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Post hysterectomy vault prolapse: Post hysterectomy vault prolapse | Oxford Gynaecology and Pelvic Floor Centre

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Post-hysterectomy vaginal vault prolapse – PubMed

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doi: 10.1016/j.maturitas.2017.07.011.

Epub 2017 Jul 31.

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  • 1 Department Of Urogynaecology, Kings College Hospital, United Kingdom. Electronic address: [email protected].
  • 2 Department Of Urogynaecology, Kings College Hospital, United Kingdom.

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Dudley Robinson et al.

Maturitas.

2018 Jan.

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doi: 10.1016/j.maturitas.2017.07.011.

Epub 2017 Jul 31.

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  • 1 Department Of Urogynaecology, Kings College Hospital, United Kingdom. Electronic address: dudley.robinson@nhs. net.
  • 2 Department Of Urogynaecology, Kings College Hospital, United Kingdom.

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Abstract

Post-hysterectomy vaginal vault prolapse (PHVP) is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse. The management of PHVP remains challenging and whilst many women will initially benefit from conservative measures, the majority will ultimately require surgery. The purpose of this paper is to review the prevalence and risk factors associated with PHVP as well to give an overview of the clinical management of this often complicated problem. The role of prophylactic primary prevention procedures at the time of hysterectomy will be discussed as well as initial conservative management. Surgery, however, remains integral in managing these complex patients and the vaginal and abdominal approach to managing PHVP will be reviewed in detail, in addition to both laparoscopic and robotic approaches.


Keywords:

Apical; Post-hysterectomy; Prolapse; Review; Urogynaecology; Vault.

Copyright © 2017 Elsevier B.V. All rights reserved.

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MeSH terms

  • Hysterectomy / adverse effects*
  • Pelvic Organ Prolapse / etiology*
  • Pelvic Organ Prolapse / surgery

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Vaginal Prolapse | Johns Hopkins Medicine

What is vaginal prolapse?

Prolapse occurs when a woman’s pelvic floor muscles, tissues and ligaments weaken and stretch. This can result in organs dropping out of their normal position. Vaginal prolapse refers to when the top of the vagina — also called the vaginal vault — sags and falls into the vaginal canal. In severe cases, the vagina can protrude outside of the body.

What causes vaginal prolapse?

There are no direct causes of vaginal prolapse. However, women are at an increased risk of developing vaginal prolapse if they:

  • Delivered children vaginally, especially repeat deliveries
  • Are approaching or experiencing menopause
  • Have certain lifestyle factors, including being overweight
  • Were born with a rare condition, such as bladder exstrophy

Vaginal Prolapse After Hysterectomy

Hysterectomy, a surgery to remove a woman’s uterus, is sometimes performed to treat uterine prolapse. However, vaginal prolapse can occur after hysterectomy (regardless of the reason for hysterectomy). This is called “vaginal prolapse after hysterectomy.

How common is vaginal prolapse?

Vaginal prolapse is relatively common. About one-third of women will experience some degree of prolapse during their lifetime. If you have more than one risk factor, your chances of developing vaginal prolapse increase.

What are the signs and symptoms of vaginal prolapse?

Vaginal Pressure

Women with vaginal prolapse often report feeling pressure in the vaginal area, described as a throbbing pain in the vagina. Women also report:

  • Vaginal fullness (such as the feeling that something is stuck in the vagina)
  • The sensation that something is falling out of her vagina

Additional Vaginal Prolapse Symptoms

The pelvic organs are all supported by each other. When one organ prolapses, it can affect the functioning of other nearby organs. Thus, some women also experience:

  • Changes in bowel function, such as difficulty having a bowel movement
  • Changes in bladder function, such as inability to empty the bladder
  • Secondary prolapses, specifically rectocele prolapse (sagging of the connective tissue between the vagina and rectum) or cystocele prolapse (sagging of the connective tissue between the vagina and the bladder).
  • Pain or discomfort during sexual intercourse
  • Difficulty using tampons

How is a vaginal prolapse diagnosed?

Your doctor will review your medical and surgical history and complete a physical exam. Additional tests, such as ultrasound or MRI, are rarely needed. In some cases, your doctor may also recommended urodynamics testing, a group of tests that evaluate bladder function.

How is vaginal prolapse treated?

Treatment for vaginal prolapse varies, depending on the severity of the symptoms. Many cases will not require treatment. In mild cases, your physician may recommend pelvic floor exercises to strengthen the muscles. In moderate cases, your doctor may insert a vaginal pessary to support your vaginal wall. In the most severe cases, you may benefit from surgery, such as colposuspension, a minimally invasive surgical procedure, where the vaginal wall is attached to a stable ligament in the pelvis.

Understanding Pelvic Organ Prolapse | ACOG

Pelvic organ prolapse is a disorder in which one or more of the pelvic organs drop from their normal position. It is caused by injury to the muscles or tissues that support the pelvic organs. The pelvic organs include the vagina, uterus, bladder, urethra, and rectum. These organs are held in place by muscles of the pelvic floor.

The main cause of pelvic organ prolapse is pregnancy and childbirth, especially vaginal childbirth. Other causes can include aging and obesity. This problem also runs in families.

The following videos show the different types of prolapse that can occur. Prolapse happens in stages. Mild cases are those in which the organs have dropped only a short distance. Severe cases are those in which the organs have dropped a greater distance. Sometimes several organs can be affected at once. There also are videos showing treatment with pessaries.

Jump To:

Types of Prolapse

Prolapse After Hysterectomy

Treatment with Pessaries


 

Types of Prolapse

Uterine Prolapse

The uterus drops down into the vagina. In severe uterine prolapse, the uterus may protrude from the vagina.


Anterior Vaginal Wall Prolapse

The bladder drops down and creates a bulge into the front wall of the vagina. In severe cases, the bulge can protrude outside the vagina. Another name for bladder prolapse is cystocele.


Posterior Vaginal Wall Prolapse

The rectum drops down and creates a bulge into the back wall of the vagina. In severe cases, the bulge can protrude outside the vagina. Another name for this condition is rectocele.


Uterovaginal Prolapse

In some cases, several organs can drop. Here the bladder, uterus, and rectum are shown shifting down.


Prolapse After Hysterectomy

Pelvic organ prolapse also can occur after hysterectomy (an operation to remove the uterus). The following videos show the different types of prolapse that can occur without a uterus.

Anterior Vaginal Wall Prolapse (After Hysterectomy)

Bladder prolapse can occur in a person without a uterus. Another name for bladder prolapse is cystocele.


Vaginal Vault Prolapse (After Hysterectomy)

The top of the vagina drops down, creating a bulge. In severe cases, the top of the vagina may protrude outside of the vagina. It also may occur with small intestine prolapse (shown here), anterior vaginal wall prolapse, or posterior vaginal vault prolapse.


Posterior Vaginal Wall Prolapse (After Hysterectomy)

The rectum can drop downward, creating a bulge into the back wall of the vagina. It may occur with prolapse of the vaginal vault. Another name for this condition is rectocele.


Treatment with Pessaries

Pessaries are a nonsurgical treatment option that can relieve prolapse symptoms. A pessary is a device that is inserted into the vagina to provide support for prolapsed organs. Three types of pessaries are shown in the following videos.

Gellhorn Pessary

This pessary is used to treat uterine prolapse.


Ring with Support Pessary

This pessary is used to treat bladder prolapse.


Ring with Knob Pessary

This pessary is used to treat urinary incontinence caused by bladder prolapse.

PEV001

Published: April 2021

Last reviewed: April 2021

Copyright 2021 by the American College of Obstetricians and Gynecologists. All rights reserved. Read copyright and permissions information.

This information is designed as an educational aid for the public. It offers current information and opinions related to women’s health. It is not intended as a statement of the standard of care. It does not explain all of the proper treatments or methods of care. It is not a substitute for the advice of a physician. Read ACOG’s complete disclaimer.

Post-hysterectomy vaginal vault prolapse – ScienceDirect

https://doi.org/10.1016/j.maturitas.2017.07.011Get rights and content

Highlights

Post-hysterectomy vaginal vault prolapse is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse.

Primary prevention can be performed at the time of hysterectomy.

