It is a medical condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself begin to fall out of their normal positions

Pelvic organ prolapse is a medical condition in which structures such as the uterus, rectum, bladder, urethra, small bowel, or the vagina itself begin to fall out of their normal positions. It is a weakness of some major parts which without medical treatment or surgery may eventually fall farther into the vagina or even through the vaginal opening if their supports weaken enough.

Pelvic floor weakness resulting in prolapse with or without urinary incontinence is a common gynaecological entity. The exact prevalence of prolapse is difficult to determine as often prolapse is not complained about. About 20% of women on gynaecological waiting list for major surgery have prolapse and this rises to 59% of elderly women undergoing major gynaecological surgery.

A combination of factors are known to contribute to the occurrence of genital prolapse, but high parity is the single most important risk factor for prolapse in both more or less developed countries. Childbirth causes degeneration and mechanical injury to the pelvic floor. Apart from the number of deliveries, obstetric factors related to the individual delivery such as prolonged second stage and poor surgical repair of perineal injury have been implicated. Other risk factors associated with development of genital prolapse are low oestrogen status of menopause, increased intra-abdominal pressure from chronic cough, staining at stooling, obesity, previous surgeries like hysterectomy and congenital factors such as skeletal deformities, connective tissue disorders, neuromuscular factors and race.




Presentation is usually a mass protrusion from the vagina. There may be ulceration on the mass. This is stasis ulcer, a recognized complication of utero-vaginal prolapse from oedema and impaired vascular drainage secondary to distorted anatomy. Ulceration could also result from trauma due to repeated rubbing. Other symptoms include urinary tract symptoms, low back pain and vaginal discharge.

 

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The diagnosis of utero-vaginal prolapse is clinical. The investigations done are to assess fitness for surgery and also to avoid complications that could result from altered anatomy. Clinically utero-vaginal prolapse is classified into 3 stages: 1st degree is the descent of the uterus into the vaginal without protrusion from the introitus; 2nd degree involves partial protrusion of cervix outside the introitus with body of the uterus still within the vaginal canal; 3rd degree involves herniation of the uterus with its fundus outside the introitus.




It is important to ensure that the pressure symptoms as well as the urinary symptoms are actually caused by prolapse and not by other pelvic or spinal conditions. Other associated or underlying conditions must be ameliorated as much as possible e.g. dieting control in the obese, treating chest infections and correcting constipation. Ulceration on the protrusion must be treated with antibiotics and daily dressing with oestrogen cream to hasten healing of the ulcer.

Management is usually surgical especially when patient is fit for surgery. Surgical options include hysterectomy ± bilateral salpingo-oophorectomy in women who have completed their families and postmenopausal women. Other forms are Manchester repair for young women who wish to retain their reproductive ability. This operation is however disfavored because of the associated complications such as infertility, cervical dystocia and premature labour. Leforte’s operation, an obliterative vaginal operation is rarely indicated in elderly women who are poor surgical candidates and who no longer desire coital function.




Conservative measures for treatment of utero-vaginal prolapse include the use of pessaries and electro-stimulation, followed by pelvic floor exercises. Both of these are useful in those with mild to moderate degree of prolapse, those who refuse surgery or for relief of symptoms while awaiting surgery and also in those desirous of further child-bearing. Pessaries could also be used as a therapeutic test to determine if pressure symptoms and urinary symptoms are due to prolapse and also to predict those in whom surgery would be of help. Its use is also recommended in pregnancy, puerperium and also to promote healing of decubitus ulcer prior to surgery. Prolonged use of pessaries is however associated with complications such as ulceration, vaginal discharge and fistula formation.

 

 

 

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