Omission and prolapse of internal genitalia( prolapse of genitals) - Causes, symptoms and treatment. MF.
Omitings and prolapses of internal genitals are related to the pathology with which the physician often meets, but not always correctly and timely resolves the issue of treatment and rehabilitation of such patients.15% of gynecological surgeries are performed just about this pathology.
The prevalence of prolapse of the genitals is striking: in India this disease is, you can say, the nature of the epidemic, and in America about 15 million women suffer from this ailment.
There is a generally accepted view that prolapse of the genitals is a disease of the elderly. This is completely wrong, if we consider that out of 100 women under the age of 30 this pathology takes place in every tenth. At the age of 30 to 45 years, it occurs in 40 cases out of 100, and after 50 years is diagnosed in every second woman.
Disease often begins in the reproductive age and is always progressive. And as the process develops, functional impairments also deepen, which often cause not only physical suffering, but also make these patients partially or completely incapacitated.
For the convenience of understanding, the descent and prolapse of the internal genitalia should be considered as a "hernia", which is formed when the closure device - the pelvic floor - has lost the ability to reduce so much that individual organs or parts of them do not fall into the projection of the supporting apparatus.
It is generally accepted that, in the normal position, the uterus is located along the wire axis of the pelvis. At the same time the body of the uterus is tilted anteriorly, its bottom does not protrude above the plane of entry into the small pelvis, the cervix is at the level of the interstitial line. The angle between the body of the uterus and the neck is greater than the straight and open anteriorly. The second angle between the cervix and the vagina is also facing anteriorly and is 70-100 °.Normally, the uterus and its appendages retain a certain physiological mobility, which contributes to the creation of conditions for their normal functioning, as well as preservation of the architectonics of the pelvic organs.
With the causes of this disease, clinical manifestations and treatment options for genital prolapse, you will get acquainted, leaf through the pages of our site. In the "Make" section, the methods of performing plastic surgeries performed with the omission and prolapse of internal genital organs are widely and clearly illustrated.
The causes of prolapse of genitals
The prolapse of gentals is a polyElogic disease and physical, genetic and psychological factors play an important role in its development.
Among the reasons that affect the condition of the pelvic floor and the ligamentous apparatus of the uterus, the following can be especially emphasized: age, heredity, childbirth, birth injuries, heavy physical work and increased intraperitoneal pressure, scars after the inflammatory diseases and surgical interventions, changes in the production of sexualSteroids that affect the response of smooth muscles, the inability of the striated muscle to ensure the usefulness of the pelvic floor, etc. The always present factor in the development of this pathology is an increase in intra-abdominal pressure and incompetence of the pelvic floor muscles, in the emergence of which there are 4 main causes, although it is possible to combine them.
- Post-traumatic pelvic floor injury( most common during labor).
- Insolvency of connective tissue structures in the form of "systemic" insufficiency( manifested by the presence of hernias of other localizations, the omission of other internal organs).
- Impaired synthesis of steroid hormones.
- Chronic diseases, accompanied by a violation of metabolic processes, microcirculation.
Under the influence of one or more of these factors comes the functional inconsistency of the ligament apparatus of the internal genital organs and the muscles of the pelvic floor. With an increase in intraperitoneal pressure, the organs begin to squeeze out beyond the pelvic floor. If any organ is found entirely within the maximally widened pelvic floor, then it, having lost all support, is squeezed out through the pelvic floor. If the part of the organ lies inside, and the part is outside the hernial gates, then the first part of it is squeezed out, the other part is pressed against the supporting base. Thus, the part that lies still outside the hernial gates keeps from squeezing the other - and the more, the stronger the intra-abdominal pressure.
Close anatomical connections between the bladder and the vaginal wall contribute to the fact that against the backdrop of abnormal changes in the pelvic diaphragm, including, naturally, the genitourinary one, the front wall of the vagina, which entails the wall of the bladder, also falls. The latter becomes the contents of the hernial sac, forming a cystocele.
Cystocele increases and under the influence of its own internal pressure in the bladder, resulting in a vicious circle. In the same way, the rectocele is formed. However, if the omission of the anterior wall of the vagina is almost always accompanied by a cystocele expressed to varying degrees, the rectocele may be absent even when the vaginal wall falls out, due to a loose connective tissue connection between the vaginal wall and the rectum.
