staging and management of genital prolapse. dr. v.p.paily md; frcog professor jubilee mission...
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Staging and Management of Staging and Management of Genital ProlapseGenital Prolapse
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Dr. V.P.Paily Dr. V.P.Paily MD; FRCOGMD; FRCOG
Professor Professor Jubilee Mission Medical College, Thrissur, Kerala.Jubilee Mission Medical College, Thrissur, Kerala.
Consultant, Consultant, Mother Hosp and Raji Nursing Home , Thrissur, KeralaMother Hosp and Raji Nursing Home , Thrissur, Kerala
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ProlapseProlapse
Very common problem.Very common problem.
Confusion regarding assessing Confusion regarding assessing
degree / stage degree / stage
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Conventional StagingConventional Staging
Cervix is the main point.Cervix is the main point.
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Conventional stagingConventional staging
Difference between British and Difference between British and American System.American System.
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Baden WalkerBaden Walker
Halfway SystemHalfway System
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Prolapse quantificationProlapse quantification
Pelvic organ prolapse Pelvic organ prolapse quantification(POP-Q)quantification(POP-Q)
Recommended by ICS, society of Recommended by ICS, society of Gyn.Surgeons &Amer. Urogyn. Gyn.Surgeons &Amer. Urogyn. SurgeonsSurgeons
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Pelvic organ prolapsePelvic organ prolapse
QuantificationQuantification POP QPOP Q
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QuantificationQuantification
Vault, Cx or Posterior fornixVault, Cx or Posterior fornix Anterior & Posterior wallsAnterior & Posterior walls IntroitusIntroitus Perineal bodyPerineal body Length of vaginaLength of vagina
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QuantificationQuantification
Anterior (a) -- Point A & BAnterior (a) -- Point A & B Posterior (p) -- Point A & BPosterior (p) -- Point A & B Point C -- Lips of CervixPoint C -- Lips of Cervix Point D -- Post.fornixPoint D -- Post.fornix
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QuantificationQuantification
Length of vaginaLength of vagina
Diameter of introitusDiameter of introitus
Perineal bodyPerineal body
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POP- QPOP- Q
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QuantificationQuantification
AaAa BaBa CC
ghgh pbpb tvltvl
ApAp BpBp DD
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POP-Q DrawbacksPOP-Q Drawbacks
Appears complicatedAppears complicated
Doesn’t include lateral prolapse. Doesn’t include lateral prolapse.
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Comprehensive pattern Comprehensive pattern required incorporating defects required incorporating defects at various levels & at various levels & compartments compartments
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Look for defectsLook for defects
At 3 levelsAt 3 levels
UpperUpper
MiddleMiddle
LowerLower
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Look for defectsLook for defects
At two compartmentsAt two compartments
AnteriorAnterior
PosteriorPosterior
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Compartmental approachCompartmental approach
Level 1Level 1
Descent of cervixDescent of cervix
Descent of vaultDescent of vault
EnteroceleEnterocele
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Compartmental ApproachCompartmental Approach
Level 2Level 2
Anterior segment –Anterior segment – cystocelecystocele
Posterior segment – rectocele Posterior segment – rectocele
Lateral detachmentLateral detachment
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Compartmental ApproachCompartmental Approach
Level 2Level 2 High rectocele can extend up to High rectocele can extend up to
post fornix and has to be post fornix and has to be differentiated from enterocele.differentiated from enterocele.
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Compartmental ApproachCompartmental Approach
Level 2Level 2 Midline defects are due to tear or Midline defects are due to tear or
weakness of fascial envelope weakness of fascial envelope – pubo vesico cervical fascia and – pubo vesico cervical fascia and rectovaginal fascia rectovaginal fascia
( Denonvilliers).( Denonvilliers).
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Compartmental ApproachCompartmental Approach
Level 3Level 3 Anteriorly – Urethrocele Anteriorly – Urethrocele Posteriorly – Detached Posteriorly – Detached
perineal body perineal body
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Compartmental ApproachCompartmental Approach
Level 3Level 3
Detached Perineal bodyDetached Perineal body
Reattach to recto vaginal fasciaReattach to recto vaginal fascia
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Practical approach to Practical approach to Level 3 defectsLevel 3 defects
Common complaintCommon complaint
Sound of air being sucked inSound of air being sucked in
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Compartmental ApproachCompartmental Approach
Lateral detachmentLateral detachment
Reattach to Arcus Tendineus Reattach to Arcus Tendineus
Fascia pelvis or Arcus Tendineus Fascia pelvis or Arcus Tendineus
Fascia RectovaginalisFascia Rectovaginalis
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Compartmental ApproachCompartmental Approach
Anterior Lateral detachmentAnterior Lateral detachment Richardson’ s operationRichardson’ s operation TransvaginalTransvaginal TransabdominalTransabdominal EndoscopicEndoscopic
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Compartmental ApproachCompartmental Approach
Posterior Lateral detachmentPosterior Lateral detachment
Reattach to Arcus tendineus fascia Reattach to Arcus tendineus fascia
rectovaginalisrectovaginalis
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SymptomatologySymptomatology
Record symptoms related to Record symptoms related to Anatomical descentAnatomical descent Urinary functionUrinary function Sexual functionSexual function Reproductive needReproductive need GI symptomsGI symptoms Air suctionAir suction
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ManagementManagement
Restore anatomy by correcting Restore anatomy by correcting the defectthe defect..
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Special SituationsSpecial Situations
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Nulliparous Nulliparous prolapseprolapse
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Older age with weak Older age with weak tissuestissues
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Mesh for RepairMesh for Repair
Concept borrowed from Hernia repairConcept borrowed from Hernia repair
Special mesh being developed.Special mesh being developed.
(Gyne mesh)(Gyne mesh)
We have tried prolene mesh.We have tried prolene mesh.
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ConclusionsConclusions
Detailed record of defectsDetailed record of defects
Detailed record of symptomsDetailed record of symptoms
Individualised surgeryIndividualised surgery
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