dr.

Bambang Widjanarko, obstetrics & gynecologist

 UTEROVAGINAL PROLAPSE : descent of
some of the pelvic organ.
 PELVIC ORGAN:
 Urethra
 Bladder
 Uterus
 Small bowell
 Rectum
 Multifactorial
 MAIN PREDISPOSING FACTOR :
 Childbirth
 Menopause
 Congenital
 Suprapubic surgery for urinary incontinence
 Genetics
 Obesity – chronic cough and constipation
INTRA-ABDOMINAL TISSUE
 Trauma of the pelvic floor
 Loss of tissue support to the pelvic organ
 Vaginal delivery
DISRUPT THE FASCIA
 Multiparity
 Prolonged Labor ( prolonged 2nd stage) –
large baby and perineal trauma
Direct damage to the FASCIA and
NEUROMUSCULAR tissue
Of the pelvic floor
 ESTROGEN DEFICIENCY: Influence of
COLLAGEN FORMATION

 LOSS OF CONNECTIVE TISSUE STRENGTH

 Neurological deficiency
 Congenital weakness
 Anatomical variants
 ORIGINAL
POSITION OF PROLAPSE SYMPTOMS
ORGAN
Urinary symptoms of discomfort –
URETHROCELE
ANTERIOR dragging – feeling of a “lump” and
CYSTOCELE
coital problem
SERVIK / UTERUS Bleeding and Discharge from
CENTRAL 1ST , 2ND and 3RD degree ulceration in association with
PROCIDENTIA procidentia
RECTOCELE Bowel symptoms
POSTERIOR
ENTEROCELE Feeling incomplete evacuation
 Urethrocele : descent of the part of the
anterior wall which is fused to the urethrae
 3 – 4 cm anterior wall distal vagina, superior
to the urethral meatus
 Urethrocele and Cystocele are often
considered together ( cystourethrocele )
cystocele
 Cervix occupies the proximal third of the vagina
 UTERINE PROLAPSE:
 1st degree : descent of the uterus and cervix within
vagina ; the cervix does not reach the introitus
 2nd degree : descent of the cervix to the level of the
introitus
 3rd degree : the cervix and uterus protrude out of the
vagina
 PROCIDENTIA : cervix and vagina outside the
introitus.
 1st degree uterine prolapse

2nd degree uterine prolapse

3rd degree uterine prolapse

 Weakening of the tissue that lies between the
vagina and rectum ( rectovaginal fascia )
 ENTEROCELE is the only type of vaginal
prolapse which is truly a HERNIA
 It has a sac – neck and contents
 SAC : protrusion of the peritoneum of the
pouch of Douglass
 May contain SMALL BOWEL or OMENTUM
  Prolapse may be asymptomatic and
detected when patients present for a cervical
smear
 Symptoms usually non-specific
STRETCH
EFFECT
On
TISSUE

- Uncomfortable dragging feeling or backache that improves when lying down.

- ‘Something coming down’.
- Coital difficulties ( sometimes ).
 Urinary symptoms ( it involves bladder and
urethra )
 Over 50% stress incontinence : cysto
urethrocele
 Other urinary symptoms :
 Frequency and urgency
 Incomplete emptying of the bladder
UTI
 Retained urine
 Examination : part of general gynaecological examination
 Suspicion :
 Obesity – mobility and general well being
 Dyspnoea – cough and abnormal chest sign
 Abdominal examination: pelvic mass may be pushing the
pelvic organ
 Inspection :
 atrophic changes of the vulva
 Prolapsus seen at the introitus
 Urinary leakage
 Bimanual examination : degree of uterine descent
 Examination in the left lateral or ‘Sims Position” be helpful
 Sometime be necessary to examine the patient in
standing position
 Conservative Treatment
 Patient does not want or is not fit enough for surgery
 Pelvic floor exercise are not effective when prolapse is well
established
 Pessaries are commonly used
 Atrofi of the lower genital tract in association with
prolapse : oestrogen cream topically

 SURGERY
 Most procedure are performed through the vagina
 Attention should be given to preserving the calibre of the
vagina if the women wishes to remain sexually active
 Stress incontinence may need to be
investigated prior to surgery
 Principle :
 Midline incision through anterior vaginal skin
 Reflect underlying bladder of the vaginal mucosa
 Lateral supporting suture are placed into fascia in
order to elevate the bladder and bladder neck
 The remaining redundant vaginal skin that has
been ’ballooning’ down are excised
 Vagina skin is the sutured closed
ANTERIOR COLPORRHAPY
and
BLADDER BUTRESS

The anterior vaginal wall is opened in the

midline and the bladder buttres by sutures
achored in the fascia either side of the
bladder neck
 Principles similar to anterior repair
 Incision posterior vaginal wall
 Rectum separated from vagina
 Supporting sutures are placed laterally to reduce
prolapse
 The lax vaginal skin is the excised
 Incision clossed
 This operation can combined with a repair of
the perineal body to support the perineum
 Particular care must be taken not to narrow
vagina and cause problem with dyspareunia
 The posterior wall is opened in the midline to expose the rectum:
 The posterior wall is closed after reducing the prolapse:
 Complete eversion of the vagina following a
hysterectomy

 The surgical option :

 Sacrocolpopexy
 Sacrospinous fixation
 Suturing the vaginal vault to the body of
sacrum either directly or indirectly
 The procedure is performed through an
abdominal incision or laparoscopically
 Suture the top of vaginal vault to the
sacrospinous ligament.
 Procedure is performed through the vagina.
 Complication : damage of sciatic nerve and
pudendal vessels