Definition :
Herniation or protrusion of a pelvic organ into or out of vaginal canal call the prolapse.
Cause :
- Atonicity or asthenia following menopause is most an important factor of prolapse.
- During menopause most of the women's pelvic muscle and the ligament that support genital tract become slack and atony because of
deficiency of oestrogen.
- Major or minor degree prolapse can occur soon after
childbirth which can be improved by pelvic floor muscle exercised. A birth injury like obtaining or tear cause anonymity.
- Delivery at home by untrained dai who ask a female to
bear down before full dilatation of the cervix.
- The prolonged second stage of labour which stretching of
uterosacral ligament.
- Ventous extraction of a foetus before full dilatation of
cervix without any application of forceps.
- False method of a downward vigorous push to the uterus to
expel placenta.
- Laceration of the perianal body during childbirth unless
sutured.
- In nulliparous or unmarried can be because of spina
bifida or split pelvis which results in the weakness of supporting muscles.
- Family or hereditary history of pelvic prolapse.
- Delivery of big baby.
- Rapid suction of pregnancy.
- Increase abdominal pressure like chronic bronchitis,
chronic constipation.
- Abdominal perineal exertion.
Classification of prolapse :
Prolapse :
1. Vaginal :
In vaginal anterior wall and posterior wall.
In anterior wall urethrocele and cystocele.
In posterior wall rectocele and enterocele.
2. Utero-vaginal :
In the uterovaginal first degree, second degree, third degree, fourth degree.
First degree means descend of the cervix in the vagina.
A second degree means the descent of cervix up to vaginal introitus.
The third degree means the descent of cervix without vaginal introitus.
Fourth degree called precedential it means the whole of uterus come out of vaginal introitus.
Clinical Feature :
- Patient complains something is descending in vaginal or
protruding out at vulva.
- Prolapse aggravation by coughing, straining, heavy work
amelioration by lying down.
- If large prolapse or external swelling may cause
discomfort while walking or carrying regular duties.
- At the end of the day mid sacral blockage.
- Sometimes vaginal discharge.
- Decubitus or friction ulcer may present on procedentia
which may be discharged by bleeding.
- Micturation difficulties like imperfect control or
stress incontinence.
- Coital difficulties which third degree and fourth
degree prolapse.
Lab diagnosis :
1. Physical examination :
- The patient is asked to cough and straining to diagnosis
nature and degree of prolapse.
- Vulval examination for perineal laceration.
- Vaginal orifice examination for relaxed opening.
- Perineal body and levator muscle are palpated to detect
tone and dimension.
- Pervaginal examination to detect vaginal prolapse and
degree of descent, condition of vagina and cervix.
- Vaginal examination: To know the length of the cervix position
and mobility of uterus.
- The general condition of a patient is evaluated decided to
fitness for surgery.
2. lab investigation :
- CBC
- Blood
- Urea
- Blood sugar
- Urine routine
- X-ray of chest and ECG
Differential diagnosis :
- Anterior vaginal wall cyst.
- Congenital elongation of the cervix.
- Cervical fibroid.
- Valvular cyst.
- A patient may mistake at rectal prolapse.
Treatment :
1. Prophylaxis :
- Careful attention during childbirth.
- Antenatal and postnatal physiotherapy.
- Proper supervision and management during the second stage
of labour.
- Adequate rest after delivery.
- The span between pregnancy should be more.
- Avoid multiparity.
- It occurring in menopausal women prophylactic treatment
HRT should be given.
2. Medical treatment :
- Pessary treatment: This is made up of soft plastic
polyvinyl chloride ( PVC ) material available in a different size is palliative but not curative.
3. Operative treatment :
Depend on the age of patient and degree
of prolapse. The desire for children to retain uterus and general condition of the patient.
- Anterior colporrhaphy.
- Posterior colporrhaphy.
- Vaginal hysterectomy.
- Abdominal celling operation.
- Anterior colporrhaphy with amputation of elongation of cervix.