Pelvic organ prolapse. Prolapse of the uterus and vagina Results of surgical treatment of genital prolapse
Current trends in pelvic floor surgery for prolapse
Current trends in pelvic floor surgery for prolapseModern trends in pelvic floor surgery for prolapseLectures for doctors "Prolapse of the genitals (uterus and vagina) - to operate or prevent?". The lecture is given by gynecologist N. Chernaya. IV Interdisciplinary forum with international participation. “The cervix and vulvovaginal diseases. Aesthetic gynecology.
The incorrect position of the genital organs is characterized by persistent deviations from the physiological position, arising under the influence of inflammatory processes, tumors, injuries and other factors (Fig. 18.1).
The physiological position of the genital organs is provided by several factors:
The presence of the ligamentous apparatus of the uterus (suspension, fixation and support);
Own tone of the genital organs, which is provided by the level of sex hormones, the functional state of the nervous system, age-related changes;
The relationship between the internal organs and the coordinated functioning of the diaphragm, abdominal wall and pelvic floor.
The uterus can move both in the vertical plane (up and down), and in the horizontal. Of particular clinical importance are pathological anteflexia (hyperanteflexia), posterior displacement of the uterus (retroflexia) and its prolapse (prolapse).
Rice. 18.1.
Hyperanteflexia- pathological inflection of the uterus anteriorly, when an acute angle is created between the body and the cervix (<70°). Патологическая антефлексия может быть следствием полового инфантилизма, реже это результат воспалительного процесса в малом тазу.
Clinical picture hyperanteflexia corresponds to that of the underlying disease that caused the abnormal position of the uterus. The most typical complaints are menstrual disorders of the type of hypomenstrual syndrome, algomenorrhea. Often there are complaints of infertility (usually primary).
Diagnosis established on the basis of characteristic complaints and vaginal examination data. As a rule, a small uterus is found, sharply deviated anteriorly, an elongated conical cervix, a narrow vagina and flattened vaginal vaults.
Treatment hyperanteflexia is based on the elimination of the causes that caused this pathology (treatment of the inflammatory process). In the presence of severe algomenorrhea, various painkillers are used. Antispasmodics are widely used (noshpa, sodium metamizole - baralgin, etc.), as well as antiprostaglandins: indomethacin, phenylbutazone and others, which are prescribed 2-3 days before the onset of menstruation.
Retroflexion of the uterus characterized by the presence of an angle between the body and the cervix, open posteriorly. In this position, the body of the uterus is tilted backwards, and the cervix is forward. In retroflexion, the bladder remains uncovered by the uterus, and loops of intestine exert constant pressure on the anterior surface of the uterus and the posterior wall of the bladder. As a result, prolonged retroflexion contributes to the prolapse or prolapse of the genital organs.
Distinguish mobile and fixed retroflexion of the uterus. Mobile retroflection is a consequence of a decrease in the tone of the uterus and its ligaments during birth trauma, tumors of the uterus and ovaries. Movable retroflexion is also often found in women with an asthenic physique and with pronounced weight loss due to general severe diseases. Fixed retroflexion of the uterus is observed in inflammatory processes in the pelvis and endometriosis.
Clinical symptoms. Regardless of the retroflexion option, patients complain of pulling pains in the lower abdomen, especially before and during menstruation, dysfunction of neighboring organs and menstrual function (algomenorrhea, menometrorrhagia). In many women, retroflexion of the uterus is not accompanied by any complaints and is detected by chance during a gynecological examination.
Diagnostics retroflexion of the uterus usually does not present any difficulties. A bimanual examination reveals a posteriorly deviated uterus, palpable through the posterior fornix of the vagina. Mobile retroflexion of the uterus is eliminated quite easily - the uterus is transferred to its normal position. With fixed retroflexion, it is usually not possible to remove the uterus.
Treatment. With asymptomatic retroflexion of the uterus, treatment is not indicated. Retroflection with clinical symptoms requires treatment of the underlying disease that caused this pathology (inflammatory processes, endometriosis). In severe pain syndrome, laparoscopy is indicated to clarify the diagnosis and eliminate the cause of pain.
Pessaries, surgical correction and gynecological massage, which were previously widely used to keep the uterus in the correct position, are not currently used.
Omission and prolapse (prolapse) of the uterus and vagina. The prolapse of the uterus and vagina is of the greatest practical importance among the anomalies in the position of the genital organs. In the structure of gynecological morbidity, prolapse and prolapse of the genital organs account for up to 28%. Due to the anatomical proximity and commonality of supporting structures, this pathology often causes anatomical and functional failure of adjacent organs and systems (urinary incontinence, anal sphincter failure).
