.

Vaginal Prolapse

Can involve the anterior or posterior wall of the vagina.

Anterior Wall

• Cystocele: Prolapse of the upper anterior wall of the vagina, close to the bladder. The bladder makes an impression on the anterior wall of the vagina.

• Urethrocele: Prolapse of the lower anterior wall of the vagina, close to the urethra. The urethra makes an impression on the lower anterior part of the vagina.

Posterior Wall

• Enterocele: Prolapse of the upper one-third of the posterior wall of the vagina, related to the pouch of Douglas and intestines.

• Rectocele: Prolapse of the middle part of the posterior wall, related to the rectum.

• Laxed Perineum: Prolapse of the lower part of the posterior wall.

Most Common

Cystocele is the most common type of vaginal prolapse.

Supports of the Uterus

Mechanical Supports

• Angle of anteversion: $90$ degrees.

• Angle of antiflexion: $90$ degrees. (Note: Transcript states both angles are $90$ degrees, but earlier stated antiflexion is $120$).

First step in prolapse: Retroversion of the uterus.

Ligamentous Supports

• Pubocervical ligament: Connects the uterus to the pubic symphysis.

• Transverse cervical ligament (Cardinal ligament or Mackinrodt ligament): Connects the uterus to the pelvic side walls (strongest of the three).

• Uterosacral ligament: Connects the uterus posteriorly to the sacrum.

These three ligaments together are called the tri-radiate ligament and are the primary supports of the uterus.

Round ligament:

• Arises from the angle of the uterus and attaches to the labia majora.

• Indirectly supports the uterus by helping to keep it in an anteverted position (secondary support).

Broad ligament:

• Actually the peritoneum of the uterus, not a true ligament.

• Does not support the uterus.

Ligament Helping Anteversion

• Best answer: Round ligament.

• Second-best answer: Uterosacral ligaments (posteriorly located).

Ligament Preventing Retroversion

• Best answer: Uterosacral ligament.

• If not given, then: Round ligament.

Muscular Supports

Perineum: Diamond-shaped space bounded by the coccyx posteriorly, pubic symphysis anteriorly, and ischial tuberosities laterally.

The perineum is divided into two triangles:

• Anterior triangle: Urogenital triangle.

• Posterior triangle: Anal triangle.

When a female is standing, the urogenital diaphragm is horizontal, and the anal triangle makes an angle of $30$ degrees with the urogenital triangle.

Layers of Support (Deep to Superficial)

• Levator ani muscle (Pelvic diaphragm): Deepest layer.

  • Made up of pubococcygeus and ileococcygeus.

  • Ischiococcygeus is NOT a part of the levator ani muscle.

• Urogenital diaphragm

  • Deep layer is the perineal membrane.

  • Deep perineal pouch: Between the perineal membrane and levator ani muscle.

    • Contains the deep transverse perineal muscle and the external urinary sphincter muscle.

    • Urogenital hiatus: Opening through which the urethra and vagina come out.

• Cole's fascia:

• Superficial perineal pouch: Between the Cole's fascia and the perineal membrane.

  • Contains three muscles:

    • Bulbospongiosus muscle (midline): Supports the uterus and vagina.

    • Ischiocavernosus muscle (sides): Does not support the uterus.

    • Superficial transverse perineum muscle: Supports the uterus.

Important Notes

• Muscles NOT part of the midline or attached to the perineal body (and don't support the uterus): Ischiocavernosus and Ischiococcygeus (both start with "ischio").

• Most important overall support of the uterus: Levator ani muscle, particularly the pubococcygeus part.

• Other muscles supporting the uterus:

  • Superficial transverse perineum muscle

  • deep Transverse perineum muscle

  • bulbospongiosis muscle

  • External urinary sphincter.

Vaginal Prolapse (Details)

Anterior Vaginal Wall

• Upper two-thirds prolapse: Cystocele.

• Lower one-third prolapse: Urethrocele.

Posterior Vaginal Wall

• Upper one-third prolapse: Enterocele.

• Middle one-third prolapse: Rectocele.

• Lower one-third prolapse: Laxed perineum.

Clinical Differentiation (Enterocele vs. Rectocele)

• Per rectal exam:

  • Bulge felt on the tip of the finger: Enterocele.

  • Bulge felt on the pulp of the finger: Rectocele.

• Transillumination test:

  • Positive in enterocele.

  • Negative in rectocele.

Supports of the Vagina (DeLancey's Levels)

Level 1 Support (Upper One-Third of Vagina)

• Structures supporting: Uterosacral ligaments and cardinal ligament.

• Defect leads to:

  • Enterocele (posterior defect).

