Vaginal prolapse: Difference between revisions
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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
- Cystocele (bladder into vagina)
- Enterocele (small intestine into vagina)
- Rectocele (rectum into vagina)
- Urethrocele (urethra into vagina)
- Uterine prolapse (uterus into vagina)
- Vaginal vault prolapse (roof of vagina, after hysterectomy)
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 into Cervical elongation grades and prolapse stages are correlated. calssified 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 weakness of , Pelvic organ prolapse is a hernia of the vaginal wall. Elements of vaginal hanging and perineum support undergo mechanical strains that lead to this pelvic floor disorder. 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. 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
- Vaginal prolapse must be differentiated from other diseases that cause urethral prolapse [6] ,cystocele, enterocele, urethral diverticulum, and Gartner duct cyst.[7] such as:[8]
- urethral prolapse
- cystocele
- enterocele
- Gartner duct cyst
- urethral diverticulum
Epidemiology and Demographics
Age
Gender
Race
- Vaginal prolapse usually affects individuals of the African Americans and Caucasians race.[11]
Risk Factors
- Common risk factors in the development of vaginal prolapse are Genetic contribution which decrease in the expression of the genes HOXA13 [12],sex steroids[13], pregnancy[14], Parity, vaginal delivery, age,obesity (increase BMI)[15],vaginal hysterectomy [16],Vaginal birth[17], menopausal status and measurement of total vaginal length [18], Pelvic floor muscle weakness[19].
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
- Vaginal prolapse is usually asymptomatic.[23]
- Symptoms of vaginal prolapse may shown feeling of bulge in the vagina[24] But When it’s demonstrate greater degrees of pelvic [25], and include the following:[26]
- bowel symptoms (constipation)[27].
- urinary(Incontinence and voiding difficulties)[28].
- sexual dysfunction
Physical Examination
- Patients with vaginal prolapse usually appear like vaginal/vestibular masses [29],or bulge in the vagina[30].
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. 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
- Vaginal prolapse may also be diagnosed using Ultrasound imaging of the perineal body, which is associated strongly with posterior compartment prolapse.[34]
- Findings on Ultrasound imaging of the perineal body include a small perineal body was strongly associated with posterior compartment prolapse.
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 it was before childbirth with a recovery time of only 2 weeks. It is performed vaginally using a laparoscope and surgical mesh to repair [35]the cystocele and rectocele and a laser to tighten the vaginal canal creating a natural support for the uterus.
Related Chapters
References
- ↑ Ziouziou I, Zizi M, Bennani H, Karmouni T, El Khader K, Koutani A | display-authors=etal (2013) [History of pelvic prolapse.] Tunis Med 91 (4):227-9. PMID: : 23673698 pmid : 23673698
- ↑ 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
- ↑ Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: 10 pmid: 10
- ↑ Mezzadri M (2019) [Pelvic organ prolapse physiopathology.] Rev Prat 69 (4):385-386. PMID: 31626487 pmid: 31626487
- ↑ 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
- ↑ Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: 10 pmid: 10
- ↑ Schmoldt A, Benthe HF, Haberland G (1975) Digitoxin metabolism by rat liver microsomes. Biochem Pharmacol 24 (17):1639-41. PMID: 10 pmid: 10
- ↑ 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
- ↑ Gyhagen M, Al-Mukhtar Othman J, Åkervall S, Nilsson I, Milsom I (2019) The symptom of vaginal bulging in nulliparous women aged 25-64 years: a national cohort study. Int Urogynecol J 30 (4):639-647. DOI:10.1007/s00192-018-3684-5 PMID: 29934770 pmid: 29934770
- ↑ 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
- ↑ Graham CA, Mallett VT (2001) Race as a predictor of urinary incontinence and pelvic organ prolapse. Am J Obstet Gynecol 185 (1):116-20. DOI:10.1067/mob.2001.114914 PMID: 11483914 pmid: 11483914