There are the following options for prolapse and prolapse of the genital organs:
Omission of the anterior wall of the vagina. Often, along with it, a part of the bladder drops out, and sometimes a part of the bladder falls out - a cystocele (cystocele;
rice. 18.2);
Prolapse of the posterior wall of the vagina, which is sometimes accompanied by prolapse and prolapse of the anterior wall of the rectum - rectocele (rectocele; fig.18.3);
Omission of the posterior fornix of the vagina of varying degrees - enterocele (enterocele);
Rice. 18.2.
Rice. 18.3.
Incomplete prolapse of the uterus: the cervix reaches the genital slit or goes outside, while the body of the uterus is within the vagina (Fig. 18.4);
Complete prolapse of the uterus: the entire uterus extends beyond the genital gap (Fig. 18.5).
Often, with the omission and prolapse of the genital organs, there is an elongation of the cervix - elongation (Fig. 18.6).
Rice. 18.4. Incomplete prolapse of the uterus. Decubital ulcer
Rice. 18.5.
Rice. 18.6.
A special group is posthysterectomy prolapses- omission and prolapse of the stump of the neck and stump (dome) of the vagina.
The degree of genital prolapse is determined using the International classification according to the POP-Q (Pelvic Organ Prolapse Quantification) system - this is a quantitative classification based on the measurement of nine parameters: Aa - urethrovesical segment; Ba - anterior wall of the vagina; Ap - lower part of the rectum; Bp - above the levators; C - Cervix (neck); D - Douglas (rear vault); TVL is the total length of the vagina; Gh - genital gap; Pb - perineal body (Fig. 18.7).
According to the above classification, the following degrees of prolapse are distinguished:
Stage 0 - no prolapse. Parameters Aa, Ar, Ba, Bp - all - 3 cm; points C and D - ranging from TVL to (TVL - 2 cm) with a minus sign.
Stage I - Criteria for Stage 0 are not met. The most distal part of the prolapse is >1 cm above the hymen (value > -1 cm).
Stage II - the most distal part of the prolapse<1 см проксимальнее или дистальнее гимена (значение >-1 but<+1 см).
Rice. 18.7. Classification of genital prolapse according to the POP-Q system. Explanations in the text
Stage III - the most distal part of the prolapse > 1 cm distal to the hymenal plane, but no more than TVL - 2 cm (value<+1 см, но Stage IV - complete loss. The most distal part of the prolapse protrudes more than TVL - 2 cm. Etiology and pathogenesis. Prolapse and prolapse of the genital organs is a polyetiological disease. The main cause of genital prolapse is rupture of the pelvic fascia due to pathology of the connective tissue under the influence of various factors, including the failure of the pelvic floor muscles and increased intra-abdominal pressure. It is generally accepted that the three-level concept of support for the pelvic organs is Delancey(Fig. 18.8). Risk factors for developing genital prolapse are: Traumatic childbirth (large fetus, prolonged, repeated childbirth, vaginal delivery operations, perineal ruptures); Failure of connective tissue structures in the form of "systemic" insufficiency, manifested by the presence of hernias of other localizations - connective tissue dysplasia; Violation of the synthesis of steroid hormones (estrogen deficiency); Chronic diseases, accompanied by a violation of metabolic processes, microcirculation. Clinical symptoms. Prolapse and prolapse of the genital organs develops slowly. The main symptom of prolapse of the uterus and vaginal walls is detected by the patient herself. the presence of a "foreign body" outside the vagina. The surface of the prolapsed part of the genital organs, covered with a mucous membrane, undergoes keratinization, takes the form Rice. 18.8. Three-level pelvic support concept Delancey Rice. 18.9. dull dry skin with cracks, abrasions, and then ulcerations. Subsequently, patients complain of feeling of heaviness and pain in the lower abdomen, lower back, sacrum, aggravated during and after walking, when lifting weights, coughing, sneezing. Stagnation of blood and lymph in the prolapsed organs leads to cyanosis of the mucous membranes and swelling of the underlying tissues. On the surface of the prolapsed cervix, a decubital ulcer is often formed (Fig. 18.9). Uterine prolapse is accompanied by difficulty urinating, the presence of residual urine, stagnation in the urinary tract and then infection, first of the lower, and with the progression of the process, of the upper parts of the urinary system. Long-term complete prolapse of the internal genital organs can be the cause of hydronephrosis, hydroureter, obstruction of the ureters. Every 3rd patient with genital prolapse develops proctological complications. The most frequent of them is constipation, moreover, in some cases it is the etiological factor of the disease, in others it is a consequence and manifestation of the disease. Diagnosis omission and prolapse of the genital organs are put on the basis of data from a gynecological examination. After examination for palpation, the prolapsed genitals are set and a bimanual examination is performed. At the same time, the condition of the pelvic floor muscles is assessed, especially m. levator ani; determine the size and mobility of the uterus, the condition of the uterine appendages and exclude the presence of other pathologies. A decubital ulcer must be differentiated from cervical cancer. For this, colposcopy, cytological examination and targeted biopsy are used. With a mandatory rectal examination, attention is paid to the presence or severity of the rectocele, the state of the rectal sphincter. Rice. 18.10. With severe urination disorders, it is necessary to conduct a study of the urinary system, according to