Whilst all women will initially benefit from conservative measures, surgical intervention remains integral in the effective management of women with post-hysterectomy vaginal vault prolapse.

Women should be counselled carefully regarding the route of surgery, the role of concomitant continence surgery, and the long-term risks which may be associated with the use of abdominal mesh.

Given the complexity of the management of post-hysterectomy vaginal vault prolapse, these patients are best managed in a tertiary centre within the auspices of a multidisciplinary team that includes urogynaecologists, urologists and colorectal surgeons.

Abstract

Post-hysterectomy vaginal vault prolapse (PHVP) is a recognised although rare complication following both abdominal and vaginal hysterectomy and the risk is increased in women following vaginal surgery for urogenital prolapse. The management of PHVP remains challenging and whilst many women will initially benefit from conservative measures, the majority will ultimately require surgery.

The purpose of this paper is to review the prevalence and risk factors associated with PHVP as well to give an overview of the clinical management of this often complicated problem. The role of prophylactic primary prevention procedures at the time of hysterectomy will be discussed as well as initial conservative management.

Surgery, however, remains integral in managing these complex patients and the vaginal and abdominal approach to managing PHVP will be reviewed in detail, in addition to both laparoscopic and robotic approaches.

Keywords

Post-hysterectomy

Prolapse

Vault

Apical

Urogynaecology

Review

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© 2017 Elsevier B.V. All rights reserved.

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Post Hysterectomy Vaginal Vault Prolapse

A vaginal vault prolapse occurs when the top of the vagina (the vault) falls toward the vaginal opening. A prolapse can be small, or incomplete, with only a little movement involved. It can also be complete, with the entire organ shifting and a portion of it protruding from the body.    

Causes of Post Hysterectomy Vaginal Vault Prolapse 

This condition occurs in up to 40% of women who have undergone a hysterectomy. Normally, the uterus supports the top of the vagina, so when the uterus is removed, that support is lost. Another factor is the gradual age-related weakening of the muscles and other tissues that support the vagina, making a prolapse more likely once the uterus is removed.  

Symptoms of Post Hysterectomy Vaginal Vault Prolapse 

Many patients don’t experience symptoms and only find out about their condition during an exam performed by a doctor.  

If symptoms develop, they can include: 

  • Pain and a feeling of fullness in the pelvic area 
  • Bulging inside the vagina 
  • Lower back pain 
  • Bladder infections 
  • Urinary incontinence 
  • Pain during sexual intercourse 
  • A portion of the vaginal vault protruding from the vagina (complete prolapse) 

Diagnosis of Post Hysterectomy Vaginal Vault Prolapse 

Proper diagnosis of this condition requires an in-office examination. Your healthcare provider will likely ask about any incontinence you’ve experienced as well as any pain or fullness in your pelvic area. If a vaginal vault prolapse is suspected, additional tests may be needed to rule out a bladder problem as the cause of the symptoms.  

Treatments for Post Hysterectomy Vaginal Vault Prolapse 

Treatment options will likely vary depending on the severity of the prolapse. Your treatment plan may also depend on factors such as your age, your sexual activity and your general health. Some nonsurgical treatment options include: 

  • Exercising the pelvic muscles 
  • Insertion of a vaginal pessary to provide support 

If surgery is deemed necessary, options include: 

Vaginal Vault Prolapse

Introduction. Vaginal vault prolapse is a common complication following vaginal hysterectomy with negative impact on women’s quality of life due to associated urinary, anorectal and sexual dysfunction. A clear understanding of the supporting mechanism for the uterus and vagina is important in making the right choice of corrective procedure. Management should be individualised, taking into consideration the surgeon’s experience, patients age, comorbidities, previous surgery and sex life. Result. Preexisting pelvic floor defect prior to hysterectomy is the single most important risk factor for vault prolapse. Various surgical techniques have been advanced at hysterectomy to prevent vault prolapse. Studies have shown the McCall’s culdoplasty under direct visualisation to be superior.
Vault prolapse repair rely on either the use of patient’s tissue or synthetic materials and can be carried out abdominally or vaginally. Sacrospinous fixation and abdominal sacrocolpopexy are the commonly performed procedures, with literature in favour of abdominal sacrocolpopexy over sacrospinous fixation due to its reported higher success rate of about 90%. Other less commonly performed procedures include uterosacral ligament suspension and illiococcygeal fixation, both of which are equally effective, with the former having a high risk of ureteric injury. Colpoclesis will play a greater role in the future as the aging population increases. Mesh procedures are gaining in popularity, and preliminary data from vaginal mesh procedures is encouraging. Laparoscopic techniques require a high level of skill and experience. There are many controversies on the mechanism of prolapse and management techniques, which we have tried to address in this article. Conclusion. As the aging population increases, the incidence of prolapse will also rise, older techniques using native tissue will continue, while new techniques using the mesh needs to be studied further. The later may well be the way forward in future.

1. Introduction

Vaginal vault prolapse has been defined by the International Continence Society as descent of the vaginal cuff below a point that is 2 cm less than the total vaginal length above the plane of the hymen [1]. It occurs when the upper vagina bulges into or outside the vagina.

Coexistent pelvic floor defects which may be a cystocoele, rectocoele or enterocoele are present in 72% of patients with vault prolapse [2]. Prolapse does have a negative impact on these women’s quality of life due to associated urinary, ano-rectal, as well as coital dysfunction. It is therefore important to counsel these women and carefully assess the defects of the various vaginal compartments before planning management. A clear understanding of the supporting mechanisms for the uterus and the vagina is important in order to make the right choice of the corrective procedure and also to minimise the risk of posthysterectomy occurrence of vault prolapse.

The surgical options for the correction of vault prolapse lie between the vaginal and the abdominal approach. The choice of procedure should be based on the patient’s age, co-morbidity, previous surgery and the level of physical and sexual activity [3]. Also the experience of the surgeon influences the choice of operation. Importantly, greater awareness of the pelvic anatomy and the technique at the time of the original hysterectomy will significantly reduce the incidence of subsequent vault prolapse.

The satisfactory correction of vaginal vault prolapse is a formidable surgical challenge and many techniques have been described for the correction of this distressing problem. The aims of prolapse surgery are to restore normal vaginal supports whilst maintaining vaginal capacity and coital function.

This article is to review the problem of vault prolapse and the various techniques for its correction, with critical evaluation of their success and possible complications.

2. Anatomic Background

The upper vagina, cervix, and uterus are attached to the pelvic sidewalls by broad sheets of endopelvic fascia. These sheets of tissue are usually referred to as the cardinal and utero-sacral ligaments. They originate over the region of the greater sciatic foramen and lateral sacrum, and insert into the side of the cervix as well as the upper one-third of the vagina. Although the cardinal and the utero-sacral ligaments have separate names, they are actually a single unit. The endo-opelvic fascia in this region consists mainly of perivascular collagen and elastin but also contains a considerable amount of nonvascular smooth muscle and the autonomic nerves to the uterus and bladder. Below the level of the uterus, the endo-opelvic fascia attaches the upper one-third of vagina to the pelvic sidewalls in the same way that the cardinal and utero-sacral ligaments provide attachment for the uterine cervix [5]. The middle one-third of the vagina is attached more directly to the lateral pelvic sidewalls by the pubocervical and rectovaginal fasciae, which are nothing more than downward continuations of the cardinal and uterosacral ligaments. These structures attach the lateral margins of the vagina to the pelvic sidewalls on each side, stretching the vagina from one side of the pelvis to the other so that its anterior wall forms a horizontal sheet on which the bladder rests. The posterior attachment of the vagina to the pelvic sidewalls creates a similar sheet that prevents the rectum from prolapsing forward. This is the rectovaginal fascia.

On the other hand the muscular levator plate provides indirect support for the upper genital tract by acting as a platform against which the upper vagina and other pelvic viscera are compressed during rises in intraabdominal pressure. The levator plate is formed by the fusion of the right and left bellies of the levator ani muscle behind the rectum and anterior to the coccyx. Sublaxation of the levator plate will cause it to act like a slide, down which the rectum and upper genital tract may descend with rises in intraabdominal pressure.