The hernial sac in certain cases with a wide rectum-uterine or vesicoureteral space may include loops of the intestine.
Classification of displacement of the vagina and uterus
- Vaginal displacement of the vagina:
- lowering of the anterior wall of the vagina, posterior or both;in all cases, the walls do not extend beyond the entrance to the vagina;
- partial prolapse of the anterior vaginal wall and part of the bladder, posterior and part of the anterior wall of the rectum, or a combination of both depositions;The walls come out to the outside of the vaginal entrance;
- complete loss of the vagina, often accompanied by prolapse and uterus.
- Displacements of the uterus down:
- uterus or cervical oviposition - the cervix is lowered to the level of the entrance to the vagina;
- partial( starting) prolapse of the uterus or cervix;the cervix of the uterus during straining extends beyond the limits of the sexual slit, and such a beginning prolapse of the uterus is most often manifested with physical stress and increased intra-abdominal pressure( tensing, coughing, sneezing, lifting weights, etc.);
- incomplete prolapse of the uterus: outside the genital cleft is determined not only the cervix, but also the part of the body of the uterus;
- complete prolapse of the uterus: outside the genital slit( between the fallen walls of the vagina), the entire uterus is determined, while the index and middle fingers of both hands above the uterine fundus can be reduced.
Symptoms of prolapse of genitalia
The flow of the vagina and internal genitalia is characterized by a slow progression of the process, although its relatively rapid course can be observed. Recently, there has been some "rejuvenation" of patients.
Almost in all cases, there are functional disorders of almost all organs of the small pelvis, which necessarily requires their identification and treatment.
When the genitalia is lowered, the symptom complex often develops, along with impaired genital functions, urologic and proctologic complications come to the fore, which cause patients in a number of cases to seek help from doctors of related specialties( urologists, proctologists).But the main symptom of the prolapse of the uterus or its cervix, the walls of the vagina and neighboring organs is the most visible formation, which swells out of the genital cleft.
The surface of the fallen part of the genitals takes the form of matte-shiny, dry skin with cracks, abrasions, and then in a number of patients deep ulcers( bedsores) appear. This is due to constant trauma, which is exposed to walking when the wall of the vagina falls.
In the presence of trophic ulcers, it is possible to infect adjacent fiber with the ensuing consequences. When the uterus is displaced downward, normal blood circulation in the pelvis is broken, stagnation occurs, then pain develops, pressure in the lower abdomen, discomfort, back pain, sacrum, worsening during and after walking. Stagnant phenomena are characterized by a change in the color of the mucous membrane up to cyanosis, swelling of the underlying tissues.
Characteristic is a change in menstrual function( algodismenorea, hyperpolymenorea), as well as hormonal disorders. Often, these patients suffer from infertility, although the onset of pregnancy is considered quite possible.
In sexual intercourse, sexual activity is possible only after the fall of the fallen organ.
There is an extreme variety of concomitant urological disorders that cover almost all types of urinary disorders. With the expressed degrees of omission and prolapse of the genital organs with the formation of cystocele, the most characteristic is difficulty urination, the presence of residual urine, stagnation in the urinary system and, as a consequence, infection of the lower ones initially, and in the process of progression of the upper parts. Prolonged existing complete loss of internal genital organs can cause obstruction of ureters, hydronephrosis, hydroureter. A special place is the development of urinary incontinence with tension. More often, pyelonephritis, cystitis, urolithiasis, etc. are already developing, urological complications are observed in almost every second patient.
Quite often the disease manifests itself as proctologic complications that develop in every third patient. The most frequent of them are constipation, and in some cases they are the cause of the disease, in others - the consequence and manifestation of the disease. Characteristic symptoms include disorders of the colon function, mainly by the type of colitis. A severe manifestation of the disease is the incontinence of gases and stool, which occur either as a result of traumatic damage to the perineal tissue, rectal wall and its sphincter, or as a result of deep functional disorders of the pelvic floor.
Varicose veins, especially the lower extremities, are common in this group of patients, which is explained, on the one hand, by the violation of venous outflow as a result of changes in the architectonics of the small pelvis, on the other - by the inadequacy of connective tissue formations, manifested as a "systemic" insufficiency.