indications, cystoscopy, excretory urography, urodynamic study. Ultrasound of the pelvic organs is also shown. Treatment. With small prolapse of the internal genital organs, when the cervix does not reach the vestibule of the vagina, and in the absence of dysfunction of neighboring organs, conservative management of patients is possible using a set of physical exercises aimed at strengthening the muscles of the pelvic floor (Kegel exercises), physiotherapy exercises, wearing a pessary (Fig. .18.10). With more severe degrees of prolapse and prolapse of the internal genital organs, surgical treatment is used. For the treatment of prolapse and prolapse of the genital organs, there are various types of surgical operations (more than 200). The vast majority of them today are only of historical interest. At the present level, surgical correction of descents and prolapses of the genital organs can be carried out by various approaches: vaginal, laparoscopic and laparotomic. The choice of access and method of surgical intervention in patients with prolapse and prolapse of the genital organs is determined by: prolapse of the internal genital organs; the presence of concomitant gynecological pathology and its nature; the possibility and necessity of maintaining or restoring reproductive, menstrual functions; features of dysfunction of the colon and rectal sphincter, age of patients; concomitant extragenital pathology, the degree of risk of surgical intervention and anesthesia. In the surgical correction of genital prolapse, both the patient's own tissues and synthetic materials can be used to strengthen the anatomical structures. Currently, preference is given to synthetic materials. We list the main operations used by most gynecologists in the treatment of prolapse and prolapse of the genital organs. 1. Anterior colporrhaphy -
plastic surgery on the anterior wall of the vagina, which consists in cutting out and excising a flap from excess tissue of the anterior wall of the vagina. It is necessary to isolate the fascia of the anterior wall of the vagina and sutured it with separate sutures. In the presence of a cystocele (diverticulum of the bladder), the fascia of the bladder is opened and sutured in the form of a duplicate (Fig. 18.11). Anterior colporrhaphy is indicated for prolapse of the anterior vaginal wall and/or cystocele. 2. Colpoperineolevathoroplasty- the operation is aimed at strengthening the pelvic floor. It is performed as the main benefit or as an additional operation for all types of surgical interventions for prolapse and prolapse of the genital organs. The essence of the operation is to remove excess tissue from the posterior wall of the vagina and restore the muscular-fascial structure of the perineum and pelvic floor. When performing this operation, special attention must be paid to the selection of levators. (m. levator ani) and linking them together. With a pronounced rectocele, diverticulum of the rectum, it is necessary to suture the fascia of the rectum and the fascia of the posterior wall of the vagina with dip sutures (Fig. 18.12). 3. Manchester operation- recommended for omission and incomplete prolapse of the uterus, especially with elongation of its neck and the presence of a cystocele. The operation is aimed at strengthening the fixing apparatus of the uterus - the cardinal ligaments by stitching them together, transposition. The Manchester operation includes several stages: amputation of the elongated cervix and shortening of the cardinal ligaments, anterior colporrhaphy and colpoperineolevatoroplasty. Amputation of the cervix, performed during the Manchester operation, does not exclude future pregnancy, but vaginal delivery after this operation is not recommended. 4. Vaginal hysterectomy consists in removing the latter by vaginal access, while anterior colporrhaphy and colpoperineolevathoroplasty are also performed (Fig. 18.13). The disadvantages of vaginal extirpation of the uterus when it prolapses include the possibility of recurrence in the form of an enterocele, the cessation of menstrual and reproductive functions in patients of reproductive age, a violation of the architectonics of the small pelvis, the possibility of progression of violations of the function of neighboring organs (bladder, rectum). Vaginal hysterectomy is recommended for elderly patients who are not sexually active. 5. Two-stage combined operation in the modification of V.I. Krasnopolsky et al. (1997), which consists in strengthening the sacro-uterine ligaments with aponeurotic flaps cut from the aponeurosis of the external oblique muscle of the abdomen (performed extraperitoneally) in combination with colpoperineolevatoroplasty. This technique is universal - it can be used with a preserved uterus, with recurrence of prolapse of the stump of the cervix and vagina, in combination with amputation and extirpation of the uterus. Currently, this operation is performed by laparoscopic access using synthetic materials instead of aponeurotic flaps. Rice. 18.11. Rice. 18.12. Stages of colpoperineolevathoroplasty: a - separation of the mucous membrane of the posterior wall of the vagina; b - separation and isolation of the muscle that raises the anus; c-d - suturing on m. levator ani; e - suturing the skin of the perineum 6. Colpopexy(fixation of the dome of the vagina). Colpopexy is performed on women who are sexually active. The operation can be performed with different accesses. With vaginal access, the dome of the vagina is fixed to the sacrospinous ligament (usually on the right). With laparoscopic or abdominal access, the dome of the vagina is fixed to the anterior longitudinal ligament of the sacrum using a synthetic mesh. (promontofixation,
or sacropexy).