The cardinal and uterosacral ligaments form a complex of visceral supporting tissues to the upper vagina and cervix and, after hysterectomy, to the vaginal cuff. They pull the upper vagina horizontally back toward the sacrum and thus suspended it over the muscular levator plate. Anatomically, the insertion of the cardinal and uterosacral ligaments to the pericervical ring occurs at the level of the ischial spines. Clinically, detachment of the cardinal—uterosacral ligament complexes from pericervical ring occurs at the level of the ischial spines and provides the anatomic rationale for development of uterine descent posthysterectomy, vaginal vault prolapse, and enterocele (apical prolapse).

3. Risk Factors

The risk of genital prolapse increases with increasing parity and advancing age. Previous surgery to correct pelvic organ support defects has been consistently identified as risk factors for the development of pelvic organ prolapse. Several other factors have also been implicated, including vaginal versus abdominal delivery for term infant, hysterectomy, congenital defects, races, lifestyle, and chronic disease that increase intrabdominal pressure (e.g., chronic constipation, pulmonary disease, and obesity). However the role of some of these factors is not fully understood.

4. Childbirth

Women who had 4 or more vaginal deliveries have 12 times more risk of genital prolapse [6]. From the literature, it appears that vaginal delivery causes damage to the pudendal nerve and promotes the development of pelvic organ prolapse. There are suggestions that instrumental vaginal delivery, especially forceps delivery increase the risk [7]. Also it was demonstrated that Caesarean section can avoid the pudendal nerve damage caused by vaginal delivery [8]. Inspite of the absence damage to the pudendal nerve at caesarean section Maclennan et al. [9] showed that there was no significant difference in pelvic floor dysfunction between caesarean section and vaginal delivery. However pelvic floor dysfunction was significantly commoner following Instrumental delivery.

5. Age

Many literatures show increasing prevalence of pelvic organ prolapse in an aged population [10]. It has been shown that there is a 12% increase in the incidence of severe pelvic organ prolapse with each year of advancing ae, or roughly a doubling of the incidence for every decade of life [11].

6.

Previous Surgery to Correct Pelvic Organ Support Defects

Recurrence rates for surgical correction pf pelvic organ prolapse are in rate 10% to 30% range [10, 12]. By analysing the different risk factors for developing severe pelvic organ prolapse, the previous surgery to correct prolapse was the single greatest risk factor [11]. It appears that pathophysiology of the prolapse is not fully understood and the current practice for surgical correction of prolapse may be inadequate.

7. Hysterectomy

There is no consensus on the role of hysterectomy as a cause of subsequent development of pelvic organ prolapse.

The incidence of prolapse, which required surgical correction following hysterectomy, is 3.6 per 1000 person-years of risk. The cumulative risk rises from 1% three years after a hysterectomy to 5% 15 years after hysterectomy. Also the risk of prolapse following hysterectomy is 5.5 times in women whose initial hysterectomy was for genital prolapse as opposed to other reasons. Some studies have reported an incidence of up to 43% [3, 13].

Dällenbach et al. conducted a case control study involving 114 women who required pelvic organ prolapse surgery after initial hysterectomy and found that risk factor included preopertional prolapse grade 2 or more, 95% CI 1.3–48.2 and history of vaginal delivery, 95% CI 1.3–19 [14]. Marchionni et al. after following up 2670 women over 9–13-years (mean 11 years) also concluded that incidence of vaginal vault prolapse was low when hysterectomy is performed in the absence of defect in the pelvic support [15]. These support the view that vault prolapse following hysterectomy is more likely if there was pre-existing pelvic floor defect or prolapse.

8. Evaluation and Description of Vault Proalpse

Most vaginal cuff prolapses include apical enterocele where the pubocervical and rectovaginal fascia have separated. The peritoneum becomes stretched and comes in direct contact with the vaginal epithelium creating a true hernia. The vaginal epithelium is stretched and becomes very smooth without rugae. There is always some degree of high cystocele formation and high rectocele formation associated with the vaginal vault prolapse.

Pelvic Organ Prolapse Quantification (POP-Q) is an objective and standardised system of prolapse classification introduced in 1996, by the International Continence Society. It is a useful tool in assessing the extent of prolapse. It has the added advantage of its use in evaluating surgical and nonsurgical treatment outcomes and for clinical research purposes.

The clinical application of 3D-MRI is unclear. A study by Cortes et al. involving 51 women aged 40–95 (mean 64 years) showed poor correlation between MRI and clinical assessment especially in vaginal apical prolapse.

However MRI allows identification of other prolapsing compartment and may be complimentary in complex apical prolapsed [16].

Vaginal prolapse is distressing and disabling condition to women. The symptom of feeling “something coming down”, “feeling pressure in the vagina” is always a common complaint. Urinary symptoms, such as poor stream, hesitancy, straining to void, incomplete emptying, recurrent urinary tract infections, and the need to reduce the bulge digitally to void or defecate may also present especially when associated with anterior and posterior compartment prolapse.

Asking women about their prolapse symptoms may cause embarrassment and a symptomatic assessment by the physician may be difficult or inaccurate. There are validated, reliable, and easily comprehensible questionnaires designed to assess the severity of symptoms of prolapse and their impact on quality of life. One very useful questionnaire is the prolapse Quality-of-life Questionnaire [17].

9. Non Surgical Management

Conservative management will include pelvic floor exercise and pessaries, commonly ring and shelf pessaries. Their role in vault prolapse management is unclear and there is no evidence to suggest that pelvic floor exercise is helpful [18]. However pessaries may have a limited role in the very frail and elderly in whom surgery is not an option.

9.1. The Surgical Management (Vaginal Approach)

The overall aim of surgery is to improve the quality of life taking into account the individual peculiarity of each patient. All aspects of the prolapse pathology, patient’s lifestyle, age, presence of co-morbidities and sexual function must be taken into consideration. It is also important for the surgeon to understand patient’s expectation, discuss available options including their drawbacks so that the appropriate procedure with potential to fulfil her expectations can be achieved.

For the patient with good pelvic floor muscle strength as assessed by clinical examination and reasonably substantive endopelvic fascia, a vaginal approach using native tissues may be appropriate. The vagina is anchored to existing stable structures like the sacospinous ligament, illiococcygeous muscle and endopelvic fascia. Women with attenuated fascia, poor pelvic floor muscle strength, repeat repair or severe ongoing physical stress are better served by a technique of vault suspension that provides compensatory repair either through vaginal or abdominal approach using the mesh.

9.2. Prevention of Vault Prolapse (McCall Culdoplasty)

It was described by McCall in 1957 as a technique to correct enterocoele [19] and involves the suspension of the vault into the origins of the uterosacral ligaments and obliteration of the cul-de-sac. The original description involved extensive excision of vaginal epithelium, which often resulted in dyspareunia. More recently Elkins et al. described a high McCall culdoplasty [20]. The technique was described to repair the prolapsed vagina at hysterectomy. After the uterine fundus was delivered through an anterior colpotomy incision, the uterosacral ligaments are systematically plicated from the posterior cervix back into the pelvic cavity, until two fingerbreadths remain between the rectum and the plicated ligaments. The main problem with this technique is the risk of ureteric injury. However this can be eliminated by the use of routine cystoscopy with or without methylene blue to identify ureteric efflux following the procedure. Cruikshank and Kovac [4] in a RCT involving 100 patients compared Moschcowit type closure, simple peritoneum closure with McCall culdoplasty. The result (Tables 1 and 2) showed that McCall culdoplasty was more effective than either simple closure of the peritoneum or Moschcowitz over a 3 year follow up in preventing enterocoele.


Type of procedureNo. of patientsProlapse rate over 3-years

Moschcowit type closure3330.3%
Modified McCall culdoplasty336.1%
Simple closure of peritoneum3439.4%


Type1 year2 years3-years

McCall culdoplasty ()Stage 1 = 0Stage 1 = 2Stage 1 = 2
Stage 2 = 0Stage 2 = 0Stage 2 = 0
()

Moschcowitz ()Stage 1 = 3Stage 1 = 3Stage 1 = 4
Stage 2 = 0Stage 2 = 2Stage 2 = 6

Simple closure of peritoneum ()Stage 1 = 4Stage 1 = 5Stage 1 = 8
Stage 2 = 4Stage 2 = 4Stage 2 = 5

Prophylactic McCall Culdoplasty at the time of vaginal hysterectomy for vaginal prolapse is our routine practice, followed by routine cystoscopy to confirm the safety of the ureters.

