KELAINAN ORGAN GENITALIA

Dr. ALI Samhur SpOG

FK UMS
PROLAPSUS ORGAN PANGGUL
JENIS JENISNYA :
1. PROLAPS UTERI → UTERUS TURUN KE
VAGINA BISA SAMPAI KELUAR DARI VAGINA
2. PROLAPS VAGINA → DISEBABKAN
KELEMAHAN FASCIA DI DPN ATAU DI
BELKANG VAGINA SHG VU DAN USUS TURUN
MENYEBABKAN DDG VAGINA MENONJOL KE
LUMEN VAGINA
PROLAPS VAGINA DPT TERJADI TERSENDIRI
TANPA DISERTAI PROLAPS UTERI, SDG PADA
PROLAPS UTERI SRG BERSAMAAN DGN PROLAPS
UTERI
PROLAPS VAGINA TDD :
1. SISTOKEL → YG TURUN ADL VESIKA
URINARIA
2. URETHROKEL → YG TURUN ADL UREHTRA
3. REKTOKEL → YG TURUN ADL REKTUM
4. ENTEROKEL → YG TURUN ADL USUS HALUS
DI TEMPAT CAVUM DOUGHLAS (HERNIA
CAVUM DOUGHLAS)
5. KOLPOKEL PASCAHISTREKTOMI →
PENURUNAN VAGINA PASCAHISTREKTOMI
KLASIFIKASI PROLAPS UTERI
1. PROLAPS UTERI TKT I → UTERUS TURUN DGN
SERVIX UTERI PLG RENDAH SAMPAI
INTROITUS VAGINA
2. PROLAPS UTERI TKT II → UTERUS SEBAGIAN
KELUAR DARI VAGINA
3. PROLAPS UTERI TKT III (PROSIDENSIA UTERI)
→ UTERUS SELURUHNYA KELUAR DARI
VAGINA
ETIOLOGI

Kelemahan jaringan ikat pada daerah

rongga panggul, terutama jaringan ikat
tranversal.

Ambulans Gawat Darurat

118
ETIOLOGI
• MULTIPARA
• PARTUS DGN PENYULIT
• TARIKAN PD JANIN PEMBUKAAN BLM LENGKAP
• PRASAT CRADE YG BERLEBIHAN
• ASITES ATAU TUMOR DIDAERAH PELVIS → faktor
resiko
• Menopause → (produksi hormon
estrogen berkurang → elastisitas dari
jaringan ikat berkurang dan otot – otot
panggul mengecil yang menyebabkan
melemahnya sokongan pada uterus)
• PROLAPS PD NULIPARA → OK KELAINAN
KONGENITAL BERUPA KELEMAHAN LIGAMENTUM
UTERI
DIAGNOSIS
 PROLAPS UTERI → TDK SULIT → DARI
KELUHAN PENDERITA, Px GINEKOLOGIK
DITENTUKAN TURUNNYA PORTIO UTERI
(PASIEN DISURUH MENGEJAN )
 SISTOKEL → PADA Px VT DITEJUMPAI
DIDINDING VAGINA DEPAN BENJOLAN KISTIK
LEMBEK DAN TDK NYERI TEKAN, BENJOLAN
BERTAMBAH BSR JIKA MENGEJAN
 REKTOKEL → DIJUMPAI PENONJOLAN
REKTUM KE LUMEN VAGINA BERBENTUK
LONJONG, KISTIK , TDK NYERI
MANIFESTASI KLINIS
1. Perasaan adanya suatu benda yang
mengganjal atau menonjol di genetalia
eksterna
2. Rasa sakit di panggul dan pinggang
(backache), keluhan berkurang bl
berbaring