  • Apical prolapse (after hysterectomy), also called walled prolapse.

  • Elongation of cervix.

Level 2 Support (Middle One-Third of Vagina)

• Structures supporting: Arcus tendinous fascia.

• Defect leads to:

  • Cystocele (anterior).

  • Rectocele (posterior).

Level 3 Support (Lower One-Third of Vagina)

• Structures supporting: Perineal body and attached muscles.

  • Deepest layer: Levator ani muscle.

  • Middle layer: Deep transverse perineal muscle and external urinary sphincter.

  • Superficial layer: Superficial transverse perineum muscle, bulbospongiosus muscle.

• Defect leads to:

  • Urethrocele (anterior).

  • Laxed perineum (posterior).

Etiology of Prolapse

Prolapse happens when muscles or ligaments become weak due to:

• Menopause.

• Repeated childbirth, especially with obstructed labor, instrumental delivery, prolonged labor, or perineal tears.

Most common in elderly, multiparous females.

Other risk factors:

• Cigarette smoking.

• Chronic increase in intra-abdominal pressure.

• Spinal cord injury.

• Connective tissue disorders.

Symptoms of Prolapse

• Something coming out of the vagina.

• Feeling of pressure.

• Decubitus ulcer on the prolapsed part.

Decubitus Ulcer

• Cause: Venous congestion (due to hampered venous return).

• Management: Packing with acriflavin (antiseptic) and glycerin (hygroscopic agent) to reduce swelling and promote healing before surgery.

Examination of Prolapse

• Always check for SUI (stress urinary incontinence) before examining for prolapse because the normal anatomical relationship between the urethra and bladder is lost and it can be hidden in patients of prolapse.

  • SUI is checked with a full bladder and with the prolapsed part pushed inside.

• Examination of prolapse should be done with an empty bladder and with the prolapsed part lying outside.

• Utero-cervical length should be checked with the uterus and cervix put back in their normal anatomical position.

  • Normal utero-cervical length is $6$ to $8$ centimeters.

• For differentiating between rectocele and enterocele, a per rectal examination should be done.

Clinical Questions Related to Prolapse

• Rectocele, cystocele and anal incontenence are due to injury to which deep structure of perineal body? The answer is pubococcygeus.

• Know that whenever you are examining a patient of prolapse and before you proceed with examination for prolapse you should always check for SUI.

• SUI check is most reliable if the bladder is full and the prolapsed part is pushed inside.

• When examining for prolapse, have the part prolapsed outside.

• For uterine cervical length, push the uterus in and check the Utero Cervical length.

• Bulge is felt on the top or pulp of the finger when examining the rectum is for rectocele versus enterocele.

Management of Vaginal Prolapse

Differs from uterine prolapse, as management doesn't depend on age and parity.

• Repair of cystocele: Anterior colporrhaphy.

• Repair of urethrocele: Anterior colporrhaphy.

• Repair of enterocele: Moskowitz repair.

• Repair of rectocele and laxed perineum: Posterior colpo-perineorrhaphy.

Anterior Colporrhaphy

Removal of the redundant part of the vaginal wall, followed by interrupted sutures (not continuous, to avoid vaginal fibrosis).

Management of Uterine Prolapse

Depends on the age and parity of the patient.

Conservative Management

• Kegel's exercises:

  • Prevent prolapse and slow progression.

  • Advised to all pregnant females during and after pregnancy.

  • Technique: Contract perineal muscles as if holding urine, then relax; repeat 10-15 times, three times a day.

• Pessary:

  • Space-occupying device that prevents the uterus from prolapsing.

  • Common types: Gellhorn and doughnut pessaries.

  • Changed every month.

  • Not a permanent cure.

  • Can manage uteroservical prolapse and cystocele.

  • Indications: Prolapse in pregnancy, immediate postpartum period, contraindications to surgery, patient refusal of surgery.

  • Changed every three months.

Surgical Management

• Permanent management for second and third-degree prolapse.

• Depends on age and parity.

Postmenopausal Female (or >= 40 years) with Completed Family

Vaginal hysterectomy plus pelvic floor repair (anterior colporrhaphy for cystocele, posterior colpo-perineorrhaphy for rectocele) = Ward Mayo hysterectomy.

Order of Clamping Ligaments (Vaginal Hysterectomy)

From below, reaching to the top

1. Uterosacral ligament.

2. Cardinal ligament.

3. Uterine artery.

4. Tubo-ovarian ligament and round ligament pedicle.

In what order do you clamp ligaments during ABDOMINAL Hysterectomy and the answer will the reverse order of the hysterectomy clamp.