9.3. Sacrospinous Fixation

The procedure was first described by Miyazaki [21] in 1987 and later popularised by Sharp and Richer [6, 22] and by Erata et al. and Lang et al. [23, 24]. It was originally described as a bilateral procedure but subsequently being done as a unilateral procedure. The later results in less tension, though the bilateral technique is more anatomical and maintain a wide vaginal vault.

The technique comprises dissection into the paravaginal space and the ischial spine is identified. Using a Deschamps ligature carrier, two nonabsorbable sutures are placed through the sacrospinous ligament, one and a half to two fingerbreadths medial to the ischial spine. One end of each suture is attached to the under surface of the posterior vaginal wall at the apical area. When the posterior colporrhaphy reaches the mid-portion of the vagina, the sacrospinous sutures are tied, firmly attaching the vaginal apex to the surface of the coccygeal-sacrospinous ligament complex with no intervening bridge of suture material. Several modifications of this technique were described and mainly involved different methods of placing the sutures into the ligament. The Miyazaki technique uses the Miya hook ligature carrier [25], and the Sharp technique uses the Shutt suture punch system [26].

There are no randomised studies to compare efficacy of either unilateral or bilateral vaginal vault suspension, so there is no evidence to recommend either bilateral or unilateral sacrospinous fixation [27].

In an extensive review of the literature Virtanen and Makinen [28], quoted 18% recurrent prolapse between vault eversion, cystoceles, and rectoceles. More specifically Holley (1995) showed the development of asymptomatic cystocele in 92% [29]. Retrospective study by Colombo et al. involving 124 women who had either sacrospinous fixation or McCall’s culdoplasty found no significant difference in the incidence of vaginal vault prolapse after 4 years, but sacrospinous fixation took longer to perform and was associated with more blood loss. Also more women who had sacrospinous fixation, later developed grade 2 or 3 anterior vaginal wall prolapse [30]. It is not an ideal operation for the sexually active woman, as it leads to a less physiological axis than sacrocolpopexy. It is also associated with exaggerated retroversion of the vagina [31].

Although infrequent, haemorrhage is the most common complication but it is rarely of a life threatening nature. It could be a result of injuring the pudendal artery or vein, or the hypogastric venous plexus.

Other complications include injury to the bladder or rectum. Transient and self-limiting gluteal pain could result from injuring the small nerve that runs through the coccygeal-sacrospinous ligament complex. Immediate and severe postoperative gluteal pain radiating to the posterior surface of the leg, and often associated with perineal parathesia, indicates posterior cutaneous, pudendal, or sciatic nerve trauma. The recommended treatment for the later is immediate reoperation and releasing the offending suture and repositioning it to a more medial position [32]. In a study by Pollak et al. complication rates were compared for three techniques, namely standard needle driver with direct visualisation, Deschamps ligature carrier by palpation and Miya hook ligature carrier by palpation and the conclusion was that postoperative complications related to suture passage were lower under direct visualisation 2% versus 18%, [33].

Anterior compartment displacement following this procedure has commonly been reported though debate persists with some surgeons believing that these are actually pre-existing defect missed at initial evaluation. Routine anterior repair at sacrospinous fixation has been suggested by some as a way to address this [34]. This though is not the universal practice.

De novo urinary symptoms like overactive bladder or stress incontinence can occur just like in prolapse operations involving the anterior vaginal wall, but in spite of some of these drawbacks, this procedure may be more suitable for the elderly where sexual function is not important. More importantly in these elderly patients with coexisting chronic medical conditions where general anaesthesia is unsuitable or outright dangerous, sacrospinous fixation which can be performed under regional anaesthesia will be the procedure of choice. Success rate of between 75% and 97% has been reported [35].

9.4. Iliococcygeal Fixation

The technique was first described by Sze and Karram in 1997 [36] and comprises the fixation of the everted vaginal apex to the ilioccygeal fascia just below the ischial spine. It has subsequently been popularised by Holley et al. [37]. It is usually done as a bilateral procedure as it imposes less tension on the vaginal wall than sacrospinous fixation. The iliococcygeal muscle can be approached through either an anterior or posterior vaginal wall incision. It is relatively easier than sacrospinous fixation and can be done in conjunction with vaginal hysterectomy or as a separate procedure for correction of vault prolapse. A lower rate of postoperative cystocoele, bleeding and pain has been suggested but in a study [38] comparing illiococcygeal fixation to sacrospinous fixation, there was no difference in outcome for postoperative cystocoele, bleeding and pain in both procedures. Success rate were also similar.

In a small series Carey reported 11% recurrence following sacrospinous fixation and 14% following iliococcygeal fixation with cystocele being the commonest recurrent prolapse in both groups [39].

There has been suggestion of reduced risk of injury to the pudendal nerves and vessels, and less chance of vaginal shortening, but certainly illiococcygeal fixation offers no additional benefit over sacrospinous fixation. The Royal College of Obstetricians and Gynaecologists (RCOG) in its green-top guideline, no. 46 states “Illiococcygeus fixation does not reduce the incidence of anterior vaginal wall prolapse associated with vaginal sacrospinous fixation and should not be routinely recommended” [40].

9.5. Utreosacral Suspension

This has been described as a bilateral procedure carried out vaginally. It can also be carried out via an abdominal or laparoscopic approach. The aim is to place sutures through the uterosacrals at the level of the ischial spine, with one arm brought out through the lateral aspect of the rectovaginal fascia and the other through the pubocervical fascia on each side. These are tied anchoring the vaginal cuff to the uterosacrals. The biggest risk is injury to the ureters (up to 10.9%) due to its proximity to the anterior border of the uterosacrals, especially at the level of the cervix. Other complications include bowel injury, bladder injury, urinary tract infection and blood transfusion. Barber et al. followed up of 46 women, after vaginal uterosacral suspension over a mean period of 15 months and showed 90% had resolution of prolapse symptoms and improvement in the stage of prolapse [41]. Most gynaecologist believe the uterosacral ligaments are compromised in the first place, for prolapse to occur, and for this reason will prefer sacrospinous fixation, while some suggest that the uterosacral ligaments are not weakened, but instead break at specific points resulting in enterocoele and vault prolapse. The later school of thought believe that the uterosacral can be used, even in severe prolapse by identifying the distal portion of breakage and anchoring the vagina high above this point to the uterosacral ligament using an intraperitoneal approach [34].

9.6. Infracoccygeal Sling Sacropexy

Petros [42] described this new technique and reports on his experience of the first 75 cases. The principle of this technique is to create artificial uterosacral ligaments by inserting woven nylon tapes along their anatomical path [42].

The technique comprises a transverse incision on the posterior vaginal wall 1.5–2 cm below the hysterectomy scar line and opened anteroposteriorly. The enterocele sac is placed backwards and allowed access to the laterally displaced uterosacral ligaments. At this point the enterocele sac is reduced with a purse string suture. The next step is making bilateral incisions 0.5 cm long in the perianal skin at 4 and 8 o’clock, halfway between the coccyx and external anal sphincter. Having slid the conical head of the tunneller subdermally to the level of 3 and 9 o’clock, the handle is lifted upward 90 degrees so that the head is parallel to the floor. The shaft of the tunneller is then thrust forward into the ischiorectal fossa. This action penetrates the levator plate and brings the conical head into a position behind the uterosacral ligament. Under direct vision, with finger placed in the rectum to locate the position of the rectal wall, the conical tip of the tunneller is gently inclined medially towards the vaginal vault. The tip is then penetrating the fascia adjoining the vagina and rectum. A 6 mm woven nylon tape was threaded into the eye of the plastic insert and brought into the transverse incision. The procedure is repeated on the contralateral side, leaving the tape as a U entirely unfixed at the sacral end. The tape is then sutured to the vault at each corner at the estimated insertion site of the uterosacral ligament. The tape is then gently stretched by pulling on each perineal end, and left entirely free and unfixed.