Such an operation can be performed both after extirpation of the uterus and after its supravaginal amputation (the dome of the vagina or the stump of the cervix is fixed). 7. Operations of suturing (obliteration) of the vagina(operations of Lefort-Neigebauer, Labgardt) are non-physiological, exclude the possibility of Rice. 18.13. life, relapses of the disease also develop. These operations are performed only in old age with complete prolapse of the uterus (if there is no pathology of the cervix and endometrium) or the dome of the vagina. These operations are extremely rare. 8. Vaginal extraperitoneal colpopexy (TVM operation - transvaginal mesh) -
a system for the complete restoration of a damaged pelvic fascia using a synthetic prosthesis. Many different mesh prostheses have been proposed, the most versatile and easy-to-use system for restoring the pelvic floor Gynecare prolift(Fig. 18.14). This system completely eliminates all anatomical defects of the pelvic floor according to a standardized technique. Depending on the location of the defect, the procedure can be performed as a reconstruction of the anterior or posterior sections or a complete restoration of the pelvic floor. For plasty of a cystocele, a transobturator approach is used with fixation of the free parts of the prosthesis behind the distal and proximal parts of the tendinous arch of the pelvic fascia (arcus tendineus). The posterior wall of the vagina is reinforced with a prosthesis passed through the sacrospinal ligaments. Being located under the fascia, the mesh prosthesis duplicates the contour of the vaginal tube, reliably eliminating prolapse without changing the direction of the vector of the physiological displacement of the vagina (Fig. 18.15). The advantages of this technique are in the versatility of its application, including recurrent forms of prolapse in previously operated patients, patients with extragenital pathology. In this case, the operation can be performed in combination with a hysterectomy, amputation of the cervix, or with preservation of the uterus. Rice. 18.14. mesh prosthesis Gynecare prolift Rice. 18.15. 18.1. Urinary incontinence
Urinary incontinence
(involuntary urination) - a pathological condition in which volitional control of the act of urination is lost. This pathology is a social and medical-hygienic problem. Urinary incontinence is a disease that occurs both in young and old age and does not depend on living conditions, the nature of the work or the ethnicity of the patient. According to European and American statistics, about 45% of the female population aged 40-60 years, to one degree or another, have symptoms of involuntary loss of urine. According to domestic studies, symptoms of urinary incontinence occur in 38.6% of Russian women. The normal functioning of the bladder is possible only with the preservation of innervation and the coordinated work of the pelvic floor. When the bladder is full, resistance increases in the area of the internal opening of the urethra. The detrusor remains relaxed. When the volume of urine reaches a certain threshold, impulses are sent from the stretch receptors to the brain, triggering the urination reflex. In this case, a reflex contraction of the detrusor occurs. In the brain is the urinary center associated with the cerebellum. The cerebellum coordinates the relaxation of the pelvic floor muscles, as well as the amplitude and frequency of detrusor contractions during urination. The signal from the urethral center enters the brain and is transmitted to the corresponding center located in the sacral segments of the spinal cord, and from there to the detrusor. This process is controlled by the cerebral cortex, which exerts inhibitory influences on the center of urination. Thus, the process of urination is normally an arbitrary act. Complete emptying of the bladder occurs due to prolonged contraction of the detrusor while relaxing the pelvic floor and urethra. Urinary retention is influenced by various external and internal factors. External factors - pelvic floor muscles that contract when intra-abdominal pressure rises, compressing the urethra and preventing involuntary leakage of urine. With the weakening of the visceral fascia of the pelvis and the muscles of the pelvic floor, the support they create for the bladder disappears, and pathological mobility of the bladder neck and urethra appears. This leads to stress incontinence. Internal factors - muscular membrane of the urethra, sphincters of the bladder and urethra, folding of the mucous membrane, the presence of α-adrenergic receptors in the muscular membrane of the urethra. Insufficiency of internal factors occurs with malformations, estrogen deficiency and innervation disorders, as well as after injuries and as a complication of some urological operations. There are several types of urinary incontinence in women. The most common are stress urinary incontinence and bladder instability (overactive bladder). For diagnosis and treatment, the most difficult cases are those with complex (in combination with genital prolapse) and combined (combination of several types of urinary incontinence) forms of urinary incontinence. Stress urinary incontinence (stress incontinence - SUI)- uncontrolled loss of urine during physical effort (coughing, laughing, straining, playing sports, etc.), when the pressure in the bladder exceeds the closing pressure of the urethra. Stress incontinence may be due to dislocation and weakening of the ligamentous apparatus of the unchanged urethra and urethrovesical