More often than in other gynecological diseases, the pathology of the respiratory system, endocrine disorders are noted, which can be considered as a predisposing background.
Diagnosis of genital descent and prolapse
Colposcopy is mandatory.
The presence of cysto- or rectocele is determined. A preliminary assessment of the functional state of the sphincter of the bladder and rectum( i.e., whether there is incontinence of urine, gases at a voltage, for example, when coughing).
Studies should include:
- a general urine test;
- bacteriological examination of urine;
- excretory urography;
- urodynamic study.
Patients with prolapse and prolapse of internal genitalia should undergo rectal examination, which draws attention to the presence or severity of rectocele, the condition of the sphincter of the rectum.
In cases where it is intended to perform an organ-preserving plastic surgery, and in the presence of concomitant pathology of the uterus, special methods should be included in the study complex:
- hysteroscopy with diagnostic curettage,
- hormonal studies,
- smear test for flora and purity, as well as atypical cells,
- analysis of vaginal discharge, etc.
Prophylaxis of genital prolapse
- Rational mode of work and education, starting with childhood, especially pubertal.
- Rational tactics of managing pregnancy and childbirth. It is known that not only the number of births, but also their nature, has a decisive influence on the occurrence of pustules and prolapses of internal genital organs and urinary incontinence under stress. In childbirth there are various intrasternal lesions of the lumbosacral plexus, causing paralysis of the blocking, femoral and sciatic nerves and, as a consequence, incontinence of urine and feces. One should strive to apply such a technique of delivery, in which the pelvic floor musculature and its innervation would be protected from damage during labor. Do not allow prolonged labor, especially the II period. The timely production of a medio-lateral episiotomy, mainly right-sided, in which the integrity of the pudendal nerve is preserved and, consequently, the innervation of the pelvic floor muscles is anatomically and physiologically justified. The second important point is the restoration of the integrity of the perineum with the correct matching of tissues.
- Prevention of purulent-inflammatory complications and the implementation of rehabilitation measures aimed at a more complete restoration of the functional state of the pelvic floor and pelvic organs in the postpartum period - special physical exercises, laser therapy, electrostimulation of pelvic floor muscles using an anal electrode.
Treatment of the descent and prolapse of the internal genital organs
The choice of tactics of treatment, the definition of a rational method of operational assistance is of particular complexity. It is determined by a number of factors:
- degree of omission of internal genital organs;
- anatomo-functional changes in the organs of the reproductive system( the presence and nature of concomitant gynecological pathology);
- opportunity and the need to preserve or restore the childbearing, menstrual function;
- features disruption of the function of the colon and sphincter of the rectum;
- by age of patients;
- concomitant extragenital pathology and the degree of risk of surgical intervention and anesthesia.
Conservative treatment of the descent and prolapse of the internal genital organs
With the omission of the internal genital organs, when the latter do not reach the vestibule of the vagina and in the absence of disruption of the functions of neighboring organs, conservative management of the patients is possible, including:
- Kegel exercises,
- Yunusov's exercise( voluntary contraction of the pelvic musclesbottom during urination until urinary flow ceases),
- lubrication of the vaginal mucosa with an ointment containing estrogens, metabolites,
- Pessaries, medical bandage.
Surgical treatment of descent and prolapse of internal genital organs
With a more severe degree of descent and prolapse of internal genital organs, the method of treatment is surgical. It should be noted that no other pathology has proposed as many methods of a surgical manual as for a given one. They are counted in several hundred, each having, along with certain advantages, disadvantages, which is mainly expressed in relapses of the disease. The latter most often occur within the first 3 years after the intervention and reach 30-35%.
All treatment methods can be grouped into one main feature - which anatomical education is used and strengthened to correct the position of the internal genitalia.
The most common surgical options.
- Group I. Operations aimed at strengthening the pelvic floor-colpoperineolevatoroplasty. Given that the pelvic floor muscles are pathogenetically always involved in the process, colpoperineolevatoroplasty should be performed in all surgical cases as an additional or basic benefit. This also includes plastic surgery on the anterior wall of the vagina, aimed at strengthening the vesicovaginal fascia.