In his series of 75 patients Petros reported 5% recurrence of vault prolapse at a follow up between 1–4 years, 16% de novo anterior wall prolapse, and 4% partial rectocele [42]. Rectal perforation during insertion of the tape was reported in 2 patients, identified during the procedure and had no long-term sequel. Current evidence on the efficacy and safety of this procedure is inadequate. Few clinical data are available on the success rate of this procedure, though a recent report quoted a 75% improvement in vault prolapse [43].

The National Institute for Health and Clinical Excellence recommends that this procedure should only be used with special arrangement in a clinical governance or research setting [44].

10. Abdominal Approach
10.1. Abdominal Sacrocolpopexy

Abdominal sacrocolpopexy, employing retroperitoneal interposition of a suspensory synthetic, autologous or allograft prosthesis between the vaginal vault and the sacral promontory was first described by Lane in 1962 [45]. This method has proven to be superior to other surgical techniques in terms of restoration of the normal vaginal axis and maintenance of vaginal capacity [46, 47]. Although the short-term success rates reported for this procedure are in excess of 90%, the long-term outcome remains unclear and significant complications include postoperative stress urinary incontinence, dyspareunia and erosion of synthetic graft material.

The abdominal sacral colpopexy employs the interposition of a synthetic mesh or tissue graft between the vagina and sacrum. This technique allows for more global support of the vagina and distribution of tension over a larger surface area. Previous authors have reported severe and occasionally life-threatening haemorrhage from the preexistingsacral vessels, when sutures were placed in the hollow of the sacrum [48, 49]. To reduce this risk the operative technique was therefore modified and sutures placed more proximally over the sacral promontory. Contrary to previous reports, the point of sacral attachment does not affect the vaginal axis and attachment to the sacral promontory allows effective restoration of vaginal support, while maintaining both vaginal capacity and coital function. [50, 51]. Most surgeons will bury the mesh under the peritoneum to avoid bowel erosion, while some do not and others will tunnel the mesh from the vaginal vault to the sacral promontory without dissecting the peritoneum. Which method is best is still controversial. Different methods of mesh attachment to the vagina have been described and to date these remain very controversial. These include attaching a full length of mesh to the whole length of the rectovaginal septum. Another method involves a double attachment of the mesh to the anterior and posterior vaginal surfaces with reported good results. There are usually other associated defects like anterior or posterior vaginal wall defect in varying degrees with divided opinion and debate amongst surgeons on completing it either vaginally or abdominally [34]. There is no simple answer, but every patient has to be considered individually and the associated defects assessed properly, so that a clear plan of surgical repair can be agreed with the patient bearing in mind other factors like coital function.

Consistent cure rate of more than 90% has been reported [52], with some studies reporting up to 95% [53].

Mesh erosion following the use of polypropylene graft was reported to complicate 2–2.7% of cases [54, 55]. This will necessitate revision or removal of the mesh. In most of the cases, this occurs at the vaginal vault resulting in dyspareunia and vaginal discharge within the first six months. Mesh erosion is usually predisposed to by marked scarring and thinning of the vagina from previous vaginal repairs or a combined abdominal hysterectomy and sacral colpopexy. This problem can be eliminated by the use of donor fascia lata or a xenograft.

This procedure has added advantage over the traditional procedures because it maintains the normal axis of the vagina, with preservation of maximal vaginal length which is desirable for optimal sexual function. It also provides a source of strength in patients with weak tissue or recurrent prolapse [56]. For these reasons it is quite a fairly common operation with 38% of surgeons in a national survey carrying it out for vault prolapse [57]. It is further associated with a lower rate of recurrent prolapse and dyspareunia [58] which makes it popular choice amongst surgeons especially in fit patients. Part of its drawback includes the fact that it is performed via laparotomy with all the associated risk of internal organ injury, longer operation time and hospital stay, so these need to be balanced against the benefits. In the very elderly with coexisting medical pathology, the risk of laparotomy coupled with the extra risk of general anaesthesia will make this procedure unsuitable [56].

11. Laparoscopic Approach
11.1. Laparoscopic Sacral Colpopexy

In theory laparoscopic approach to the repair of the vault prolapse should follow the same principle as in the open technique, with laparoscopy only being the mode of surgical access. However a highly skilled and experienced laparoscopic surgeon is crucial. This approach has a steep learning curve and takes many years of practise to acquire the necessary skills.

In a small study by Hsiao et al. in 2004, comparing laparoscopic sacrocolpopexy (25 patients) and abdominal sacrocolpopexy (22 patients), it showed that blood loss and hospital stay was significantly less in the laparoscopic group (), though operation time was longer (). However there was no difference in efficacy of both methods. Success rates of 95% for abdominal and 100% for laparoscopic techniques has been reported [53].

11.2. Laparoscopic Uterosacral-Ligament Vault Suspension

The technique begins with the identification of the vaginal vault apex, and the rectovaginal and pubocervical fascia facilitated by the use of a vaginal probe. Traction is placed on the vaginal probe forward to stretch the utero-sacral ligaments so they can be identified and traced backwards. At this stage both ureters are identified. The peritoneum overlying the vaginal apex is incised to expose the pubocervical fascia anteriorly and the rectovaginal fascia posteriorly. The rest of the procedure will follow along the same steps for the open technique, and the uterosacral ligament on each side is attached using nonabsorbable sutures to the ipsilateral side of the vaginal vault. Intra- or extracorporeal knots can be used depending on the surgeon’s preference.

There is a high risk of ureteric injury, so cystoscopy is advised after suture placement. Success rate of up to 90% over a 2 year period has been reported [59].

Laparoscopic surgery has a steep learning curve and not all surgeons will have the necessary skill to excel especially considering the technical difficulty and longer operation time. The main advantage is good exposure of the operation field enabling the surgeon to fully evaluate and treat other components of the prolapse effectively. Most recently new innovations like robotics, though in its infancy is helping to address some of the limitations of laparoscopy by providing better technical features such as 3D vision and more precise robotic instrument manoeuvrability. One of the latest and increasingly popular systems with varied application in different specialities, the Da Vinci system is at the fore of this new frontier [60].

11.3. Colpocleisis

This is a procedure that may gain in popularity in the coming years and as life expectancy rises in an aging population.

Colpocleisis involves surgical obliteration of the lumen of the vagina. Different methods are described including purse-string closure, vaginectomy and in association with other continence procedures [40]. Basically the vaginal epithelium is mobilised anteriorly and posteriorly leaving about 2 cm from the vault above and also from the urethral meatus below. The prolapse is reduced by placing progressive sutures anteroposteriorly, till the prolapsed tissues are above the level of the levator plate. It can also be carried out as a partial or total procedure. The partial procedure is usually reserved for women with an intact prolapsed uterus with the aim of giving access to any discharge or bleeding from the uterus via a small opening.

It is suitable for the frail elderly woman who is not sexually active and for whom conservative methods like the pessary is not ideal. It has the advantage that it can also be carried out under local anaesthesia and involves a shorter operation time. Essentially it is about improving the quality of life. In one of the largest case series involving 41 women carried out at Temple University Philadelphia between November 1994 and June 2001, there was only one case of bladder injury, 2 cases of self limiting rectal bleed and average hospital stay of 2 days [61].

De novo urinary stress incontinence of up to 27% in previously continent women has been reported [62], though no intraoperative complication has been reported in the literature [63].

Success rate of 97% and above have also been reported [64].

12. Vaginal versus Abdominal Approach

A prospective randomised study [12] compared vaginal (bilateral sacrospinous vault suspension and paravaginal repair) versus abdominal (colposacral suspension and paravaginal repair).

These patients were followed up for up to 5 years. Table 3 represents the outcome.


Vaginal ()Abdominal ()

Hb change g/dl
Number transfused
Dyspareunia
(Sexually active )(Sexually active )
Febrile morbidity
Incontinence
Catheter duration 5 days
Time of recurrence in months

This study did show that the vaginal route had significantly higher postoperative incontinence rate, longer period of catheter use and recurrence was less likely to occur following the abdominal route. However there were more transfusions and febrile morbidity in the abdominal group, though not significant. This study also noted a higher rate of reoperation for recurrent prolapse, 33% vaginal versus abdominal 16% confirming that the abdominal route has a better success rate.

