Genital Prolapse
Introduction
Uterovaginal prolapsed is described as the
descent of some of the pelvic organs (uretra,
beldder, uterus, small bowel and rectum)
into the vagina. The structures lying
immediately above the vagina are in close
proximity to each other and, if the integrity
of pelvic facia is disrupted, descent of a
single organ seldom occurs in isolation. This
becomes important when considering
different modalities of treatment and how
best to relieve symptoms.
Aetiology
The aetiology of genital prolapsed is
multifactorial and the main predisposing
factors are listed in Box 19.1. in addition,
obesity, chronic cough and constipation,
which all raise intra-abdominal pressure, can
aggravate the condition.
Childbirth
Childbirth results in trauma to the pelpic
floor and loss of tissue support to the female
pelvic organs. Vaginal delivery, and
particular multyparity, may disrupt the
fascia and cause ligament weakening. A
prolonged second stage, a large baby, and
perineal trauma have all been implicated in
causing direct damage to the fascia and
neuromuscular tissue of the pelvic floor.
Menopause
The menopausal state, characterized by
oestrogen deficiency and loss of connective
tissue strength, is causative factor in the
development of prolapse. This may because
oestrogen influences collagen formation.
Congenital
Congenital weakness and neurological
deficiency of the tissues account for
prolapse in a small propotion of women.
Rarely, children may be born with prolapsed
or the may develop significant prolapse
during childhood. There may also be
anatomical variants that may make certain
women more susceptible to prolapsed in
later life.
Gynaecological surgery
Although surgery is often used to treat
prolapse, it may be responsible for a small
number of cases. Suprapubic surgical
procedures for urinary incontinence (e.c
burch colposuspension history box) alter
the anatomy such that the bladder neck is
approximated behind the symphysis pubis.
This increases gravitational effects on the
pouch of douglas, prolapsed of which leads
to enterocele. Prolapsed of the vaginal vault
is a not uncommon long-term consequence
of a hysterectomy.
History
John burch (1990-1977), from Nashville,
followed his father into gynaecology and
developed the burch colposuspension per-
operatively when he was unable to suspend
the bladder neck from the retropubic
periosteum (the usual operation of the time).
Genetic
Genetic factors have been implicated in the
development of prolapsed. It is uncommon,
for example, in the African population,
possibly related in some way to the different
collagen content of tissues.
Box 19.1
Factors predisposing to genital prolapsed
Childbirth
Menopause
Congenital
Suprapubic surgery for urinary
incontinence
Genetic
Classification
The classification of prolapse, and the main
symptoms, are summarized in Table 19.1.
Urethrocele/cystocele
A urethrocele is descent of the part of the
anterior vaginal wall which is fused to the
urethra. This is approximately the first 3-4
cm of the anterior wall superior to the
urethral meatus. Any descent of this tissue
may alter the urethrovesical angle and
disrupt the continence mechanism,
predisposing to strees urinary incontinence
(SUI).
The bladder base lies immediately
above this. Descent of this area is termed a
cystocele (fig. 19.1). urethroceles and
cytoceles are often considered together, and
when both are present the term
cystourethrocele is used.
Uterus and cervix
The cervix occupies the upper third of the
vagina and descends when there is uterine
prolapsed. Uterine prolapsed may be
described as first, second or third degree
(fig. 19.2).
First degree there is descent of the
uterus and cervix within the vagina but
the cervix does not reach the introitus.
Second degree descent of the cervix
to the level of the introitus.
Third degree the cervix and uterus
protrude out of the vagina.
Procidentia is a term used when the cervix,
uterus and vaginal wall have completely
prolapsed through the introitus may lead to
ulceration of the cervix and thickening of
the vaginal mucosa.
Retrocele
Weakening of the tissue thatlies between the
vagina and rectum (rectovaginal fascia)
allows the rectum to protrude into the lower
posterior vaginal wall, causing a rectocele
(fig. 19.3). laxity of the perineum may also
be present which gives a gaping appearance
to the fourchette (the posterior margin of the
introitus).
Table 19.1
Type of genital prolapsed
Original prolapse Symptoms*
position
of organs
anterior Urethrocele Urinary
and cystocele symptoms
(stress
incontinence,
urinary
frequency) Fig. 19.1 Cystocele.
Central Cervix/uterus Bleeding and/or
(1st, 2nd, 3rd discharge from
degree and ulceration in Enterocele
procidentia) association with
An enterocele is the only type of vaginal
procidentia
prolapsed which is truly a hernia (fig. 19.4).
posterior Rectocele Bowel
and symptoms, it has a sac, neck and contents. The sac is a
enterocele particularly the protrusion of the peritoneum of the pouch of
feeling of douglas and may contain small bowel, or
incomplete omentum.
evacuation and
something
having to press
the posterior Symptoms
wall backwards Prolapse may be asymptomatic and it may
to pass stool only be detected when women present for
cervical cytology. If symptoms are present,
*
In addition to the general symptoms of the are ussualy non-specific but there may
discomfort, dragging, the feeling of a be features that are related to a specific type
lump, and, rarely, coital problems. of prolapse (table 19.1)
Non-specific symptoms may be
attributable to the stretch effect on tissues.
Women may also describe something
coming down. Coital difficulties are an
uncommon presenting symptom.
Anterior wall prolapse may cause
urinary symptoms because it involves
baldder and urethra.over 50% of women
with SUI have a significant
cystourethrocele. Other urinary symptoms
such us frequency urgency may also be
present. A large systocele can cause exerting gentle traction with the speculum
problems of incomplete emptying of the on the posterior vaginal wall. Sponge
bladder, and retained urine and predisposes forceps are occasionally use during this
to recurrent urinary tract infections. examination to reduce a large prolapse or to
Uterine prolpase does not ussualy enable the examiner to distinguish the
presentuntil the woman feels a lump. If anatomy. The speculum can then be slowly
there is procidentia, then there may be withdrawn along the posterior wall of the
bleeding or discharge from ulceration of the vagina and the full extent of any rectocele
cervix or vaginal wall. will come into view. If a prolapsed is not
Bowel symptoms related to a apparent with the women lying down, it may
rectocele involve a feeling of incomplete sometimes be necessary to examine her in
evacuation of the bowel contents. When the strainding position.
straining occurs with defecation, the
rectocele balloons forward and some woman
need to digitally recude the rectocele to pass Managenent
stool. Enteroceles usually present as a lump If a prolapse is not causing symptoms and
but may be also associated with non-specific the woman is unaware of it, then one must
lower abdominal discomfort. question whether any treatment is necessary.
Simply because a doctor notices laxity
whithin the vagina does not mean that
Signs surgery should be performed.
Examination for prolaps froms part of the
general gynaecological examination.
Abdominal examination is then performed,
initially with the patient supine. On
inspection of the vulva, one may note
atrophic changes (scanty hair, thinning of
the labia). The women is asked to abduct her
legs and strain. By gently parting the labia
majora with the thumb and index finger of
the left hand, prolapse may be seen
appearing at the introitus. Urinary leakage
may also be apparentand an assessment of
the perineum can also be made. A bimanual
examination may than be performed, and
may give a useful indication of uterine
descent.
Examination in the left lateral
position can also be helpful. This allows a
systematic examination of the entire vagina,
Fig. 19.2 uterine prolapse. (A)first-degree,
(B) second-degree, and (C) third-degree Fig. 19.4 Enterocele.
prolapsed.

