Genital prolapse is one of the common clinical conditions met in day to day gynaecological practice

 

INTRODUCTION

 

          Genital prolapse is one of the common clinical conditions met in day to day gynecological practice.  In prolapse, straining causes protrusion of the vaginal walls at the vaginal orifice, while in severe cases the cervix of the uterus may be pushed down to the level of the vulva.  In extreme cases the whole uterus and most of the vaginal walls may be extruded from the vagina.  This happens mostly in postmenopausal and multiparous women.

 

Definition

          Uterine prolapse is the descent of the uterus through the vagina.

ETIOLOGY OF PROLAPSE

Uterine prolapse result from

a.        Weakness of the structures supporting the organs in position.

b.        Raised intra abdominal pressure

The Other Factors are:-

I.             Predisposing factors

II.           Aggravating Factors

 

I.             Predisposing factors again divided into two

a.   Acquired

b.   Congenital

 

a) Acquired

          Vaginal delivery with consequent injury to the supporting structures is the single most important acquired predisposing factor in producing prolapse.

          The injury is caused by,

·        Overstretching of the uterosacral ligments.

·        Over stretching of the endopelvic fascial shealth of the vagina.

·        Over stretching of the perineum

·        Sub involution of the supporting structures

Particularly noticeable in:-

·        Ill – nourished women

·        Reapeated child births etc

b) Congenital

          congenital weakness of the supporting structure is responsible for prolapse.

II. Aggravating factors

The factors are:-

a.    Post menopausal atrophy

b.    Increased intra abdominal pressure

c.    Increased weight of the uterus

d.    Under nutrition

e.    Traction by the anterior vaginal wall.

Types of uterine prolapse

1.    Vagino – uterine prolapse

2.    Utero – vaginal prolapse

 

1. Vagino – Uterine prolapse

          In vagino uterine prolapse, primary vaginal prolapse drags the uterus down.  This is the commonest type.  This is associated with cystocele, rectocele and relaxed perineum.

 

2. Utero – Vaginal prolapse:

          In vaginal prolapse, primary descent of the uterus causes inversion of the vagina.  This type is often seen in nulliparous women and hence called nulliparous prolapse.  The cause is congenital weakness of the supporting structures holding the uterus in position.  In this type, there may be not be any cystocele or rectocels.

 

DEGREE OF UTERINE PROLAPSE

a)   First Degree: The cervix and the uterine body descent from its normal position into the vagina.

b)   Second degree: Descent of the cervix upto the introitus.

c)    Third degree: Descent of the cervix outside the introitus.

d)   Procidentia: Whole of the uterus descend, outside the vaginal introitus.

 

CLINICAL MANIFESTATION

Symptoms

1.    Feeling of something coming down per vaginam.

2.    Backache or dragging pain in the pelvis

3.    Urinary symptoms such as

a.   Difficulty in passing urine

b.   Urgency and frequency of micturition

c.    Painful micturation or burning micturition

d.   Scanty urine

e.    Stress incontinence is usually due to associated urethorcele.

f.     Retention of urine may rarely occur

4.    Bowel symptoms like

a.   Difficulty in passing stool

b.   Excessive white or blood stained discharge per vagina, usually foul smelling discharge

Signs

a)   It is uncommon to find in women below 25 years after child birth.

b)   General health may be either normal or poor.

c)    She may be anaemic

d)   Abdomen may be lax

e)    In first degree uterine prolapse is bimanually felt normal size.

f)     In second degree prolapse, bimanual examination may reveal the supra vaginal elongation of cervix.

g)    In third degree prolapse the protruding mass contains the external os.

 

DIAGNOSTIC EVALUATION

a)    History collection

b)   Inspection

c)    Palpation

d)   Speculum examination

DIFFERENTIAL DIAGNOSIS

a)    Cyst of anterior vaginal wall

b)   Congenital elongation of the cervix

c)    Chronic inversion

d)   Fibroid polyp

e)    Post menopausal bleeding

 

MANAGEMENT

·        Preventive management

·        Conservative management

·        Surgical management

Preventive management

          The following guidelines may be prescribed to prevent or minimize genital prolapse.