segment, as well as insufficiency of the urethral sphincter. clinical picture. The main complaint is the involuntary leakage of urine during exercise without the urge to urinate. The intensity of urine loss depends on the degree of damage to the sphincter apparatus. Diagnostics consists in establishing the type of urinary incontinence, the severity of the pathological process, assessing the functional state of the lower urinary tract, identifying possible causes of urinary incontinence and choosing a correction method. During perimenopause, the frequency of urinary incontinence increases slightly. Patients with urinary incontinence are examined in three stages. Stage 1 - clinical examination. Most often, stress urinary incontinence occurs in patients with prolapse and prolapse of the genital organs, so the patient should be examined in the gynecological chair (as the ability to detect prolapse of the genital organs, assess the mobility of the bladder neck during a cough test or straining, the condition of the skin of the perineum and the mucous membrane of the vagina); in severe forms of urinary incontinence, the skin of the perineum is irritated, hyperemic, sometimes with areas of maceration. When collecting an anamnesis, risk factors are ascertained: among them are the number and course of childbirth (large fetus, perineal injuries), heavy physical exertion, obesity, varicose veins, splanchnoptosis, somatic pathology accompanied by an increase in intra-abdominal pressure (chronic cough, constipation), previous surgical interventions on the pelvic organs. Laboratory examination methods include a clinical analysis of urine and urine culture for microflora. The patient is advised to keep a urination diary for 3-5 days, noting the amount of urine released per urination, the frequency of urination per day, all episodes of urinary incontinence, the number of pads used and physical activity. Such a diary allows you to evaluate urination in a familiar environment for a sick person. For the differential diagnosis of stress urinary incontinence and an overactive bladder, it is necessary to use a specialized questionnaire and a table of working diagnoses (Table 18.1). Table 18.1. 2nd stage - ultrasound; is carried out not only to exclude or confirm the presence of pathology of the genital organs, but also to study the urethro-vesical segment, as well as the condition of the urethra in patients with stress urinary incontinence. Ultrasound of the kidneys is also recommended. During abdominal scanning, the volume, shape of the bladder, the amount of residual urine are assessed, and the pathology of the bladder (diverticula, stones, tumors) is excluded. 3rd stage - combined urodynamic study (CUDI)-
an instrumental research method using special equipment that allows you to diagnose the type of urinary incontinence. Especially KUDI Rice. 18.16. indicated for suspected combined disorders, when it is necessary to determine the predominant type of urinary incontinence. Indications for mandatory CUDI are: lack of effect from ongoing therapy, recurrence of urinary incontinence after treatment, discrepancy between clinical symptoms and research results. KUDI allows you to develop the right treatment tactics and avoid unnecessary surgical interventions. Treatment. Numerous methods have been proposed for the treatment of stress urinary incontinence, which are combined into groups: conservative, medical, surgical. Conservative and medical methods:
Exercises to strengthen the muscles of the pelvic floor; Replacement hormone therapy in menopause; The use of α-sympathomimetics; Pessaries, vaginal cones, balls (Fig. 18.16); Removable urethral obturators. Surgical methods. Of all the known surgical techniques for the correction of stress urinary incontinence, sling operations turned out to be the most effective. Sling (loop) operations consist in imposing a loop around the neck of the bladder. At the same time, preference is given to minimally invasive interventions using freely located synthetic loops (TVT, TVT-O, TVT SECUR). The most common and minimally invasive sling operation is transobturator urethrovesico-pexy with a free synthetic loop (Transobturator vaginal tape - TVT-O). During the operation, a synthetic prolene loop is inserted from an incision in the anterior vaginal wall in the area of the middle urethra through a Rice. 18.17. foramen magnum on the inner surface of the thigh - retrograde (Fig. 18.17, 18.18). Periurethral injections are a minimally invasive method of treating bladder sphincter insufficiency, which consists in introducing special substances into the tissues that facilitate the closure of the urethra with an increase in intra-abdominal pressure (collagen, autofat, Teflon). Conservative methods of treatment are possible with a mild degree of urinary incontinence or the presence of contraindications to the surgical method. Difficulties in choosing a method of treatment arise when urinary incontinence is combined with prolapse and prolapse of the genital organs. Plastic surgery of the anterior wall of the vagina as an independent type of surgery for cystocele and stress urinary incontinence is ineffective; it must be combined with one of the types of anti-stress operations. The choice of surgical treatment for uterine prolapse depends both on the age of the patient, the presence and nature of the pathology of the internal genital organs (uterus and its appendages), and on the capabilities of the surgeon performing the operation. Various operations can be performed: vaginal hysterectomy, vaginal extraperitoneal colpopexy using synthetic prostheses, sacrovaginopexy. But all these interventions must be combined with one of the types of sling (loop) operations. Detrusor instability, or an overactive bladder manifested by urinary incontinence. In this case, patients experience involuntary urination with an imperative (immediate) urge to urinate. The characteristic symptoms of an overactive bladder are also frequent urination and nocturia. The main method for diagnosing an overactive bladder is a urodynamic study. An overactive bladder is treated with anticholinergic drugs - oxybutynin (driptan), tolterodine (detrusitol), Rice. 18.18. trospium chloride (Spasmex), solifenacin (Vesicar), tricyclic antidepressants (imipramine), and bladder training. All postmenopausal patients simultaneously undergo HRT: suppositories with estriol (topically) or systemic drugs, depending on age. With unsuccessful attempts at conservative treatment, adequate surgical intervention is necessary to eliminate the stress component. Combined forms of urinary incontinence(a combination of detrusor instability or its hyperreflexia with stress urinary incontinence) present difficulties in choosing a treatment method. Detrusor instability can also be detected in patients at different times after anti-stress operations as a new urination disorder. The anatomical and topographic features of the pelvic organs, common blood supply, innervation, as well as close functional ties allow us to consider them as a whole single system in which even local changes cause damage to the function and anatomy of neighboring organs. Therefore, the main goal of prolapse treatment is to eliminate not only the underlying disease, but also to correct violations of the genital organs, bladder, urethra, rectum and pelvic floor. Among the factors that determine the tactics of treatment of patients with prolapse of the genital organs, the following are distinguished: Restorative treatment. This type of therapy is aimed at increasing the tone of tissues and eliminating the causes that contribute to the displacement of the genital organs. Recommended: good nutrition, water procedures, gymnastic exercises, changing working conditions, uterine massage. Surgical treatment of genital prolapse. Surgical intervention should be considered a pathogenetically substantiated method of treating female genital prolapse. To date, more than 300 methods of surgical correction of this pathology are known. Known methods of surgical correction of genital prolapse can be divided into 7 groups, based on the anatomical formations that are strengthened to correct the incorrect position of the genital organs. In recent years, the tactics of combined correction of genital prolapse with the use of laparoscopy and vaginal access has gained popularity. Orthopedic treatments for genital prolapse. Methods for the treatment of prolapse and prolapse of the genital organs in women with the help of pessaries are used in old age if there are contraindications to surgical treatment. Physiotherapy treatment. Of great importance in the treatment of pubescence of the genital organs and urinary incontinence in women are timely and correctly applied methods of physiotherapy, diadynamic sphincterotonization. Prolapse does not pose a threat to life, but it can significantly reduce its quality, so this disease should not be considered a manifestation of the natural aging process. This disease can and should be treated. Proper treatment will allow you to return to a fulfilling life and feel healthy again. Genital prolapse is a condition in which the pelvic organs prolapse or prolapse through the vagina. If the ligaments and muscles of the small pelvis are weakened or damaged, then under the influence of gravity and with an increase in intra-abdominal pressure, a descent first occurs, and then a complete prolapse of one or another organ through the vagina. The condition in which the bladder prolapses through the anterior wall of the vagina is called a cystocele. This is the most common type of prolapse. Prolapse of the uterus is also quite common. If the uterus has been removed, then the dome of the vaginal stump may droop. The descent of the rectum through the posterior wall of the vagina is called a rectocele, the prolapse of the loops of the small intestine through the posterior fornix of the vagina is called an enterocele. This type of prolapse is relatively rare. Genital prolapse can be either isolated or combined, when several organs prolapse, for example, cystorectocele - prolapse of the bladder and rectum. The severity of prolapse can also be different - from the minimum degree of prolapse to complete loss. Currently, several classifications of genital prolapse have been proposed, the most common of which is the POP-Q (Pelvic Organ Prolapse Quantification System) classification. Among the reasons for the development of genital prolapse, leading to disruption of the muscles and ligaments of the pelvis, pregnancy and childbirth most often appear. The age of the mother, the weight of the fetus, the number and duration of childbirth play an important role. Accordingly, the more a woman gave birth through the natural birth canal, the larger the fetus was and the longer the birth was, the higher the risk of developing genital prolapse. In this case, prolapse can manifest itself both after a relatively short time after childbirth, and in a very remote period. The natural aging process and associated age-related deficiency of sex hormones can also