Conservative
Conservative treatment may be considered if
a woman does not want, or is not fit enough
for, surgery. Conservative measures may
also be used for temporary relief before
surgery and even as a therapeutic test to see
if reduction of the prolapse improves
specific symptoms.
Pelvic floor exercises are not
effective when prolapse is well established.
They do have a role in the treatment of
associated urinary incontinence, but their
main value may be as a prophylactic
intervention, particularly postpartum and
postoperatively.
Pessaries are commonly used. A ring
pessary is an inert plastic ring which is
placed in the vagina so that one edge of the
ring is behind the symphysis pubis and the
other is in the posterior fornix (fig. 19.5 and
19.6). the ring tends to support the uterus
and vault of the vagina. It may also help
reduce cystocele but it will not reduce a
Fig. 19.3 rectocele. rectocele. Once a ring is fitted, arrangements
are usually made to change it every 4-6
months. At this examination, the vagina is
inspected thoroughly for atrophic changes
and ulceration due to pressure necrosis.
Complications from the ring may include
urinary symptoms (frequency, infection),
vaginal discharge, bleeding or, very rarely,
fistula formation (if the ring is neglected).
Other types of ring pessary are available,
particularly the shelf pessary which has
useful role in procidentia.
Fig. 19.6 ring pessary in situ. Note that the
anterior vaginal wall is elevated to reduce
the cystocele and the uterine prolapse has
been corrected.
If atrophy of the lower genital tract
is noted in association with prolapse, a
course of oestrogen therapy (commonly
administered topically as acream) may
improve vaginal tissue thickness. This may
improve some symptoms and it facilitates
any planned vaginal surgery.
Surgery
Most procedures for the treatment of genital
prolapsed are performed through the vagina,
with only a few requiring an abdominal
approach. When considering a surgical
technique, particular attention should be
given to preserving the caliber of the vagina
if the women whishes to remain sexually
active. This aspect should always be
discussed before operation.
Anterior vaginal wall anterior repair
(anterior colporrhaphy)
Anterior vaginal wall prolapse may be
associated with stress urinary incontinence
which may need to be investigated prior to
surgery. The principle of anterior repair is to
make a midline incision through the vaginal
skin and to reflect the underlying baldder off
the vaginal mucosa. Once this is achieved,
lateral supporting sutures are placed into
fascia in order to elevate the bladder and
bladder neck. The remaining redundant
vaginal skin that has been ballooning
down is excised, and the vaginal skin is then
sutured closed.