A. Effective antenatal care

·        Nutritional supplement

·        Antenatal hygiene

·        Physiotherapy with relaxation exercises

b. Adequate intranatal care

·        To prevent premature bearing down efforts.

·        To prevent premature application of forceps before the cervix is fully dilated

·        To avoid too much fundal pushing to expel placenta.

·        To perform timely and adequate episiotomy

·        To repair any perineal injuries immediately and accurately.

c.  Adequate post natal care

·        Prevent undue distention of bladder

·        Encourage early ambulance

·        Encourage pelvic floor exercise by seqeezing the pelvic floor muscle in the puerperium.

d. General measures

·        This is to avoid strenuous activities for at least 6 months following delivery.

·        To avoid future pregnancy too soon and too many by contraceptive practice.

Conservative management

This includes

·        Assurance

·        Improvement of nutritional status

·        Pelvic floor exercises in an attempt to strengthen the muscles.

Pessary treatment

          The ring pessary made of soft plastic polyvinyl chloride material is available in different sizes.

·        Its use in indicated in a woman who is unfit for surgery or is a high risk case for surgery on account of some medical disorder.

·        A pregnant woman with prolapse needs a ring pessary in the first trimester of pregnancy.

·        As the uterus grows abdominally, the prolapse gets reduced, and the pessary can be removed.

·        Pessary treatment may be needed in a puperial woman with severe degree of prolapse.

·        Depending upon the elasticity of cervix the pessary insertion is to be done.

·        Pessary treatment is never curative and can only be palliative.

Surgical Management

Surgical correction to place the herniated mass in position is the treatment of prolapse.  For this following guidelines are prescribed

·        Surgery is the corrective treatment of symptomatic prolapse unless there is sufficient reason to withhold it.

·        Surgical correction is to be withheld to asymptomatic prolapse detected accidentally.

·        Young age with future potentialities are no bar to withhold surgery in sympatomatic cases.

·        Meticulous examination, if necessary under anaesthesia, is necessary to establish the correct diagnosis of the organ prolapsed so that effective and appropriate repair can be carried out with reasonable success.

·        There is no uniform procedure to all types of prolapse.

·        Due consideration is to be given but the age, reproductive and sexual function.

 

Types of operation

1.    Anterior colporrhaphy

2.    Fothergills repair or Manchester operation

3.    Vaginal hysterectomy

4.    He fort’s repair

 

1. Anterior colporrhaphy

          This operation is performed to repair a cystocele and cystourethrocele.  Traction is given to expose the anterior vaginal wall.

2. Fothergills repair

          The operation is designed to correct uterine descent associated with cystocele and rectocele.

3. Vaginal hysterectomy

          Removal of uterus per vaginum mostly done in case of uterine prolapse.  It is suitable for women over the age of 40 years, those who have completed their families and are no longer keen on retaining their child bearing and menstrual functions

4. He fort’s repair

          This operation is reserved for the very elderly menopausal patients with an advanced prolapse.  Contraindications are menstruating women, women leading active sexual life and with stress-incontinence.

 

Nursing Management

·        Patient is prone for infection so that probable precautions should be carried out.

·        Patient should be put to bed with foot of the bed raised.

·        The infected cervix should be kept in position by sterile vaginal pack should be changed atleast twice a day.

·        Do antiseptic dressing to dimish the infection

·        Advice the mother to avoid strenuous activities.

·        Advice the mother to drink more water.

·        Advice the mother to empty the bladder frequently.

·        Teach the mother to do pelvic floor exercise to strengthen the muscle.

 

 

CONCLUSION

 

          Genital prolapse is one of the common clinical conditions met in day to day gynaecological practice.  Uterine prolapse is the descent of the uterus through the vagina.  It occurs due to weakness of the structures supporting the organs in position and because of increased intra abdominal pressure.  It has a preventive, conservative and surgical management to correct the prolapse.