Complications After Vaginal Hysterectomy:

• Vault prolapse (apical prolapse): Can be prevented by uterosacral suspension (attaching the uterosacral ligament to the apex of the vagina).

• Enterocele: Can be prevented by McCall culdoplasty (obliterating the pouch of Douglas, pushing the intestines up and putting stitches in the pouch to prevent future enterocele.

Preferred Hysterectomy Method

Vaginal hysterectomy is generally the preferred method.

Maximum Risk of Ureter Injury

• Wertheim's hysterectomy (for malignant causes) -due to cutting medial half of the cardinal ligament . Followed by radical hysterectomy. In rad hysterectomy they remove the entire thing.

• By root of hysterectomy: laparoscopic hysterectomy > abdominal hysterectomy > vaginal hysterectomy.

Ward Mayo's Surgery and Mccal culdoplasty

• When you are doing vaginal hysterectomy at same time perform Mccal culpoplasty so future enterocyle does not not occur

• Remember Mccall and uterosacral suspension can be done at the time of vaginal hysterectomy for prolapse. (Whether given in this vignette or story or not!

Hysterectomy will have either be post-menopausal or more than equal to 40 and has completed her family, if you can perform ward mayo's, perform mccalls and if there, then, perform everything!

Case 2 Patient with Comorbidities

Postmenopausal female (age 60-65) with contraindications to prolonged anesthesia: LeFort colpocleisis (obliteration of the vagina by suturing the anterior and posterior walls together) under local anesthesia.

Contraindicated in young females (interferes with coital function and no space for menstrual blood to come out). Can be used for vault prolapse.

Case 3- Elderly Comorbid Female You Can NOT DO ANESTHESIA/OPERATE AT ALL.

80-85 is old, comorbidities, go for PESSARY use

Prolapse in Reproductive Age Group

Sling surgery or Fothergill's repair.

• Sling surgery is performed by inserting artificial slings by the uterus.

• Fothergill's repair:

  • Amputation of the cervix (not always done, see Shirodkar's modification below).

  • Plication of the cardinal ligaments (reattaching them to the anterior uterus to provide stronger anterior support.)

Surgical Management in Reproductive Age/Nulliparous

• If you have a choice on treatment of reproductive Nulliparous patient do slinging of choice (If reproductive age, If Nulliparous. If wants future childbearing etc!)..
  Sling

• If it says Utero cervical is length, you wanna start with Father gill, if utero cervical is not normal, then you start considering father gill.

• In Father Gills you amputate cervix. Then can lead to cervical incompetence. Cervical stenosis or cervical dystocia (Labor can get problematic. Do further gilt if they do not want to become pregnant!

• Shirudka has a modification, can actually you simply do the second step!!!

  • Then the Chirodkars you could go to in Females that could do it.

  If it child bearing the prerequisite the uteo cervical length has to be NORMAL!,

Fathergil can mange increased cerival length.

Sling Surgeries (Reproductive Age)

Sling surgery is mainly for uterus and cervix .

• Anterior Sling: Sling attached to the Anterioer isthmus. Isthmus is lower part of the uterus.

• Postereior Part: Sling attached on Postereior to isthmus.

PURANDHRE SLING:

Purandhre is known the sling is the other end goes rectus sheath. Since the second attachment point moves (DYNAMIC point) it can always also be a sling, Purandahre will only be in Female That can be in Ab tone.
SHIRODKAR. Is always static sling- The Sacro spineless is the only static ligament.
One is attache post 2 issmus of the Uterus
The is always static and more complication than that

Sigmoid to Colon (If she presses what happened):
To prevent that for happening we hook and is the Swiss muscle that will lead hook for it from happening.
Complication with Shirokha (is on LEFT sidE)

1. Obstructed Sigma Colon!
   We prefer do the Vitrock Sling - or the composite Sling
   On Write SIde: We do Shiroka
   On left Side: we doing Purandhre!

Chirokha Needle . This look like question mark that we been to see

Walled = Proplase

1. You do a uterus Sacril Suspension (you do to wall prolapse)
   Adominal Surgeries Sacral Colpopherxy.

2. Meshes you can sacrum (One ent Sacrum).
   The Other ent, if mesh it will go ANterioer
   3/ The meshes will be adheions. THis will HEAL wi fibroses

*Sacrospinsu Fixation . Put suture where apex the vagina the Sacri Sphinous ligaments to the not prolapes!
*Lefford's Cooglysis : (Earlier

Colpocyspension NOT surge for Wallprolase: This is surgery for incontinence.

Important Reminders!

86 year old female.
Secong degree prolapse uterus. SHE HAS NO COMPLAINT.
THIS IS A PREVENTIVE Check Up: DO REASSURE!

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