lead to weakening of supporting structures, so genital prolapse is more common in older women. The cause of prolapse can be a number of diseases, which are characterized by a periodic increase in intra-abdominal pressure. These include chronic bronchitis, chronic constipation, bronchial asthma and a number of other diseases. Increased intra-abdominal pressure is transmitted to the pelvic floor muscles and ligaments, which over time leads to their weakening and the development of prolapse. In addition, a number of hereditary diseases and syndromes have been described that are characterized by a congenital defect in the connective tissue that makes up all the ligaments in the human body. Such patients are characterized by the appearance of prolapse at a fairly young age, as well as the presence of concomitant diseases, also associated with weakness of the connective tissue. The most common complaint with genital prolapse is the feeling of a foreign body ("ball") in the vagina. Difficulty urinating, a feeling of incomplete emptying of the bladder, frequent urination, and an urgent urge to urinate may also be of concern. These complaints are characteristic of bladder prolapse. With prolapse of the rectum, there may be complaints about the difficult act of defecation, the need for manual assistance for its implementation. Discomfort during intercourse is possible. There may also be a feeling of heaviness, pressure and discomfort in the lower abdomen. Before proceeding to describe the various treatments, it should be noted that genital prolapse is fortunately not a life-threatening condition. A certain danger is represented by extreme degrees of prolapse, in which the normal outflow of urine from the kidneys may be disturbed due to partial compression of the ureters, but such situations are rare. Many women have a minimal degree of prolapse that does not bother them. In such cases, you can limit yourself to observation. The need for treatment, especially surgery, arises only when the prolapse causes significant discomfort and anxiety. All methods of treatment of genital prolapse can be divided into 2 groups: surgical and conservative. Conservative treatments include pelvic floor strengthening exercises and the use of a pessary (which is explained below). Exercises for the pelvic floor muscles can slow down the progression of prolapse. They are especially effective in young patients with minimal prolapse. To achieve noticeable positive results, these exercises must be performed for a sufficiently long time (at least 6 months), follow the regimen and technique of their implementation. In addition, heavy lifting should be avoided. It is also recommended to bring your weight back to normal if there is an excess of it. With a significant degree of prolapse, as well as in elderly patients, the effectiveness of exercise is almost zero. If it is necessary to delay surgical treatment, for example, in case of a planned pregnancy or if there are contraindications to surgery in somatically burdened patients, a pessary may be used. A pessary is a special device that is inserted into the vagina. It, having a certain shape and volume individually selected for each patient, restores or improves the anatomical relationships of the pelvic organs while it is in the vagina. In order to avoid traumatic effects on the walls of the vagina, it is necessary to periodically replace the pessary. It is also advisable to use estrogen-containing vaginal creams. There are a number of surgical interventions aimed at eliminating pelvic organ prolapse. The choice of a particular operation depends on the type of prolapse, its severity and a number of other factors. Basically, they can be divided depending on the access used. Operations performed by vaginal access. They can be performed both using the patient's own tissues, and using special synthetic meshes. Using own tissues, operations such as anterior and posterior colporrhaphy are performed. During these interventions, the anterior and / or posterior walls of the vagina are strengthened, respectively, with cystocele and rectocele. Using local tissues, sacrospinal fixation is also performed, in which the dome of the vaginal stump is fixed to the right sacrospinous ligament. Accordingly, this operation is used for prolapse of the vaginal stump. Operations using local tissues are preferably performed in young patients in whom the condition of these tissues is good, as well as with a small degree of prolapse. In elderly patients, especially with significant prolapse, it is preferable to use synthetic meshes, because. when using own tissues, the probability of recurrence is high. The synthetic mesh consists of a specially developed material - polypropylene, which does not dissolve in the tissues of the body and does not cause an inflammatory reaction. The mesh is also placed through the vagina. Modern synthetic prostheses make it possible to perform plastic surgery when the anterior and posterior walls of the vagina are lowered, as well as when the uterus is lowered. Elderly patients with a significant degree of prolapse may be offered colpoclesis - stitching the anterior and posterior walls of the vagina. The obvious disadvantage of this operation is the impossibility of sexual activity due to the shortening of the vagina. On the other hand, this intervention is extremely effective and is performed relatively quickly from the vaginal approach. Operations performed by laparoscopic access. These operations are performed with special instruments that have a very