- II group. Operations using various modifications of shortening and strengthening of the round ligament of the uterus and fixation of the uterus with the use of these formations. The most typical and often used is the shortening of the round uterine ligaments with their fixation to the anterior surface of the uterus. Shortening of round ligaments with their fixation to the posterior surface of the uterus by Webster-Bundy-Dartiga, shortening of the round ligament of the uterus through inguinal canals through Alexanders-Adams, ventriculosis of the uterus along the Doleer-Giilliams, ventrophy of the uterus according to Kocher, etc.
However, this group of operations is considered ineffective, since after them the greatest percentage of relapses of the disease is observed. This is due to the fact that as a fixing material used deliberately insolvent tissue - round ligament of the uterus.
- III group. Operations aimed at strengthening the fixation apparatus of the uterus( cardinal, sacro-uterine ligaments) due to their cross-linking, transposition, etc. However, even these operations, despite the fact that they imply the consolidation of the uterus at the expense of the most powerful ligaments, do not completely solve the problem, since they eliminate one link in the pathogenesis of the disease. This group includes the "Manchester operation", which is considered one of the most effective methods of surgical treatment. The operation is traumatic, as it deprives the patients of reproductive function.
- IV group. Operations with the so-called rigid fixation of the fallen organs to the walls of the pelvis( to the pubic bone, to the sacrum, the sacrospinal ligament, etc.).
- V group. Operations using alloplastic materials to strengthen the ligamentous apparatus of the uterus and fix it. They did not justify themselves, because they did not reduce the number of relapses due to frequent alloplastic rejection, and also led to fistula development.
- VI group. Operations aimed at partial obliteration of the vagina( middle Lefort-Neigebauer colporphy, vaginal-perineal adhesion - Labgardt's operation).
- VII group. Radical methods of surgical treatment of internal genital prolapse include vaginal extirpation of the uterus.
All of the above operations are performed through the vagina or through the anterior abdominal wall.
In recent years, more combined surgical treatment is preferred, which is preferred by most gynecologists. These interventions include the strengthening of the pelvic floor, the plasticity of the vaginal walls and the holding of the uterus, the cervix or the vaginal canopy mainly by one of the above methods. But, unfortunately, this does not always contribute to the complete recovery of patients, since sometimes functional impairments of neighboring organs, especially the organs of the urinary system, remain.
Anterior colporapathy is an operation performed when the front wall of the vagina is lowered.
Anterior colporaphy with reposition of the bladder
With a significant lowering of the anterior wall of the vagina, the bladder also descends with time, forming a cystocele, therefore, with the help of only anterior colporphy, a good result can not be achieved.
When the posterior wall of the vagina and rectum are lowered, the integrity of the pelvic floor and sometimes the external sphincter of the anus and rectum is broken with long crotch ruptures. In such patients, the genital gap gapes, the posterior wall of the vagina, and eventually the rectum descends. In neglected cases, the vagina is turned out and the uterus descends beyond the limits of the sexual slit, it falls out. Dismantling and prolapse of the genitals are facilitated by heavy physical work( lifting weights), fast and sharp weight loss, exhaustion and aging of the body. As the genitalia, as well as the bladder and rectum descend, some patients develop urinary incontinence, especially when coughing, sneezing, laughing, with straining, and there are abundant discharge from the vagina. Discharge( leucorrhoea), flowing to the external genitalia, can cause irritation of the adjacent areas of the skin. In violation of the integrity of the external sphincter of the anus, patients suffer from partial or complete incontinence of gases and feces. These sufferings are further intensified if the rectum is ruptured.
Therefore, prompt restoration of the integrity of the perineum is advisable in some patients to prevent painful symptoms of omission and prolapse of the genital organs, and in others - to eliminate these sufferings.
Usually omission of the anterior and posterior walls of the vagina occurs simultaneously with the descent of the bladder and rectum;while the uterus descends. Operative treatment for genital descent should usually consist of three stages: anterior colpaphyphia, colpoperineoraphy and one of the operations correcting the position of the uterus: ventrosuspension, ventrofixation or shortening of the uterine ligaments.
Fixation of the uterus using the rectum-uterine ligaments of the
The operation of fixation of the uterus using the rectal-uterine ligaments is performed in addition to the anterior colpaphia of the colpoperineoraphy.
