Vaginal prolapse

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Eman Alademi, M.D.[2]

Synonyms and keywords: Female genital prolapse, procidentia and ptosis.

Overview

Vaginal prolapse is characterized by a portion of the vaginal canal protruding from the opening of the vagina. The condition usually occurs when the pelvic floor collapses as a result of childbirth and is inherent among tall Caucasian women.

Types of vaginal prolapse

Historical Perspective

Vaginal prolapse was first discovered in era of the pharaohs, about 1500 years before Christ. Then MRI/surgery was developed by Hippocrates to treat/diagnose vaginal prolapse over the centuries, different treatment modalities, some of which we can currently seem strange[1]

Classification

Vaginal prolapse may be classified according to Uterine cervical elongation that found in patients undergoing hysterectomy for pelvic organ prolapse, Cervical elongation grades and prolapse stages are correlated. Vaginal prolapse is classified as physiological uterine cervical elongation based on corpus/cervix ratio to (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5)[2][3]

Pathophysiology

The pathogenesis of Pelvic organ prolapse like vaginal prolapse is not fully understood. It is thought that vaginal prolapse is characterized by two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated, Pelvic organ prolapse is a hernia of the vaginal wall. The utero-sacral ligaments and the arcus tendineus of the pelvic fascia lose their elasticity. Atrophic levator anii muscles do not play their trempoline, active support anymore To the pelvic floor. That is related to the aging of these structures but also to excessive mechanical strains -pregnancy, delivery, dyschesia, physical practices-. Moreover, postural disorders lead to a direct orientation of these strains on the genital slit[4]

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence[5]

Differentiating vaginal prolapse from other Diseases

Epidemiology and Demographics

Age

Gender

Race

Risk Factors

Natural History, Complications and Prognosis

  • The majority of patients with vaginal prolapse remain asymptomatic .
  • Common complications of vaginal prolapse include [bladder incarceration[20]], [consecutive irreducible rectal prolapse[21]],
  • Prognosis is generally [excellent], and No serious perioperative complications[22]

Diagnosis

Symptoms

Physical Examination

Laboratory Findings

  • There are no specific laboratory findings associated with vaginal prolapse.

Imaging Findings

  • Pelvic MRI is the imaging modality of choice for vaginal prolapse. It has the ability to identify changes related to uterosacral ligament disruption and to document the corrective changes after surgical repair of this ligament. In the future, pelvic MR imaging is help to document and advance knowledge of surgical repair methodology[31]. Dynamic pelvic MRI (D-MRI ) provides an accurate diagnostic evaluation of the pelvis,which seems an appropriate tool in pre-operative assessment of cases with vaginal prolapse. It will help in focusing our surgical strategy, especially in cases that present post-hysterectomy and in cases with residual or recurrent prolapse.[32]
  • On Pelvic MRI, vaginal prolapse is characterized by Defects of musculofascial component of the pelvic floor with Offten demonstrate combination of defects MLA( musculus levator ani ), EF ( sacrouterine ligaments  ) and SUL ( sacrouterine ligaments)[33]

Other Diagnostic Studies

Treatment

Vaginal prolapses must be treated according to the severity of symptoms.

Non-Surgical Therapy

  • With conservative measures (changes in diet and fitness, Kegel exercises, etc.)
  • With a pessary, to provide support to the weakened vaginal walls

Surgical Therapy

A new minimally invasive surgical procedure is effective in restoring a woman's anatomy to the condition before childbirth with a two weeks recovery period. It is performed vaginally using a laparoscope and surgical mesh to repair the cystocele and rectocele and a laser to tighten the vaginal canal, which create a natural support for the uterus[35][./Vaginal_prolapse#cite_note-pmid:_8934045-35 [35]]

Related Chapters

References

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  2. Mothes AR, Mothes H, Fröber R, Radosa MP, Runnebaum IB (2016) Systematic classification of uterine cervical elongation in patients with pelvic organ prolapse. Eur J Obstet Gynecol Reprod Biol 200 ():40-4. DOI:10.1016/j.ejogrb.2016.02.029 PMID: 26967345 pmid: 26967345
  3. Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: 10 pmid: 10
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  5. Marinkovic SP, Stanton SL (2004) Incontinence and voiding difficulties associated with prolapse. J Urol 171 (3):1021-8. DOI:10.1097/01.ju.0000111782.37383.e2 PMID: 14767263 pmid: 14767263
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  7. Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: 10 pmid: 10
  8. Chai TC, Davis R, Hawes LN, Twaddell WS (2014) Ectopic ureter presenting as anterior wall vaginal prolapse. Female Pelvic Med Reconstr Surg 20 (4):237-9. DOI:10.1097/SPV.0000000000000082 PMID: 24978091 pmid: 24978091
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  10. Pahwa AK, Siegelman ES, Arya LA (2015) Physical examination of the female internal and external genitalia with and without pelvic organ prolapse: A review. Clin Anat 28 (3):305-13. DOI:10.1002/ca.22472 PMID: 25256076 pmid: 25256076
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  13. Alperin M, Moalli PA (2006) Remodeling of vaginal connective tissue in patients with prolapse. Curr Opin Obstet Gynecol 18 (5):544-50. DOI:10.1097/01.gco.0000242958.25244.ff PMID: 16932050 pmid: 16932050
  14. Tsikouras P, Dafopoulos A, Vrachnis N, Iliodromiti Z, Bouchlariotou S, Pinidis P | display-authors=etal (2014) Uterine prolapse in pregnancy: risk factors, complications and management. J Matern Fetal Neonatal Med 27 (3):297-302. DOI:10.3109/14767058.2013.807235 PMID: 23692627 pmid: 23692627
  15. Vergeldt TF, Weemhoff M, IntHout J, Kluivers KB (2015) Risk factors for pelvic organ prolapse and its recurrence: a systematic review. Int Urogynecol J 26 (11):1559-73. DOI:10.1007/s00192-015-2695-8 PMID: 25966804 PMID: 25966804
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  17. Mirskaya M, Lindgren EC, Carlsson IM (2019) Online reported women's experiences of symptomatic pelvic organ prolapse after vaginal birth. BMC Womens Health 19 (1):129. DOI:10.1186/s12905-019-0830-2 PMID: 31664987 PMID: 31664987
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  24. Chai TC, Davis R, Hawes LN, Twaddell WS (2014) Ectopic ureter presenting as anterior wall vaginal prolapse. Female Pelvic Med Reconstr Surg 20 (4):237-9. DOI:10.1097/SPV.0000000000000082 PMID: 24978091 PMID: 24978091
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  28. Chai TC, Davis R, Hawes LN, Twaddell WS (2014) Ectopic ureter presenting as anterior wall vaginal prolapse. Female Pelvic Med Reconstr Surg 20 (4):237-9. DOI:10.1097/SPV.0000000000000082 PMID: 24978091 PMID: 24978091
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  35. <pmid>8934045</pmid>


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