13. Role of Mesh in Vault Prolapse

Synthetic mesh has been commonly used to manage pelvic organ and prolapse, even though the more traditional suture repair technique is still the primary choice, with the mesh mainly reserved for repeat procedures and large defects.

A multicentric retrospective study [65] involving 110 patients, of which 59 had total mesh repair, (transvaginal) using the prolift (Gynaecare) system, showed a recurrence rate of 4.75% at 3 month follow up. In spite of the short follow-up in this study, the total mesh may possibly address the issue of high rate of recurrence commoner with the more traditional methods. Other types of mesh like the Apogee (posterior vaginal wall) and Perigee (anterior vaginal wall) have been used for management of recurrent cystocoele and rectocoele with or without vault prolapse. Success rate of 93% has been reported [66]. However there are no randomised controlled studies to compare this procedure with abdominal sacrocolpopexy or uterosacral suspension for now [67].

14. Conclusion

Vault prolapse repair is based on use of native tissues or synthetic materials. There is no consensus on the mechanism and management of vault prolapse, but what is accepted by all is the need to properly assess these patients, involve them in the management and to agree on the type of surgery that will be suitable for their own peculiar circumstance. The mesh is gaining in popularity, but there are no studies yet on its long term efficacy though initial results are very encouraging.

Repair of Vaginal Wall Prolapse (Vaginal Vault Prolapse)

Surgery Overview

Vaginal vault prolapse occurs when the upper portion of the vagina loses its normal shape and sags or drops down into the vaginal canal or outside of the vagina. It may occur alone or along with prolapse of the bladder (cystocele), urethra (urethrocele), rectum (rectocele), or small bowel (enterocele). Vaginal vault prolapse is usually caused by weakness of the pelvic and vaginal tissues and muscles.

Symptoms of vaginal vault prolapse include:

  • Pelvic heaviness.
  • Backache.
  • A mass bulging into the vaginal canal or out of the vagina that may make standing and walking difficult.
  • Involuntary release of urine (incontinence).
  • Vaginal bleeding.

During surgery, the top of the vagina is attached to the lower abdominal (belly) wall, the lower back (lumbar) spine, or the ligaments of the pelvis. Vaginal vault prolapse is usually repaired through the vagina or an abdominal incision and may involve use of either your tissue or artificial material.

What To Expect After Surgery

General anesthesia is usually used for vaginal vault prolapse repair. You may stay in the hospital from 1 to 2 days. You will probably be able to return to your normal activities in about 6 weeks. Avoid strenuous activity for the first 6 weeks. And increase your activity level gradually.

Most women are able to resume sexual intercourse in about 6 weeks.

Why It Is Done

Repair of a vaginal vault prolapse is done to manage symptoms such as sagging or drooping of the top of the vagina into the vaginal canal, urinary incontinence, and painful intercourse.

Vaginal vault prolapse often occurs with other pelvic organ prolapse. So tell your doctor about other symptoms you may be having. If your doctor finds prolapse of other pelvic organs during your pelvic exam, that problem may also be repaired during surgery.

Your doctor may do an examination while you have a pessary in your vagina. This exam will help him or her see if urinary incontinence would be a problem after surgery. If the exam shows that urinary incontinence will be a problem, another surgery can be done at the same time to fix the problem.

How Well It Works

There are many surgical ways to fix a vaginal vault prolapse. The kind of surgery you have will depend on the doctor performing it, where you have it done, and your unique health situation. Experts disagree about which surgery gives patients the best results.footnote 1

Risks

Complications of surgery for vaginal vault prolapse are uncommon but include:

  • Bleeding.
  • Mild buttock pain for 1 to 2 months following surgery.
  • Urinary incontinence.
  • Urinary retention.
  • Infection.
  • Formation of an abnormal opening or connection between organs or body parts (fistula).

What To Think About

Surgical repair may relieve some, but not all, of the problems caused by a vaginal vault prolapse. If pelvic pain, low back pain, or pain with intercourse is present before surgery, the pain may persist after surgery. Symptoms of urinary retention may return or get worse following surgery.

You can control many of the activities that may have contributed to your vaginal vault prolapse or made it worse. After surgery:

  • Avoid smoking.
  • Stay at a healthy weight for your height.
  • Avoid constipation.
  • Avoid activities that put strain on the lower pelvic muscles, such as heavy lifting or long periods of standing.

References

Citations

  1. Lentz GM (2012). Anatomic defects of the abdominal wall and pelvic floor. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 453–474. Philadelphia: Mosby Elsevier.

Credits

Current as of:
July 17, 2020

Author: Healthwise Staff
Medical Review:
Sarah Marshall MD – Family Medicine
Kathleen Romito MD – Family Medicine
Martin J. Gabica MD – Family Medicine
Femi Olatunbosun MB, FRCSC – Obstetrics and Gynecology

Current as of: July 17, 2020

Author:
Healthwise Staff

Medical Review:Sarah Marshall MD – Family Medicine & Kathleen Romito MD – Family Medicine & Martin J. Gabica MD – Family Medicine & Femi Olatunbosun MB, FRCSC – Obstetrics and Gynecology

Lentz GM (2012). Anatomic defects of the abdominal wall and pelvic floor. In GM Lentz et al., eds., Comprehensive Gynecology, 6th ed., pp. 453-474. Philadelphia: Mosby Elsevier.

90,000 Consequences of removal of the uterus. Prolapse and prolapse of the vagina: causes, symptoms, treatment, surgery.

Vaginal prolapse is a condition characterized by the displacement of one or more walls of the vagina relative to its natural position. Formally, prolapse of the vaginal walls is characteristic of any prolapse, however, this term is more often used to describe prolapse that develops after removal of the uterus.At the same time, the term incomplete prolapse of the vaginal walls is often used, which characterizes the initial degrees of prolapse of the uterus and vagina.

Symptoms

Symptoms of vaginal prolapse, depending on the organ involved, can be divided into the following groups:

  • Associated with prolapse of the bladder (prolapse of the anterior wall of the vagina): difficulty urinating, urinating in small portions, the need to adjust the prolapse to empty the bladder completely, feeling of incomplete emptying of the bladder, frequent urination, loss of urine with tension and against the background of sudden urge to use the toilet
  • Associated with prolapse of the rectum (prolapse of the posterior wall of the vagina): difficult defecation, feeling of incomplete emptying of the rectum, defecation in portions, the need to adjust the prolapse or empty the colon with a finger to empty it completely

In addition, the prolapse of any of the walls of the vagina is characterized by a feeling of a foreign body in the vagina, discharge from the vagina, dryness of the vaginal mucosa that has descended outward, trauma to the prolapsed vaginal walls with possible formation of ulcers, discomfort during sexual intercourse, as well as pulling pains in the lower abdomen


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Reasons

The nature of the prolapse of the vaginal walls is a multifactorial and long-term process. The main cause of the disease is childbirth, during which the supporting apparatus of the pelvic floor is damaged. This factor becomes critical in the case of prolonged labor, large fetus, delivery using forceps or a vacuum extractor.

Of course, this is only a triggering mechanism, since most often there is a predisposing factor – hereditary weakness of the connective tissue. Another mechanism for the development of the disease is chronically high intra-abdominal pressure, which significantly increases the load on the ligamentous apparatus of the pelvic floor. The main culprits of this condition are hard physical labor, chronic lung disease, accompanied by severe cough, and chronic constipation.

Another reason that leads to prolapse of the vaginal walls is surgery to remove the uterus. The fact is that most often these interventions are performed as a method of treating prolapse of the uterus and vaginal walls. Unfortunately, in this situation, this often leads to even greater damage to the supporting apparatus of the pelvic floor and relapse of the disease, reaching up to 50%. A so-called prolapse of the vaginal stump or posthysterectomy prolapse is formed, in which the walls of the vagina are partially and completely turned outward.

Most of the patients receive help free of charge (without hidden surcharges for “nets”, etc.) within the framework of compulsory medical insurance ( under the compulsory medical insurance policy ).

