What is Prolapse of the Uterus and Vagina?
This pathology has the greatest practical value among the abnormalities of the position of the genital organs. In the structure of gynecological morbidity, omissions and prolapses of the genital organs account for up to 28%. Due to the anatomical proximity and commonality of supporting structures, this pathology often causes anatomical and functional failure of adjacent organs and systems (urinary incontinence, failure of the anal sphincter).
Causes of Prolapse of the Uterus and Vagina
The omission and prolapse of the genitals is a polyetiological disease, it is based on the failure of the muscles of the pelvic floor and ligamentous apparatus of the uterus, increased intra-abdominal pressure. Pelvic floor muscle failure contributes to:
- traumatic birth;
- failure of connective tissue structures in the form of “systemic” insufficiency with hernias of other locations, omission of other internal organs, i.e. splanchnoptosis;
- violation of the synthesis of steroid hormones (estrogen deficiency);
- chronic diseases accompanied by metabolic disturbances, microcirculation.
Under the influence of one or more of the listed factors, functional failure of the ligamentous apparatus of the internal genital organs and the pelvic floor occurs. With an increase in intra-abdominal pressure, organs begin to “squeeze out” of the pelvic floor. There are several options for the pathogenetic mechanisms of prolapse of the uterus and vagina:
- the uterus is completely outside the sprawled pelvic floor;
- part of the uterus is located inside, and part outside the hernia gate; the first part is “squeezed out”, and the other is pressed against the supporting base. With this option, the vaginal part of the cervix due to constant pressure inside the hernial portal can go down and stretch (elongatio coli – elongation of the neck); the body of the uterus, lying outside the hernial gate, counteracts the complete loss of the organ.
Pathogenesis during Prolapse of the Uterus and Vagina
There are several classifications of the displacement of the vagina and uterus downward. The most simple and convenient classification is M.S. Malinowski:
- I degree – the walls of the vagina reach the entrance to the vagina and there is an external pharynx of the cervix, located below the spinal awns;
- II degree – the cervix extends beyond the genital gap, the uterine body is located above it;
- III degree (complete prolapse of the uterus) – the entire uterus is located – below the genital gap.
A special form of genital prolapse is prolapse of the stump of the cervix or the dome of the vagina after a hysterectomy.
Together with the front wall of the vagina, part of the bladder usually falls and falls out, the so-called cystocele (cystocele) occurs. There are 4 degrees of cystocele (Green, 1962):
- I degree – cystocele is detected only when straining and does not go beyond the vagina;
- II degree – cystocele is detected without straining, and when straining is determined in anticipation of the vagina;
- III degree – without straining the cystocele is detected on the eve of the vagina, and when straining it goes below the external labia;
- IV degree – the anterior wall of the vagina is located outside the pelvic cavity.
The prolapse and prolapse of the posterior wall of the vagina is often accompanied by prolapse and prolapse of the anterior wall of the rectum – rectocele.
The prolapse and prolapse of the genital organs is sometimes accompanied by an enterocele, which is a hernia of the posterior vaginal fornix; intestinal loops, omentum enter the hernial sac.
With prolapse and prolapse of the genital organs, elongation of the cervix is often noted (elongation).
Symptoms of Uterine and Vaginal Prolapse
The prolapse and prolapse of the genitals develops slowly. The main symptom of prolapse of the uterus and the walls of the vagina becomes the “foreign body” detected by the patient herself in the vagina. The surface of the prolapsed part of the genital organs, covered with a mucous membrane, undergoes keratinization, takes the form of dry skin with cracks, abrasions, and then with ulcerations. Subsequently, patients complain of a feeling of heaviness and pain in the lower abdomen, lower back, sacrum, aggravated during and after walking, lifting weights, coughing, sneezing. Stagnation of blood and lymph in the precipitated organs leads to cyanosis of the mucous membranes and edema of the underlying tissues.
Uterine prolapse is accompanied by difficulty urinating, residual urine, congestion in the urinary tract and then infection, first lower, and with the progression of the process and upper parts of the genitourinary system. Long-existing complete prolapse of the internal genital organs can cause hydronephrosis, a hydroureter, and obstruction of the ureters.
Every 3rd patient with prolapse of the genitals develop proctologic complications. The most common of them are constipation, and in some cases they serve as the etiological factor of the disease, and in others they become a consequence and manifestation of the disease.
