GENITAL PROLAPSE

It is the condition of descent of uterus & vagina from their normal anatomical position either partial or completely.
Aetiology=
1.Birth trauma-repeted deliveries within short interval,prolonged & difficult labour,delivery of big baby,premature bearing down before full dilatation of cervix ,injudicious application of forceps,perineal injuries in second stage
2.Postmenopausal atrophy-after menopause due to withdrawn of estrogen leading to decreased blood supply there is atrophy of genital tract & its supports causing genital prolapse
3. Genetic & racial-congenital weakness of ligaments & muscle is found in some patient
4.Precipitating factors-
   a)increased intra abdominal pressure-chronic cough ,chronic constipation,heavy weight lifting
    b)increased wt of uterus-myohyperplasia,fibroids,adenomyosis,subinvolution
    c)pull from below-myomatous polyp,primary cystocoele
    d)surgery-if vaginal vault is not adequately supported at the time of hysterectomy can lead to vault prolapse

classification=
1>anterior vaginal wall-
  upper two third- cystocele
  lower one third-urethrocele
2>posterior vaginal wall-
  upper one third -enterocele
  lower two third -rectocele
degrees of uterine descent-
primary-descent of cervix into the vagina
sec-descent of the cervix upto the introitus
ter-descent of the cervix outside the uterus
symptoms-
1)something coming out through vagina with standing position,straining or coughing.
2)pelvic pain ,dragging pain in abdomen either continuous or on standing which is relieved on lying down
3)bach ache-low diffuse in nature & without any local tenderness
4)leucorrhoea -it may be blood stained due to ulcer
5)urinary-frequency of micturition,dysuria,difficulty in micturion
6)bowel-difficulty in defecation,constipation
7)sexul-difficulty in coitus ,unsatisfaction
8)infertility

investigations-
1)blood-hb,blood urea,blood sugar
2)urine-urine culture
3)ecg
4)high vaginal swab in case of vaginitis

DD-
1.Vulval cyst &tumour
2.Cyst of anterior vaginal wall
3.Congenital elongation of cervix
4.Cervical fibroid polyp
5.Urethral diverticula

managment=
A>prevention=
most of the causes are acqired therfore prevention plays imp role
 1)antenatal-improve general health& nutrition of patient
  2)intrapartum-
   - avoid premature bearing down
   -avoid ironing of vagina
   -give adequate and timely episiotomy when indicated
   -treat prolonged second stage by approprite means
 3)postpartum-
-postnatal physiotherapy
-early ambulation but no heavy weight lifting during puerperium
-adequate interval between two sccessive deliveries
 4)general-limit family size to 1/2 children.
Hrt after menopause

B)NON OPERATIVE TREATMENT
1)pelvic floor muscle exercises-voluntary contracting perineal muscle as if to stop the act of defecation.perform such exercises 6 to 8 times a day  .It improves the tone of pelvic floor musculature
2)pessary-it is the  palliative treatment and does not cure the prolapse hence less prefered.
Indications-
a)a young women planning a pregnancy
b)during early pregnancy
c)puerperium
d)temporary use while clearing infections
e)a woman unfit for pregnancy
f)when woman refuse surgery
Limitations-
a)never curative only palliative
b)can cause vaginitis
c)need to be changed after every three months
d)wearing of pessary is not comfortable to some woman
e)if vaginal orifice is very patulous it can not be retained
f)forgotten pessary can cause ulcer or rarely carcinoma of vagina
g)does not cure urinary stress incontinance.
Ring pessary made up of soft plastic  polyvinyl chloride material of different size is used
 
C)Surgical treatment=
AIMS-
 relieve symptoms
 restore anatomy
 restore sexual functions
1>anterior colporrhaphy-to repair cystocele & cystourethrocele
2>posterior colporrhaphy-to correct rectocele &to repair deficient perineum.
3>Fothergill's repair-anterior colporrhaphy  combined with amputation of cervix
4>abdominal sling operation-
for young women suffering from second or third degree uterine prolapse
  following are common sling operations-
a)abdominocervicopexy
b)shirodkar's abdominal sling operation
c)khanna's abdominal sling operation