Application for treatment under compulsory medical insurance

Diagnostics

Diagnosis of prolapse of the vaginal walls consists in performing a standard gynecological examination, which determines the vaginal department involved in the pathological process and the degree of prolapse. In total, there are 4 degrees of prolapse of the vaginal walls:

  • 1 degree – Characterizes a condition when the walls of the vagina have displaced from their natural position, but have not yet reached the entrance to the vagina by 2 cm or more
  • Grade 2 – At this stage of prolapse, the walls of the vagina are at the level of the entrance to the vagina.
  • Grade 3 – In this case, there is a prolapse of the walls of the vagina beyond the genital slit, but no more than 2/3 of its length
  • Grade 4 – Complete prolapse of the vaginal walls

At the first two degrees, the patient may not feel the prolapse and it is often asymptomatic and requires only observation.3-4 degree of prolapse is an advanced stage of the disease, in which treatment is necessary.

Treatment

Treatment of prolapse of the vaginal walls is performed only in case of a significant decrease in the quality of life of patients and dysfunction of internal organs. In principle, all types of assistance can be divided into conservative and operational.

The first type includes pelvic floor muscle training and pessaries. Exercises for prolapse of the vaginal walls are ineffective, since most often there is damage to the ligamentous apparatus of the pelvic floor, which cannot be restored with training.This is especially true for posthysterectomy prolapse. Pessaries are devices that, like a spacer, prevent the falling walls of the vagina from falling out. This method can be considered as a temporary measure when, for some reason, surgical treatment is impossible. Moreover, the use of pessaries is accompanied by discomfort in the vagina, leading to chronic inflammation and discharge, which requires regular visits to the gynecologist.

The only effective method of treatment is surgical.At the same time, it is also the most difficult, since performing operations after removal of the uterus is associated with a high risk of complications and relapses. Interventions for prolapse of the vaginal walls can be carried out both through the abdominal cavity and through the vagina. The first option, in addition to expensive equipment and the cost of treatment, is associated with a long duration of the operation, which requires the patient to be in good health. It is also characterized by specific complications: the risk of damage to the abdominal organs and ureters and postoperative problems with defecation.The more popular is the transvaginal type of reconstruction, which has a shorter duration of operations, which means it is easier to tolerate by patients.

Damage to the abdominal organs is almost completely excluded. Moreover, it allows you to simultaneously perform the reconstruction of both walls of the vagina and perineum. At the same time, the risk of developing complications associated with the use of synthetic prostheses, both in abdominal and transvaginal operations, is the same and directly depends on the experience of the surgeon.The most popular are now hybrid operations, which combine the advantages of using synthetic materials and the patient’s own tissues.

Aesthetic gynecology: we solve problems that are not customary to talk about

The life of a modern woman is different from what it was 100 years ago. And many of the problems that our great-grandmothers had to endure or perceive as “female share” can now be solved, the main thing is to contact a specialist in time with complaints.

Prolapse of female genital organs (prolapse or prolapse of internal pelvic organs, prolapse of the uterus, bladder, etc. ) is not a fatal disease, but it greatly impairs the quality of life of a woman at any age.

According to research data, up to a third of the female population in Russia suffers from this problem, while at the age of 50, the frequency of this pathology increases to 40%. In recent years, there has been a “rejuvenation” of this pathology and an increase in the number of complicated and recurrent forms of the disease.

Prolapse of the female genital organs is a disease in which the internal genital organs are displaced downward, towards the entrance to the vagina. In this case, there is a protrusion of the walls of the vagina, the cervix with the uterus itself and adjacent organs (bladder, rectum) beyond the genital gap. The prolapse of the uterus is associated with a weakening of the ligamentous apparatus that supports the pelvic organs in a normal position, which can be due to the following 90,099 reasons: 90 100

  • childbirth;
  • surgical interventions in the past;
  • connective tissue dysplasia;
  • changes in hormonal levels in pre- and postmenopausal women;
  • 90,011 obesity.

This disease inevitably progresses. In the early stages, it develops slowly and gets worse in the later stages. That is why you need to be especially careful about any discomfort that occurs in the genital area, and also pay attention to the following characteristic signs:

  • Presence of protrusion from the genital crevice
  • Feeling of heaviness in the vaginal area
  • Feeling of tension or tension in the pelvic area
  • Pain when standing up
  • Pain during sexual intercourse
  • Vaginal pain, feeling of pressure, irritation, bleeding or bleeding
  • Frequent back pain
  • Stress or urgent urinary incontinence
  • Inconvenience with displacements of internal organs
  • Difficulty urinating, urinary retention or weak jet pressure.

Prolapse of the female genital organs can be of the following types:

  1. Prolapse of the vaginal vault , with the prolapse of the uterus, cervix, and even partial or complete prolapse. A special category for this type is made by patients after surgical removal of the uterus due to the fact that the ligamentous apparatus of the uterus is crossed.
  2. Prolapse of the anterior wall and bladder. This problem is often accompanied by complaints of urinary incontinence during exertion.
  3. Prolapse of the posterior vaginal wall. Quite often, these species are found in all sorts of combinations.

With such a variety of problems, it is difficult for the patient to understand everything herself. It is important to remember, however, that doctors have ways to help the patient. The main thing is to contact a specialist in time and follow his recommendations. So, in the arsenal of a doctor there are both surgical methods, which cannot be dispensed with in the later stages, and non-surgical methods that are used in the early stages and after the operation.

Even women who are contraindicated for surgery for prolapse / prolapse of the uterus can also help relieve suffering!

What is the danger of vaginal prolapse and how to treat it

What is vaginal prolapse

Vaginal prolapse , or prolapse, is a condition in which the walls of the vagina are displaced from their anatomical position. In doing so, they can carry along with them the bladder, uterus or rectum. Therefore, it is more correct to call this disease pelvic organ prolapse.

Doctors distinguish several types of pathology, depending on which wall of the vagina has shifted to the perineum. Here they are :

  • prolapse of the vaginal vault – the upper part of the vagina, located near the cervix, sank down;
  • prolapse of the uterus – the organ gradually moves down, sometimes even appears outside the genital slit;
  • cystocele – the front wall of the vagina descends along with the bladder;
  • urethrocele – the front wall also shifted downward and carried the urethra with it;
  • rectocele – a condition in which the back wall of the vagina descends along with part of the rectum;
  • enterocele – prolapse of the back of the vagina along with the small intestine, often combined with prolapse of the vaginal fornix.

What are the reasons for the prolapse of the vagina and other organs of the small pelvis

The pelvic organs are held in one position thanks to the muscles and ligaments. But when they are weakened, the uterus, the walls of the vagina may fall or fall out. Doctors believe that the following factors provoke this:

  • Vaginal labor. They can be accompanied by trauma to the pelvic floor muscles, ligament rupture. The risk of prolapse is higher if forceps or a vacuum extractor were used.
  • Heredity. The pathology of the connective tissue is transmitted from the parents, due to which it becomes loose and extensible.
  • Operations and injuries. Prolapse develops in women with a remote uterus, for example due to a tumor. The risk of the disease increases after other surgical procedures, as well as after serious falls or car accidents.
  • Health status. Women with obesity, chronic constipation, or cough are more likely to develop vaginal prolapse.
  • Menopause.During this period of life, the level of estrogen decreases, so the connective tissue of the ligaments becomes loose and extensible.
  • Lifestyle. Prolapse can occur under the influence of smoking and strenuous exercise.

What are the symptoms of prolapse of the vagina and other pelvic organs?

Signs of prolapse may vary from woman to woman. Doctors advise you to pay attention to the following manifestations of :

  • Feeling of bloating, a foreign body in the vagina.The sensation may become stronger when coughing or when the woman is pushing.
  • Drawing pain in the lower back.
  • Difficulty urinating, urinary incontinence or frequent urge to use the toilet.
  • Constipation, feeling of incomplete emptying of the intestines.
  • Pain or discomfort during intercourse and examination by a gynecologist.
  • Unable to insert the swab.
  • Protrusion or prolapse of the uterus from the vagina.

If these symptoms are left unaddressed, due to the displacement of the bladder, urine will flow continuously.Or, on the contrary, there will be an acute urinary retention, when you really want to go to the toilet, but it is impossible to go. Severe prolapse of the back of the vagina can lead to daily constipation, when you cannot empty your bowels without the help of your hands.

In severe cases, when organs fall out, they become easily infected and inflamed. And sex becomes physically impossible.