Diagnosis of Prolapse of the Uterus and Vagina
The diagnosis of prolapse and prolapse of the genital organs is based on examination and palpation. After examination and palpation, the prolapsed genital organs are corrected and a bimanual examination is performed, while the state of the muscles of the pelvic floor, ligamentous apparatus, appendages of the uterus are assessed and other pathology is excluded. A decubital ulcer located on the walls of the vagina and the vaginal part of the cervix must be differentiated from the tumor. To do this, use colposcopy, cytological examination and targeted biopsy.
With a mandatory rectal examination, attention is drawn to the presence or severity of rectocele, the condition of the sphincter of the rectum.
With severe urination disorders, it is necessary to examine the urinary system, according to indications, do cystoscopy, excretory urography, and urodynamic examination.
Treatment of Prolapse of the Uterus and Vagina
Treatment of patients with omissions and prolapse of the genitals is determined by the degree of omission of the internal genital organs; concomitant gynecological pathology; preservation or restoration of childbearing and menstrual functions; impaired function of the colon and sphincter of the rectum, age of the patient; concomitant extragenital pathology and the risk of surgical intervention and anesthetic benefits.
With small omissions of the internal genital organs, when they do not reach the vestibule of the vagina, and in the absence of impaired function of neighboring organs, conservative management of patients with the appointment of exercise therapy is possible.
With more severe omissions and prolapse of the internal genital organs, surgical treatment is used. Many surgical operations V.I. Krasnopolsky et al. (1997) was divided into 7 groups according to the anatomical education used to correct the position of the internal genital organs.
1st group. Surgery aimed at strengthening the pelvic floor – colpoperineolevatoroplasty. The operation is performed both as the main allowance, and as additional for all all types of surgical operations for omissions and prolapse of the genitals.
2nd group. Operations with the use of various modifications of shortening and strengthening the suspensory apparatus of the uterus (round ligaments). This is an operation according to Webster-Bundy-Dartig (shortening and fixing of round ligaments to the posterior surface of the uterus); shortening and fixing of round ligaments to the anterior surface of the uterus; operation according to Alexandrov-Adams (shortening of the round ligaments through the inguinal canals); uterus ventrosuspension according to Doleri-Williams; uterine fixation of the uterus according to Kocher et al. These operations are currently not recommended due to their low efficiency, which is due to the use of obviously insolvent tissue as uterine round ligaments as fixing material.
3rd group. Operations aimed at strengthening the fixative apparatus of the uterus (cardinal, sacro-uterine ligaments) by stitching them together, transposition, etc. This group includes the “Manchester” operation. These operations eliminate only one link in the pathogenesis of the disease.
4th group. Operations with rigid fixation of the fallen organs to the walls of the pelvis (pubic bone, sacrum, sacrospinal ligament, etc.). These operations are associated with possible serious complications (osteomyelitis, pain), in addition, they create an operational and pathological position of the pelvic organs with all the ensuing consequences.
5th group. Operations using alloplastic materials to strengthen the ligamentous apparatus and fixation of the uterus. These operations did not justify themselves enough, since they did not reduce the number of relapses of the disease as a result of frequent rejection of the prosthesis, and also led to the development of fistulas.
6th group. Operations with partial obliteration of the vagina (median colporography of the Neugebauer-Lefor, vaginal perineal glutis – Labgardt’s operation). The operations are non-physiological, exclude sexual activity, relapse of the disease is possible. These operations are applicable only in old age with a complete loss of the uterus and the absence of pathology of the cervix and endometrium.
7th group. Radical methods of surgical treatment (vaginal extirpation of the uterus). After vaginal extirpation of the uterus, organ prolapse is completely eliminated, but negative aspects arise: the possibility of relapse in the form of enterocele, cessation of menstrual and reproductive functions in patients of reproductive age, violation of the architectonics of the small pelvis, and the possibility of progression of dysfunction of neighboring organs (bladder, rectum). Vaginal extirpation of the uterus is recommended for elderly patients who do not live sexually.
The listed features and disadvantages of various surgical methods for treating prolapse and prolapse of the genitals make it more often to use combined and combined methods: laparoscopic or laparotomy access in combination with vaginal. Moreover, to strengthen the overstretched ligamentous apparatus of the uterus, synthetic inert non-absorbable materials (mercilene, prolene, dexon, gortex) are used.
The two-stage combined operation in the modification of V.I. Krasnopolsky et al. (1997), which consists in strengthening the sacro-uterine ligaments with aponeurotic flaps cut from the aponeurosis of the external oblique muscle of the abdomen (performed extraperitoneally) in combination with colpoperineoleoplasty. The operation can be performed with the uterus preserved, with relapse of prolapse of the stump of the cervix and vagina, in combination with amputation and extirpation of the uterus. Currently, it is performed by laparoscopic access using synthetic materials instead of aponeurotic flaps.