Median colporphy of Lefor-Neugebauer
This operation is rational in the case of complete loss of the uterus in elderly women who do not live sexually, whose more complicated operation is not indicated for health reasons.
The essence of the operation of medial colporphy, as its name suggests, is to stitch the symmetrical wound surfaces of the anterior and posterior walls of the vagina after excising the flaps of the same size and shape from them.
The operation is technically simple, it is greatly facilitated by correctly conducted infiltration anesthesia.
Operation of Labgardt( incomplete vaginal-perineal adhesion)
This operation is carried out for women of senile age who do not live a sexual life, with complete or incomplete loss of the uterus;it gives more persistent results and is more physiological than middle colporaphy.
The main points of Labgardt's operation after the preparation of the operating field and thorough anesthesia are the following:
- scraping the flap out of the vaginal walls;
- layer-by-layer suturing of the extensive wound( stitching around the vaginal and near-intestinal tissue) and the connection of the muscles lifting the anus;
connection of the edges of the cut of the skin of the perineum.
Vaginal extirpation of the uterus with simultaneous anterior colpaphyphia and colpoperineoraphy
This operation is performed for women in the elderly with a prolapse of the uterus, an elongated hypertrophied neck and an inverted vagina, as well as incomplete uterine prolapse, if for some reason other methods of surgical treatment are undesirable or unreliable( obesity, glandular muscle hyperplasia, erosion and other precancerous conditions of the cervix).With complete loss of the uterus, organ extirpation is indicated to women aged 45-50 years, if preservation of the uterus is irrational( erosion, glandular muscle hyperplasia of the cervix, ectropion, endometrial polyposis and other precancerous diseases of the body and cervix).
The main points of the operation of vaginal hysterectomy when it falls out after the preparation of the operating field are as follows:
- maximal reduction of the cervix by forceps and infiltration of the okolovaginal and okolozubuzyrnoy fiber with 0.25% solution of novocaine for the purpose of hydro-preparation;
- conducting delineating incisions and cutting off a triangular flap from the anterior wall of the vagina;
- cutting off the edges of the vagina to the sides and the bladder from the cervix;
- autopsy of the peritoneum of the vesicle-uterine cavity;
- excretion of the uterus from the abdominal cavity;
- one-stage clamping and cutting of the fallopian tubes, ovaries' own ligament and round ligament of the uterus first with one, then on the other;
- clamping and cutting of the uterine vessels on both sides;
- clamping and cutting of rectum and uterine ligaments and rectum-uterine fold of peritoneum;
- dissection of the posterior wall of the vaginal vault;
- replacement of clamps by ligatures;
- abdominal closure with extraperitoneal stump placement;
- suturing the posterior wall of the bladder;
- connection of the edges of the wound of the anterior wall of the vagina;
- cut and remove the triangular flap from the back wall of the vagina;
- suturing the anterior wall of the rectum and applying submerged sutures to the perforated and near-intestinal tissue;
- connection of the muscles lifting the anus, by two ligatures;
- connection of the edges of the wound of the vagina and perineum with knotty catgut sutures.
Vaginal extirpation of the uterus with simultaneous extirpation of the vagina according to Fait-Okinchitsa
Panthistectomy with a preliminary complete vaginal eruption is performed with complete loss of the uterus in elderly women who do not live sexually. It is indicated for relapses after plastic surgery.
Technically, the operation is simple.
The main points of pangysterectomy with simultaneous complete vaginal extirpation after the preparation of the operating field are the following:
- fixation of the cervix by forceps and its reduction;
- thorough infiltration anesthesia with novocaine solution in addition to the main method of anesthesia;
- circular outline incision of the vaginal wall along the border of its opening and its separation up to the cervix;
- excision of the bladder and opening of the peritoneum of the vesicle-uterine cavity;
- excretion of the uterus from the abdominal cavity;
- dissection at the clamps of the ligament of the uterus and vessels;
- dissection of rectum-uterine folds of the peritoneum and removal of the uterus;
- replacement of clamps by ligatures;
- abdominal closure with extraperitoneal stump placement;
- stitching of fiber-reinforced fiber by superimposed dashed catgut nodular circular seams in 4-5 floors;
- connection of the edges of the wound.