Fig. 19.7 posterior colporrhaphy. (a) the
posterior wall is opened in the midline to
expose the rectum. (b) the posterior wall is
closed after reducing the prolapse.
Uterine descent vaginal hysterectomy or
Manchester repair
History
William fothergill (1865-1926) was born in
Southampton to a quaker family. He
proposed suturing the stumps of cardinal
ligament to the cervical stump to provide
uterine support.
Vaginal hysterectomy is commonly
performed for uterine prolapse. However,
one must not presume that just because the
uterus is prolapsing, it can be remove
vaginally, as it may be too large to remove
because of, for example, associated fibroids.
One should also consider wether the uterus
is being pushed down from a mass above
(e.g.advanced ovarian cancer with gross
ascites), or whether bowel is likely to be
adherentto the uterus (e.g. after previous
abdominopelpic surgery, endometriosis or
severen infection). Once the uterus is
removed, it is important that thesupporting
ligaments are approximated so as to prevent
futher prolapse of the vaginal vault.
Manchester repair (also called fothergill
repair- history box) has a role treating
uterine prolpase, but is less commonly
performed then vaginal hysterectomy. The
uterosacral ligament are divided and
shortened, the cervix is amputated, and the
shortened ligament are approximated
anterior or to the cervical stump. The body
of the uterus is not removed.
Posterior vaginal wall posterior repair
(posterior colpo-perineorrhaphy)
The principles of a posterior repair are
similar to those of an anterior repair. An
incision made in the vaginal wall and the
rectum is separated from the vagina (fig.
19.7). supporting sutures are placed laterally
to the reduce the prolapse. The lax vaginal
skin is the excised and the incision closed.
This operation can be combined whith a
repair of the perineal body to support the
perineum. Again, particular care must be
taken not to narrow the vagina and create
dyspareunia.
Fig. 19.8 vault prolapse.
As the procedure reaches the apex of
the rectocele, the surgeon must identify
whether or not there is an enterocelepresent.
If one is present, the peritoneum must be
opened (avoiding bowel injury). The hernia
sac must betransfixed and excised, and
supporting lateral tissue approximated in
order to prevent recurrence.