- ↑ Graham CA, Mallett VT (2001) Race as a predictor of urinary incontinence and pelvic organ prolapse. Am J Obstet Gynecol 185 (1):116-20. DOI:10.1067/mob.2001.114914 PMID: 11483914 pmid: 11483914
- ↑ 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
- ↑ 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
- ↑ 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
- ↑ Nováčková M, Pastor Z, Brtnický T, Chmel R (Fall) [What is the risk of pelvic organ prolapse recurrence after vaginal hysterectomy with colporrhaphy?] Ceska Gynekol 82 (5):383-389. PMID: 29020786 PMID: 29020786
- ↑ 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
- ↑ Girgis M, Shek KL, Dietz HP (2019) Total vaginal length: Does it matter for assessing uterine prolapse? Int Urogynecol J 30 (8):1279-1282. DOI:10.1007/s00192-018-3779-z PMID: 30357469 PMID: 30357469
- ↑ Schachar JS, Devakumar H, Martin L, Farag S, Hurtado EA, Davila GW (2018) Pelvic floor muscle weakness: a risk factor for anterior vaginal wall prolapse recurrence. Int Urogynecol J 29 (11):1661-1667. DOI:10.1007/s00192-018-3626-2 PMID: 29552738 PMID: 29552738
- ↑ Ober CA, Peștean CP, Bel LV, Taulescu M, Cătoi C, Bogdan S | display-authors=etal (2016) Vaginal prolapse with urinary bladder incarceration and consecutive irreducible rectal prolapse in a dog. Acta Vet Scand 58 (1):54. DOI:10.1186/s13028-016-0235-2 PMID: 27660054 PMID: 27660054
- ↑ Ober CA, Peștean CP, Bel LV, Taulescu M, Cătoi C, Bogdan S | display-authors=etal (2016) Vaginal prolapse with urinary bladder incarceration and consecutive irreducible rectal prolapse in a dog. Acta Vet Scand 58 (1):54. DOI:10.1186/s13028-016-0235-2 PMID: 27660054 PMID: 27660054
- ↑ Kavallaris A, Köhler C, Diebolder H, Vercellino F, Krause N, Schneider A (2005) Repair of prolapse with vaginal sacrocolporectopexy: technique and results. Eur J Obstet Gynecol Reprod Biol 122 (2):237-42. DOI:10.1016/j.ejogrb.2005.01.020 PMID: 15950362 PMID: 15950362
- ↑ Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V (2005) The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 112 (7):971-6. DOI:10.1111/j.1471-0528.2005.00568.x PMID: 15958002 PMID: 15958002
- ↑ 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
- ↑ Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V (2005) The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 112 (7):971-6. DOI:10.1111/j.1471-0528.2005.00568.x PMID: 15958002 PMID: 15958002
- ↑ Digesu GA, Chaliha C, Salvatore S, Hutchings A, Khullar V (2005) The relationship of vaginal prolapse severity to symptoms and quality of life. BJOG 112 (7):971-6. DOI:10.1111/j.1471-0528.2005.00568.x PMID: 15958002 PMID: 15958002
- ↑ Ober CA, Peștean CP, Bel LV, Taulescu M, Cătoi C, Bogdan S | display-authors=etal (2016) Vaginal prolapse with urinary bladder incarceration and consecutive irreducible rectal prolapse in a dog. Acta Vet Scand 58 (1):54. DOI:10.1186/s13028-016-0235-2 PMID: 27660054 PMID: 27660054
- ↑ 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
- ↑ Manothaiudom K, Johnston SD (1991) Clinical approach to vaginal/vestibular masses in the bitch. Vet Clin North Am Small Anim Pract 21 (3):509-21. DOI:10.1016/s0195-5616(91)50057-7 PMID: 1858246 PMID: 1858246
- ↑ 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
- ↑ Martin DR, Salman K, Wilmot CC, Galloway NT (2006) MR imaging evaluation of the pelvic floor for the assessment of vaginal prolapse and urinary incontinence. Magn Reson Imaging Clin N Am 14 (4):523-35, vi. DOI:10.1016/j.mric.2007.01.004 PMID: 17433981 PMID: 17433981
- ↑ Obringer L, Roy C, Mouracade P, Lang H, Jacqmin D, Saussine C (2011) [Vaginal prolapse. What dynamic pelvic MRI adds to clinical examination?.] Prog Urol 21 (2):93-101. DOI:10.1016/j.purol.2010.07.011 PMID: 21296275 PMID: 21296275
- ↑ Němec M, Horčička L, Dibonová M, Krčmář M, Urbánková I, Krofta L | display-authors=etal (Summ) [MRI analysis of the musculo-fascial component of pelvic floor in woman before planned vaginal reconstruction procedur for symptomatic pelvic organ prolapse.] Ceska Gynekol 83 (2):84-93. PMID: 29869505 PMID: 29869505
- ↑ Asfour V, Digesu GA, Fernando R, Khullar V (2020) Ultrasound imaging of the perineal body: a useful clinical tool. Int Urogynecol J 31 (6):1197-1202. DOI:10.1007/s00192-019-04166-7 PMID: 31828399 PMID: 31828399
- ↑ <pmid>8934045</pmid>