Assistant professor Dr shaymaa Kadhim GENITAL PROLAPSE Common complaint of elderly woman Mostly in post menopausal and multiparous women In prolapse straining causes protrusion of vaginal walls at vaginal orifices ID: 1045884
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1. Anatomy of Female Urogenital System And Clinical ApplicationAssistant professorDr. shaymaa Kadhim
2. GENITAL PROLAPSECommon complaint of elderly womanMostly in post menopausal and multiparous womenIn prolapse straining causes protrusion of vaginal walls at vaginal orificesExtreme cases uterus may be protrude
3. Normal axis Axis of the uterus and vagina: anteverted and anteflexed
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5. PELVIC SUPPORTSPELVIC FLOOR Comprises Pelvic diaphragmEndopelvic fasciaPerineal membranePerineal body
6. PELVIC DIAPHRAGM
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8. Uterine ligaments
9. PERINEAL BODY
10. The pelvic structures are divided into 3 compartments : Anterior : urethra /bladder Middle : uterus/vault Posterior : rectum/anus
11. Levels of support of uterusDeLancey's three levels of support 3 levels
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13. Level 1 (suspensory axis)Level I- Uterosacral and cardinal ligaments support the uterus and vaginal vault.
14. Round ligament(mackenrodts lig / transverse/lateral cevical cervical ligament at the base of broad lig with uterine A & V
15. Defects in level 1Uterovaginal UV prolapseEnteroceleVault prolapse
16. Level 2 (attachment axis) Level II- Pelvic fascias and paracolpos Fascial septae connects mid vagina to the pelvic sidewalls AnteriorlyPubocervical PosteriorlyRectovaginal faciawhich connects the vagina to the white line on the lateral pelvic wall through arcus tendinous
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18. Defects in level2 Paravaginal & para rectal defects
19. Level 3 (fusion axis ) Level III-Levator ani muscle supports the lower one-third of vagina.Anteriorly UrethraUrogenital diaphragmPubis laterallyLevator ani fasciaPosteriorlyPerineal body
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22. Etiology birth injury Prolonged bearing down in the second stage Delivery of a big baby Rapid succession of pregnancies Lack of rest in peuperium Peripheral nerve injuryraised intra-abdominal pressure Surgeries Congenital
23. prolapse of menopausal age when the pelvic floor musclesd/t oestrogen deficiency and decreased collagen content in fascias atonicity and asthenia
24. Causes related to child birthBirth injury
25. Raised intra abdominal pressure chronic bronchitis, large abdominal tumours or obesity Smoking, chronic cough and constipation
26. Prolapse in unmarried or nulliparous womenspina bifida occulta and split pelvisCollagen vascular diseases
27. Surgeries Abdominoperineal excision of the rectum and radical vulvectomy Operations for stress incontinence such as Stamey and Pereyra operations
28. Classification of prolapse
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30. Cystocele the vesical and vaginal fasciae are thinned out and fail to support the bladder, so that the bladder prolapses with the anterior vaginal wall.
31. Urethrocele When the urethra along with the lower one-third of the anterior wall prolapses (failure of pubocervical ligament Rare stress incontinence
32. SignsAssessment of prolapseIn lithotomy positionLook for stress incontinence on a full bladderpatient is asked to strain / perform valsalva manoeuvreStress incontinence Vulva examined for perineal laceration Three compartments evaluated separately;decubitus ulcer
33. Per speculum examination
34. Pelvic floor musclesPubococcygeus part of levator ani assessed at 4 and 8o’clock position Perineal body Rectal examination – tone of anal sphincter
35. Lab investigationsHb Urine examination,Urine culture,Xray,ECGHigh vaginal swab in cases of vaginitisRFT in long standing prolapseUrodynamic investigations in case of incontinenceUSG to pelvic mass and hydronephrosisIVP }massive prolapseCT/MRI}
36. Differential diagnosisVulval cyst or tumourCysts of anterior vaginal wallUrethral diverticulaCongenital elongation of cervixvaginal portion of the cervix is elongated andno vaginal prolapse. deep fornicesCervical fibroid polypChronic inversion
37. COMPLICATIONS OF PROLAPSE Kinking of ureter with resulting renal damage Surgical injury to ureterUrinary tract infection (chronic) in large cystocele with residual urinedecubitus ulcer and keratinisation pigmentationif ring pessary is left in over a long period malignancy
38. ProphylaxisAntenatal physiotherapy ,relaxation exercises, attention to weight gain and anaemiaProper supervision and management of second stage of labourA generous episiotomyLow forceps delivery if there is delay in second stageSuture perineal tear Postnatal exercises and physiotherapyearly postnatal ambulationAdequate spacing of birthsAvoid multiparityProphylatic HRT in postmenopausal women
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