3. PD PROLAPS UTERI :
AKAN MENGGANGGU PENDERITA SAAT
BEKERJA ATAU BERJLN, DEKUBITUS KRN
GESESKAN PORSIO DGN CELANA, LEUKOREA
KRN KONGESTI PEMB DRH DI SERVIX, INFEKSI
SERTA LUKA PD PORSIO
PD SISTOKEL :
 SERING MIKSI DAN SEDIKIT2
 PERASAAN KANDUNG KENCING TDK KOSONG
SEPENUHNYA
 STRESS INCONTINENCE → TDK DPT MENAHAN
KENCING JIKA BATUK, MENGEJAN DSB
REKTOKEL
 OBSTIPASI KRN FAESES BERKUMPUL DLM
RONGGA REKTOKEL
BISA DEFEKASI SETLH DILAKUKAN TEKANAN
PD REKTOKEL DARI VAGINA
KOMPLIKASI
 KERATINISASI MUKOSA VAGINA DAN PORSIO
UTERI → MUKOSA VAGINA DAN SERVIX UTERI
MENJD TEBAL, BERKERUT, WARNA KEPUTIHAN
 DEKUBITUS
 HIPERTROPI SERVIX DAN ELONGASIO KOLLI
 GANNGUAN MIKSI DAN STRES INCONTINENCIA
 ISK
 INFERTIL
 KESULITAN PARTUS
 HEMOROID
 INKARSERASI USUS HALUS
PENANGANAN
1. PREVENTIF
 TDK TERLALU SERING PARTUS
 PIMPNAN PERSALIN YG BENAR SAAT PARTUS
 MOBILISASI SEDINI MUNGKIN POST PARTUS
 MENGHINDARI PEKERJAAN YG MENGANGKAT
BARANG2 BERAT
GIZI YG BAIK
2. KURATIF
a) TANPA OPERASI :
LATIHAN OTOT DASAR PANGGUL
STIMULASI OTOT DGN ELEKTRIK
PEMASANGAN PESSARIUM → KI BILA ADA
RADANG PELVIS AKUT/SUBAKUT DAN Ca.
b) OPERATIF
PD PROLAPS UTERI → PERTIMBANGAN : INGIN
HAMIL/TDK, UMUR, TKT PROLAPS, KELUHAN
 OPERASI MANHCESTER → AMPUTASI SERVIX,
PENJAHITAN LIG CARDINALE DI DPN SERVIX
(MEMPERDEK LIG), KOLPORAFI ANT
 HISTREKTOMI VAGINAL
 KOLPOKLEISIS (Operasi Le Fort) → MENUTUP
VAGINA DGN MENJAHIT DINDING VAGINA
DEPAN DGN DINDING VAGINA BELAKANG, ES
DPT TERJADI INKONTINENSIA URIN
 VENTROFIKSASI → MENJAHIT FUNDUS UTERI
PD DINDING PERUT
 INTERPOSISI → MELETAKKAN UTERUS
ANATARA VU DAN VAGINA , OPERASI INI SDH
TDK DILAKUKAN LAGI
Macam – macam Pessarium
Pessarium
KISTA BARTHOLINI
RADANG PD GLANDULA BARTHOLINI YG
TERJADI BERULANG2 DAN KRONIS SHG
GLANDULA BARTHOLININ TERBENTUK BERUPA
KANTONG BERISI CAIRAN
TDK SELALU MENYEBABKAN KELUHAN
KECUALI SDH BESAR SHG TERASA SBG BENDA
BERAT DAN MENIMBULKAN KESULITAN
KOITUS
Tx → MARSUPIALISASI, TINDAKAN YG AMAN
DAN HASIL YG MEMUASKAN. EXTIRPASI →
RESIKO PERDARAHAN
BARTHOLINITIS
INFEKSI PD GLANDULA BARTHOLINI
DPT DISEBABKAN OLEH BAKETRI GO,
STREPTOKOKUS / BASILUS
PD YG AKUT → GLANDULA ( KELNJAR)
MEMBESAR, MERAH, NYERI, PANAS → ISINYA
NANAH YG DPT KELUAR MELALUI
DUKTUSNYA, BL DUKTUS TERSUMBAT
TERBENTUK ABSES YG DPT MEMBESAR SD
SETELUR BEBEK
Tx → ANTIBIOTIK BL BLM TERBEBENTUK
ABSES, KL ABSES → INSISI
HEMATOKOLPOS
 TERKUMPULNYA DARAH HAID DALAM VAGINA
OK TDK BISA KELUAR DISEBABAKAN ADANYA
HYMEN INFERFORATA ( HIATUS HIMENALIS TDK
TERBENTUK)
 DARAH YG TERKUMPUL DI DLM VAGINA
MENYEBABKAN HYMEN TERLIHAT KEBIRU2AN
DAN MENONJOL KELUAR
 KELAIANAN INI BIASANYA DIKETAHUI SETELAH
MENARCHE → ADANYA MOLIMINA
MENSTRUALIA SETIAP BULAN TP DARAH HAID
TDK KELUAR
 BL DIBIARKAN → UTERUS JG AKAN TERISI DARAH
HAID DAN MEMBESAR (HEMATOMETRA)
AKAN BERLANJUT JD HEMATOSALFINKS →
TERISINYA TUBA KA DAN TUBA KI OLEH
DARAH HAID YG KDG2 DPT DIRABA DARI LUAR
SBG TUMOR KISTIK DI KA DAN KI ATAS
SIMFISIS
DIAGNOSIS → TDK SULIT
THERAPI → HYMENEKTOMI ( MEMBUAT
HIATUS HYMENALIS DGN INSISI PD HYMEN )
KISTA VAGINA