Total vault prolapse (after hysterectomy)

This condition refers to the complete
eversion of the vagina following
hysterectomy (fig. 19.8). it is effectively
procidentia without the uterus, not unlike a
sock that has been turned inside out.
Surgical options are sacrocolpopexy,
sacrospinous fixation and vaginal mesh
insertion.

Sacrocolpopexy
Sacrocopopexy involves suturing the vaginal
vault to the body of the sacrum, either
directly, or indirectly by using a graft
(porcine dermis, gore-Tex,Marlex)
interposed between the two structures. The
procedure is performed through an
abdominal incision but can be carried out
laparoscopically.

Fig. 19.9 repair of complete vault

prolapse.

Sacrospinous fixation
Sacrospinous fixation requires the surgeon
to suture the to of the vaginal vault to the
sarcospinous ligament. The procedure is
performed throught the vagina.
Complications of the procedure include
damage to the sciatic nerve and pudendal
vessels.
Vaginal mesh repairs
Reccurence of prolapsed after surgical
correction is common, with up to 30% of
women requiring a second operation within
5 years. The reccurence may be due to the
fact that the repaired tissues were weak even
before the original operation; consequently,
there is increased interest in mesh-
augmented pelvic floor repair. Meshes are
used with the aim of improving tissue
strength and support. Types of mesh used
are synthetic biocompatible meshes (e.g.
polypropylene) and biological meshes (e.g.
porcine dermisor bovine pericardium), and
these can also be either absorbable or non-
absorbable.
Currently, mesh is most popularly provided
as mesh repair kits. They use
monofilament, low-weight, marcoporous
polypropylene meshes to reinforce the
pubocervical and rectovagina fascia. The
operation involves the blind insertion of
trocars into the obturator foramen,
ischiorectal fossa, ileococcygeus muscule
and sarcospinous ligament. Most meshes
have tree parts, which are placed between
the bladder and vagina, through each
obturator foramen and between the rectum
and vagina (fig. 19.9)
Meshes have been associated with an
increased risk of complications, however,
partly from the risk of insertion and partly
because they are foreign bodies. Operative
complication include bladder injuries, rectal
injuries and vascular damage (cystoscopy is
recommended to exclude bladder damage).
Long-term complications include
dyspareunia, erosion or rejectionof the
mesh, and mesh-related infection. Infection
after use of a vaginal polypropylene mesh
has been reported in around 8% of cases,
with erosion occurring in about 12%.
Necrotizing fasciitis is also a possibility.
Although mesh repair kits are associated
with low recurrence and low morbidity
rates, some of the uncommon complications
are serious and potentially life-threatening,
and it is suggested that these repairs should
be carried out only by specialists.
Key points
Genital prolapsed describes the descent
of the pelvic organs (urethra, bladder,
uterus, small bowel and rectum) into the
vagina.
It is more common after childbirth in
obese women, postmenopausal women
and those with conditions which raises
intra-abdominal pressure, such as
chronic cough or constipation.
Prolapse may be classified as; anterior
compartment defect (urethrocele or
cystocele-uretra or bledder,
respectively); a central compartment
deficit leading to the prolapse of the
uterus (first-, second,- or thrird-degree
prolpase); or a posterior compartment
deficit (prolapse of the rectum or small
bowel rectocele and enterocele,
respectively).
Women with prolapse may present with
a semething coming down,
discomfort, or urinary or bowel
symptoms. Asymptomatic prolapse does
not usually need to be treated.
Treatment may be conservative (ring
pessaries, pelviv floor exercises) or
surgical repair, i.e. repairing the
vaginalwall defect or performing
vaginal hysterectomy for uterine
prolapse.