Clinical presentation and local changes
Patients with genital prolapse most commonly complain of a nagging pain and a sensation of heaviness in the lower abdomen, sacrum, and lower back. These symptoms significantly worsen with physical exertion such as walking, coughing, sneezing, or lifting heavy objects.
Organ displacement causes blood and lymphatic stasis, leading to edema of the underlying tissues and cyanosis of the mucous membranes. The skin and mucosa in the prolapse area become dry and dull, with abrasions and fissures. A characteristic specific complication is the formation of a decubitus ulcer on the surface of the prolapsed cervix.
Impaired function of adjacent organs
Alteration of normal pelvic anatomy inevitably affects neighboring systems, causing a number of serious complications.
- Urological disorders: displacement of the urinary tract impedes urine outflow. Residual urine appears, leading to stasis that causes infection of the lower and subsequently the upper urinary tract. In prolonged complete prolapse, severe conditions may develop: hydronephrosis, hydroureter, and ureteral obstruction.
- Proctological disorders: occur in every third patient. The main manifestation is constipation. It is important to understand that constipation has a dual nature: it can act both as an etiological factor (trigger) that provoked the development of prolapse and as its direct consequence.
Diagnostic Principles
The basis of diagnosis is a gynecological examination. The doctor performs a visual inspection, then replaces the prolapsed organs for adequate palpation, and conducts a bimanual examination. The size and mobility of the uterus, the state of the appendages, and the tone of the pelvic floor muscles are assessed (special attention is paid to the m. levator ani).
Mandatory diagnostic steps:
- Rectal examination: necessary to assess the state of the anal sphincter and detect rectocele.
- Pelvic ultrasound: indicated for absolutely all patients.
- Differential diagnosis: decubitus ulcer must be strictly differentiated from cervical cancer. For this purpose, colposcopy, cytologic examination, and targeted biopsy are used.
In cases of pronounced urinary symptoms, cystoscopy, excretory urography, or urodynamic testing are additionally prescribed.
Conservative and surgical treatment
Management tactics depend on the degree of descent and the presence of complications.
Conservative therapy is used for mild degrees of prolapse (when the cervix does not reach the vaginal introitus) and normal function of adjacent organs. Patients are prescribed medical gymnastics (physiotherapy), Kegel exercises to strengthen the pelvic floor, and the use of a pessary.
Surgical treatment is indicated for severe forms of descent and prolapse. Access can be vaginal, laparoscopic, or laparotomic. The choice of method is strictly individual and depends on age, concomitant pathologies, the state of the anal sphincter, and the need to preserve reproductive function.
Main types of surgeries:
- Anterior colporrhaphy: plastic repair of the anterior vaginal wall with fascial plication. In the presence of cystocele, a duplication of the pubocervical fascia is formed.
- Colpoperineolevatoroplasty: strengthening of the pelvic floor by isolating and approximating the levators (m. levator ani). Often performed as an adjunctive procedure during other interventions.
- Manchester operation: indicated for uterine prolapse with cervical elongation and cystocele. It includes amputation of the elongated cervix and shortening of the cardinal ligaments.
- Vaginal hysterectomy: recommended for elderly patients who are not sexually active. Associated with a risk of recurrence in the form of enterocele and disruption of pelvic architecture.
- Two-stage combined surgery (modified by V.I. Krasnopolsky): a modern approach performed laparoscopically using synthetic materials for reliable reinforcement of the ligamentous apparatus.
Briefly: answers to topical questions
What stages of pelvic organ prolapse are distinguished according to the POP-Q classification?
The sources mention only stages III and IV of the POP-Q classification; the beginning of the list (stages 0–II) is omitted. Stage III means that the most distal part of the prolapse is more than 1 cm distal to the hymenal plane, but protrudes no further than the total vaginal length (TVL) minus 2 cm. Stage IV is complete prolapse, in which the most distal part of the prolapse protrudes further than TVL − 2 cm.
- Stage III — >1 cm distal to the hymenal plane, but ≤ TVL − 2 cm
- Stage IV — complete prolapse, >TVL − 2 cm
What etiological factors and risk factors lead to the development of pelvic organ prolapse?
Genital descent and prolapse is a polyetiological condition, the main cause of which is considered to be a tear in the pelvic fascia due to connective tissue pathology. Contributing factors include pelvic floor muscle insufficiency and elevated intra-abdominal pressure, while the anatomical basis for the development of the disease is DeLancey's three-level support concept for pelvic organs (DeLancey).
- Traumatic childbirth — fetal macrosomia, prolonged labor, repeated births, operative vaginal delivery, perineal tears
- Connective tissue dysplasia — "systemic" deficiency manifested by hernias of other locations
- Estrogen deficiency — impaired steroid hormone synthesis
- Chronic diseases — with impaired metabolic processes and microcirculation
- Constipation — can be both a cause and a consequence of prolapse
To which anatomical structures is the synthetic implant attached during laparoscopic sacrocolpopexy (promontofixation)?
During laparoscopic promontofixation (sacropexy), a synthetic mesh fixes the vaginal vault to the anterior longitudinal ligament of the sacrum. The procedure is applicable both after hysterectomy, when the vaginal vault is fixed, and after subtotal hysterectomy, when the cervical stump is fixed. In sacropexy, the vaginal vault or cervical stump is suspended from the sacral promontory at the L5/S1 level using an inverted Y-shaped strap, the ends of which pass anterior and posterior to the vagina.
- Anterior longitudinal ligament of the sacrum — mesh fixation point in promontofixation
- Sacral promontory (L5/S1) — level of suspension of the vaginal vault or cervix
What are the absolute and relative contraindications to the placement of a pessary?
The sources do not provide a direct list of absolute and relative contraindications to pessary placement. Criteria for effective placement and reasons for discontinuation are provided:
- The pessary should not cause discomfort in the upright position, walking, coughing, sneezing, and straining.
- The pessary must be easily inserted and removed.
- There should be no urinary or fecal obstruction.
- The pessary should not provoke occult urinary incontinence.
- Reasons for discontinuation: discomfort during wear, pain syndrome, development of urinary incontinence, abnormal vaginal discharge, colpitis, decubitus ulcers, fistulas, erosions, as well as the patient's decision in favor of surgery.
To remember the examination algorithm for prolapse, keep the rule of three "O's": Observation (visual and bimanual examination with assessment of the levators), Obligatory rectal examination (for rectocele), and Oncological screening (differential diagnosis of decubitus ulcer and cervical cancer).
Class and exam questions
What disease must decubitus ulcer be strictly differentiated from?
With cervical cancer. For accurate differential diagnosis, colposcopy, cytologic examination, and targeted biopsy are used.
Is pregnancy and childbirth possible after the Manchester operation?
The surgery does not preclude future pregnancy, but vaginal delivery after it is not recommended.
What is the key step of colpoperineolevatoroplasty?
The key step of this procedure is the isolation of the levator ani muscle and suturing its crura together to restore the musculofascial structure of the perineum.
When is exclusively conservative treatment indicated for a patient?
With mild degrees of prolapse, when the cervix does not reach the vaginal introitus, and in the complete absence of dysfunction of adjacent organs.
What else to study on this topic
- Technique of anterior colporrhaphy and formation of the vesicovaginal fascia duplication
- Criteria for choosing the surgical approach (vaginal, laparoscopic, laparotomic)
- Pathogenesis of hydronephrosis and hydroureter development in prolonged complete uterine prolapse
- Features of the two-stage combined surgery modified by V.I. Krasnopolsky
- Disadvantages and risks of vaginal hysterectomy in patients of different age groups
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