ADA 2 JENIS KISTA KONGENITAL VAGINA

1. TERJADI DARI SISA2 EPITEL DUKTUS MULLERI
2. TERBENTUK OLEH SISA2 DUKTUS GARTNER
YG TERLETAK DI BAGIAN ANTEROLATERAL
VAGINA

PENGBATAN KEDUA JENIS KISTA INI DGN

KISTEKTOMI ( PENGANGKATAN KISTA DGN
PENGUPASAN DARI SIMPAINYA
Genital fistula
 FISTULA GENITALIA
• TERBENTUKNYA RONGGA / SALURAN
ABNORMAL DIANTARA DUA ORGAN YG
BERDEKATAN
• GENITO-URINARIA FISTULA → ADANYA HUB
ABNORMAL ANTARA TRACT URINARIA DGN
ORGAN GENITALIA
• RECTO-VAGINAL FISTULA → ANTARA VAGINA
DGN RECTUM
Genitourinary fistulae are:
• Vesicovaginal (42 %)
• Ureterovaginal (34 %)
• Urethrovaginal (11 %)
• Vesicocervical (3 %).
 Sites of fistula
Fistula
 ETIOLOGI
VESICOVAGINAL FISTULA :
1. gynaecological surgery
• Hysterectomy.(75% of cases).
• Anterior colporrhaphy.
• Laparoscopic pelvic surgery and urological
surgery.
Risk factor during surgery are:
• Previous surgery.
• Fibroids or endometriosis.
2. pelvic malignancy.
3. pelvic trauma and radiotherapy.
4. obstetric trauma in the developing world.
Congenital dan Inflammatory → jarang
 Vesico-vaginal fistula
Tanda dan gejala :
• Incontinence urine. (Leakage of urine).
• Pruritus regio genital and paha.
• Miksi terasa panas / dysuria.
• meningkatnya vaginal discharge bila
fistula kecil
• Umumnya timbul setelah 5–10 hari post
operasi
 DIAGNOSIS
• ADANYA RIWAYAT OPERASI SEBELUMNYA
• PD FISTEL YG BESARA DPT TERLIHAT KETIKA Px
POSISI MIRING KIRI DGN MENGGUNAKAN
sim’s speculum.
• TEST CELUP Methylene blue – UTK
MEMBEDAKAN vesicovaginal,
urethrovaginal and ureterovaginal fistula
• Metal catheter – DIMASUKKAN MELALUI
URETHRA AKAN KELUAR MELALUI FISTULA KE
VAGINA
 Bonney’s ‘three swab test
• 3 pieces of swab kept in vagina.
• 200 cc of dilute methylene blue injected
into bladder via catheter
• If upper or middle piece stains blue – vvf
• If none of the piece stains blue but is wet
with urine – ureteric
• If lower piece stained blue then -urethral
 Management of VVF
• Conservative measures.
• Complex surgical procedures.
• Management of symptoms.
• Barrier creams
incontinence pads.
• Prophylactic antibiotics.
 Management of vvf…cont.
Bladder damage during childbirth:
• Catheter for 7-10 days.
• Antibiotic coverage.
Established fistula:
• Wait for 3 months.
• Repair.
Fistula following cancer:
• Biopsy to be taken from the edge of fistula
 Vaginal route of repair
• Latzko procedure → high colpocleisis technic
• Flap splitting technique
• In case of extensive fibrosis, then omental
grafts or gracilis muscle graft is applied
• In case of large and high VVF, trans peritoneal
approach is preferred.
 URETERIC FISTULA
• Injury of ureter most commonly following
surgery:
• Obstruction
• Transection
• Devascularisation
 Treatment of ureteric fistula
• Total obstruction
• Detected early during surgery- removal of ligature
and stenting
• If detected late, ureter implanted into bladder
• Transection

