Pelvic organ descent

Types of genital prolapse

The pathology is classified depending on which exact anatomical structures are involved in the displacement process:

• Cystocele — prolapse of the anterior vaginal wall. The anatomical prerequisite is a defect of the pubocervical fascia. The condition is often accompanied by displacement of a part of the urinary bladder.
• Rectocele — prolapse of the posterior vaginal wall, involving the anterior wall of the rectum in the process.
• Enterocele — prolapse of the posterior vaginal fornix of varying severity.

Clinical presentation and local changes

Patients complain of pain and a feeling of heaviness in the lower abdomen, sacrum, and lower back. Symptoms manifest clearly and worsen with physical activity: walking, lifting heavy objects, as well as with increased intra-abdominal pressure (coughing, sneezing).

Due to impaired normal anatomy, blood and lymph stasis occurs in the prolapsed organs. This leads to cyanosis of the mucous membranes and pronounced edema of the underlying tissues. The skin and mucous membranes become dry and dull, and abrasions and fissures easily form on them. A specific complication is a decubitus ulcer, which forms on the surface of the prolapsed uterine cervix due to constant friction and trophic disorders.

Impact on adjacent organs

Due to anatomical proximity and shared supporting structures, prolapse inevitably disrupts the function of neighboring systems:

1. Urological complications. Changes in the anatomy of the urinary tract make urination difficult. Residual urine appears, stasis occurs, which paves the way for infection (the lower sections are affected first, then the upper ones). With prolonged complete prolapse, hydronephrosis, hydroureter, and ureteral obstruction develop.
2. Proctological complications. Found in every third patient. The main manifestation is constipation. It has a dual nature: it can act as an etiological factor in the development of prolapse (due to regular straining) and be its direct consequence.

Diagnostic guidelines

The diagnosis is established based on a gynecological examination, which includes a strict algorithm:

1. Visual assessment of the external genitalia.
2. Reduction of prolapsed structures to perform adequate palpation.
3. Bimanual vaginal examination. The physician assesses the size and mobility of the uterus, the state of the appendages, rules out concomitant pathology, and checks the tone of the pelvic floor muscles (special attention is paid to the levator ani muscle — m. levator ani).
4. Mandatory rectal examination to assess the rectal sphincter and the severity of the rectocele.

All patients are prescribed pelvic ultrasound. If there are pronounced urinary problems, cystoscopy, excretory urography, and urodynamic study are added strictly according to indications.

Critically important: decubitus ulcers must be strictly differentiated from cervical cancer. For this purpose, colposcopy, cytological smear analysis, and targeted biopsy are used.

Conservative and surgical treatment

Conservative tactics are justified only for mild degrees of prolapse (when the cervix does not reach the vaginal introitus) and in the absence of dysfunction in adjacent organs. Kegel exercises to strengthen the pelvic floor, therapeutic physical training (exercise therapy), and the use of a uterine pessary are employed.

Surgical treatment is indicated for severe forms of prolapse. Access can be vaginal, laparoscopic, or laparotomic. The choice of technique is strictly individual and depends on age, the degree of prolapse, concomitant extragenital and gynecological diseases, the need to preserve reproductive function, and the state of the rectum. To strengthen anatomical structures today, synthetic materials are preferred over the patient's own tissues. Out of more than 200 existing types of operations, the overwhelming majority today are of historical interest only.

The role of laparoscopy in gynecology

Laparoscopic access is widely used both for prolapse correction and for other pathologies (endometriosis, myoma, ovarian tumors, polycystic ovary syndrome, pain of unclear etiology).

• Emergency indications: ectopic pregnancy, ovarian apoplexy, torsion of a tumor pedicle or subserous myoma, acute inflammation of the appendages.
• Absolute contraindications: hemorrhagic shock, cardiovascular and respiratory decompensation, uncorrectable coagulopathy, hepatorenal failure, and conditions where the Trendelenburg position is unacceptable (e.g., consequences of traumatic brain injury).
• Complications directly depend on the surgeon's qualifications and may be associated with anesthesia or the manipulation itself (injury to major vessels, GI and urinary tract trauma, gas embolism, mediastinal emphysema).

Class and exam questions

What else to study on this topic

• Technique of anterior colporrhaphy and features of flap excision
• Relative contraindications to elective laparoscopic interventions
• Prevention of complications in endoscopic gynecological surgeries
• Urodynamic studies: indications and interpretation of results in prolapse
• Management of patients with uterine retroflexion against the background of inflammatory processes

Other topics in the "Gynecology" section

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.