What to do if these symptoms appear

If a woman notices the first signs of prolapse of the vagina and other pelvic organs, she should consult a gynecologist.He will conduct examinations and determine the severity of the condition. Additionally, the doctor may prescribe an ultrasound of the genitals, cystoscopy, MRI or CT of the pelvis, and X-ray examination.

How to treat prolapse of the vagina and other pelvic organs

It must be remembered that prolapse appears due to weakness of the ligaments and muscles, so tampons with medicinal plants, decoctions of the boron uterus or a red brush will not help restore the anatomical position of the organs. You can get rid of the prolapse of the vagina using scientifically proven methods, which are selected depending on the severity of the condition. Doctors recommend the following methods.

Do Kegel exercises

They help to strengthen the pelvic floor muscles, so the exercises are done to prevent and treat the early stages of vaginal prolapse. We wrote about how to do it right here.

Insert vaginal pessary

This is a plastic or silicone device. Pessaries can be shaped like a ring with holes or a cube and vary in size. The gynecologist selects the device individually for each woman.

Pessary is used with a small degree of vaginal prolapse, as well as in cases where the operation is contraindicated for health reasons.

This method of correcting prolapse has disadvantages. The pessary must be constantly looked after, otherwise inflammation may appear, and sometimes even bleeding or erosion of the vaginal mucosa.

Make corrective surgery

If simple methods of treatment do not help, the doctor will suggest an operation. The intervention is carried out in different ways , which are chosen depending on the type of prolapse of the pelvic organs. Sometimes a small incision is made in the vagina to strengthen the uterine ligaments, but in some cases, surgery is done through the anterior abdominal wall. Also, the surgeon can use special grafts made of synthetic material that hang the genitals, like in a hammock.

Elderly women who are not sexually active may be offered to completely sew up the vagina.

Remove the uterus

If the prolapse has resulted in the prolapse of the uterus, some women undergo a hysterectomy.This is an operation during which the organ is completely removed , but the ovaries are preserved and the ligaments are strengthened. It is difficult to decide on such an intervention, but after it, the prolapse of the pelvic organs will no longer happen again.

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Female genital prolapse and prolapse

Internal genital prolapse is the displacement of the vagina and / or uterus outward, and prolapse is the final stage of the process.

Classification

  • Descent of the anterior vaginal wall
  • Descent of the posterior wall of the vagina
  • Uterine prolapse
  • Descent of the posterior vaginal fornix

Causes and mechanism of omission

The main reason for the prolapse of the internal genital organs is the failure of the muscles of the pelvic floor, and the abdominal cavity (transverse m. Abdomen), also straight m. Abdomen. arising after childbirth through the natural birth canal.An additional factor is an increase in intra-abdominal pressure, which can be facilitated by chronic constipation or heavy lifting. Depending on the specific conditions, the anterior, middle or posterior pelvic organs are subjected to prolapse. Together with the anterior wall of the vagina, the urethra and bladder descend; with the uterus or separately from it, the posterior fornix of the vagina with the retinal space containing the intestinal loops can descend; the rectum descends from the back wall of the vagina.The final stage of prolapse of the uterus is its complete exit to the outside together with an everted vagina. With the “shift” of the internal organs, and the subsequent start of the problem, all internal organs suffer and over time they can assume the wrong position.

Symptoms

Symptoms of prolapse of the internal genital organs depend on the type and severity of prolapse. There may be a feeling of heaviness or pressure in the vagina, detection of a prolapsed organ outside, discomfort or pain during intercourse, difficulty urinating or emptying the bowel, gas or urinary incontinence with exertion.

Treatment

With the initial degree of descent, strengthening the pelvic floor muscles with special exercises – wumbling – can help. With more pronounced degrees of prolapse, surgical treatment is necessary. There are different types of operations depending on the type and degree of prolapse of the organs, accompanying symptoms and the woman’s age. A necessary stage of these operations is vaginoplasty. In case of contraindications to surgery or as a temporary measure, a vaginal pessary is used – a silicone or plastic ring inserted into the vagina to hold the organs inside.

References

See also

90,000 Will it hurt? What about orgasm? Gynecologist answers questions about sex after uterus removal

Every year in Russia, hysterectomy – an operation to remove the uterus – is performed on 100 thousand women.

We asked obstetrician-gynecologist Daria Burmakina the most important questions about intimate life after the operation: will libido change, what will happen to hormones and, most importantly, will the removal of the uterus affect orgasm?

How does this surgery affect hormones and libido?

When we talk about hysterectomy, it is important to clarify whether only the uterus or ovaries were removed.If the ovaries are in place, then the body continues to produce all the necessary female hormones (estrogen and progesterone. – Ed.). If they are removed, then manifestations of climacteric syndrome are possible: sweating, anxiety, vaginal dryness, decreased sexual desire. Most likely, in this case, hormone replacement therapy will be needed, but it also needs to be prescribed with caution, for example, if the ovaries were removed due to a malignant tumor, then such therapy is contraindicated in order to prevent relapses. In such cases, you can discuss with the therapist the appointment of antidepressants to reduce the frequency and intensity of hot flashes.

Libido after surgery, in principle, can decrease, because the body has experienced stress. Usually, after a recovery period of four to eight weeks, libido returns to normal. But you need to understand that sexual desire is not only a hormonal story, but also a psychological one. Some women may perceive surgery to remove the uterus as a loss of their gender identity.This can lead to depression, and one of its manifestations is anhedonia (a decrease or loss of the ability to have pleasure. – Ed.). If eight weeks have passed, and you still feel bad, your libido is at zero and additional symptoms of depression appear, nothing brings joy, you want to cry, you feel weak, you have sleep and eating disorders, it makes sense to consult a psychotherapist.

Does hysterectomy affect the ability to have an orgasm?

The presence of the uterus or its absence does not affect the ability to experience orgasm . As sexologists say, “an orgasm in the head.” A woman during sex can be distracted by thoughts, for example, that she did not have time to give birth and now cannot bear a child.

Some women, in principle, do not discuss their health status with partners. Sometimes they even ask to write out two certificates – one true, and the other for the husband.

The need to constantly hide the truth from a loved one can also affect sexual pleasure and orgasm.

How long after surgery can you have penetrative sex?

After four to six weeks, you can already try. Much depends on the access through which the operation was performed and whether there were complications during it. There can be three approaches: through the vagina, laparoscopically (small holes are made in the abdomen) or laparotomically (an incision in the abdomen). With vaginal access, spotting may persist a little longer. Then it may require sexual rest for up to six weeks.Otherwise, four weeks should be sufficient. Clitoral masturbation is possible earlier – nothing prevents it.

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Is it painful to have sex after surgery? If so, what to do about it?

Some soreness may persist during sex after surgery, especially in the area of ​​the scar.But more often not than yes. Most importantly, any pain during sex should be discussed with a gynecologist. It can arise for many reasons, so you need to understand and look for its original source. An in-person appointment with a doctor is required.

Will the partner notice anatomical changes in the body?

No, he won’t. He can only find out if he knows how to do an ultrasound. The uterus does not participate in sexual intercourse – it is a reservoir for carrying a child and no longer plays any role in the body. Even if the cervix was also removed, it feels like nothing will change : before everything rested against the cervix, but now it will rest against the vaginal vaults.

How can you help yourself recover after having your uterus removed? Do you need to do any exercises?

Immediately in the hospital the next day or after some doctors will advise getting up and walking early, depending on the woman’s well-being. This is necessary for intestinal motility and prevention of thrombosis, because prolonged lying in the intensive care unit after surgery increases the risk of their occurrence. In addition to walking after four to six weeks, as soon as all the stitches have healed, you can connect additional activities, such as swimming.After surgery, it is best not to lift heavy objects for four to six weeks. The term and restrictions can be extended on an individual basis.

What should the partner of a woman having a hysterectomy know?

First of all, the partner must understand that for some time a woman may feel sad and anxious because of what happened to her. And during this period she really needs support .

If you notice that the sadness does not go away, that the woman has stopped leaving the house and she has symptoms of depression, try to help her see a psychotherapist.

Remember that removing the uterus will not affect sexual intercourse in any way. But if a woman says that she is in pain, it is better to stop and try another time when she is ready.

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“Don’t Tell Your Husband”: Stories of Women Who Have Uterus Removed

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