• Partial – cystoscopic catheterization & stenting of

ureter
• Complete – reanastomosis or implantation of cut
end to bladder or ureteroneocystostomy
 VESICO UTERINA FISTULA
• Usually caused during cesarean section.
• Complain of cyclical hematuria.
• Treatment is usually through abdominal route
•
 URETHRO VAGINAL FISTULA
Causes in developed countries:
• Anterior repair.
• Vaginal hysterectomy.
• Urethral diverticulum or its repair.
• Bladder neck suspension procedures.
Causes in developing countries:
• Childbirth.
 Urethro-vaginal fistula….Cont.
Symptoms:
• Higher up in the urethra
 Continuous incontinence.
• Fistula nearer the bladder neck
 Stress incontinence .
 Recurrent urinary tract infections.
 Spraying of urine at micturition or post-
micturition dribble. (miksi nyimprat)
 Urethro-vaginal fistula….Cont.
 Management:
• Conservative with a urethral catheter.
• Surgical repair in specialist centre.
• Repair is most commonly through vaginal
route.
 Post-operative management
• Continous bladder drainage for 14 days
• Adequate antibiotics
• No vaginal or speculum examination.
• No intercourse for 3 months after surgery.
• Cesarean section indicated following
successful repair.
 Prevention
• Detect high risk factor at the earliest during
ANC (contracted pelvis & malpresentation)
• Avoid prolonged labor
• Avoid unskilled forceps application & risky
destructive operations
• Detect injury to the bladder at the earliest and
treatment of the same.
 Clinical features
• Large RVF – incontinence of both faeces +
flatus through vagina
• Small RVF – incontinence of flatus through
vagina
• Foul smelling vaginal discharge
 Diagnosis
• Rectovaginal examination
• Proctosigmoidoscopy
• Barium enema or CT scan can delineate high
RVF
 Management
• Pre- and post- operative preparation is very
important.
• Rectal enema
• Low residue fluid diet 5 days before surgery
• Intestinal antiseptics- neomycin
• Vaginal douche
 RVF in lower third of vagina
• Lawson tails’s operation
• Cutting remaining bridge of tissue below
fistula
• Converting fistula into complete perineal tear
• Repaired in layers like in complete perineal
tear
 RVF in middle third of vagina
• Same as described in VVF repair
• Alternative procedure is to start as in
perineorrhaphy for rectocele and extend the
dissection above the fistula
 RVF in upper third of vagina
• High RVF usually surrounded by dense fibrosis
• Difficult to close vaginally
• Best dealt by abdominal (transperitoneal)
 Post operative care
• Vulva washed with antiseptic after every
micturition
• Low residue diet
• Intestinal antiseptics
• Vaginal pack removed after 24 hrs
• Laxatives given to avoid constipation
• Elective LSCS at term advised after RVF repair