small diameter (3-5 mm) and are carried out through small punctures into the abdominal cavity. This group of operations includes the previously mentioned sacrospinal fixation, as well as sacrovaginopexy. When performing sacrovaginopexy, the vagina and cervix are fixed to the presacral ligament of the sacrum. This operation is also performed using a synthetic mesh. Sacrovaginopexy is preferably performed with isolated uterine prolapse. Unfortunately, like any other operation, surgical treatment of prolapse can be accompanied by various complications. First of all, it is the possibility of recurrence of prolapse. Even with the correct choice of the method of the operation and the observance of the technique of its implementation, the possibility of relapse cannot be completely excluded. In this regard, it is extremely important to follow the recommendations given by the doctor after the operation: limiting physical activity and a ban on sexual activity for 1 month. after the intervention. After the operation, especially if plastic surgery of the anterior vaginal wall was performed, various urination disorders may occur. First of all, this concerns urinary incontinence during stress, manifested during physical exertion, coughing, sneezing. It is observed in approximately 20-25% of cases. You don't need to get upset. Today, there are effective methods of surgical treatment of urinary incontinence using synthetic loops. This operation can be performed after 3 months. after surgical treatment of prolapse. Another possible complication may be difficulty urinating. When it occurs, the appointment of stimulating therapy (coenzymes, physiotherapy sessions aimed at stimulating the contractile activity of the bladder, etc.) is required, which in most cases allows you to restore the normal act of urination. Another urinary disorder that develops after surgery may be overactive bladder syndrome. It is characterized by sudden, hard-to-control urge to urinate, frequent daytime and nighttime urination. This condition requires the appointment of drug therapy, against which it is possible to eliminate most of the symptoms. The use of synthetic meshes inserted through the vagina can cause pain during intercourse. This condition is called "dyspareunia" and is quite rare. However, it is considered that women who are sexually active should avoid implanting mesh prostheses whenever possible to avoid these complications, as they are difficult to treat. The development of modern medical technologies makes it possible to provide highly effective assistance in the treatment of almost any genital prolapse. According to www.rmj.ru Unfortunately, many people do not even realize that their sexual problems are not a matter of whispering with a friend or discussing with a sex therapist, but a reason to go to an aesthetic medicine clinic and get rid of these problems without much difficulty - and most importantly, quickly and permanently. . Modern medicine has many different opportunities to improve the intimate health of patients, to make their sex life brighter and richer. One of them is thread plastic surgery of the vagina:
The organs of a woman's reproductive system must function like clockwork. If a failure occurs in this system, then it is necessary to establish its cause for prompt treatment. With age, especially after giving birth to more than 2 children, a woman experiences changes in the pelvic organs, in particular, genital prolapse sometimes occurs. What it is? What is genital prolapse? Genital prolapse is the prolapse and / or prolapse of the internal genital organs in women: the uterus, appendages and vagina. In fact, this is not a disease, but a condition in which the internal genital organs are in an abnormal position relative to the anatomical landmarks in the pelvis. Symptoms of prolapse of the genital organs in women Most often, such changes in the anatomical location of organs occur in women over 40 years old, although sometimes they occur at 25-30 years of age. The prolapse of the genital organs develops slowly, leads to the development of complications and the occurrence of concomitant diseases. The most common cause of genital prolapse is childbirth. Bearing a child also affects the condition of the muscles. The other most common reasons are considered to be: As a result of the omission or prolapse of organs, a violation of the joint action of the muscles related to the abdominal cavity occurs. Muscles lose their ability to keep the intestines, the uterus with appendages in the normal state, the lowered organs begin to put pressure on the underlying sections and the pelvic floor. Symptoms of genital prolapse are: Displacement and prolapse of the genital organs significantly impairs the quality of life, disrupts the function of adjacent organs. It is customary to distinguish 3 degrees of prolapse of the genital organs: How is genital prolapse treated? This pathological condition is most often treated surgically. It is not worth waiting for the complete prolapse of the uterus; at the first symptoms, you should consult a doctor. The later you see a doctor, the more difficult it will be to return the organs to their anatomical location. In the early stages, it is possible to strengthen the muscles of the pelvic floor with the help of physical exercises, water procedures. Surgical intervention can be avoided if a uterine ring is installed - a pissary that holds the cervix and the uterus itself. If prolapse has stage 2 or 3, then surgical intervention cannot be avoided. Prevention of pelvic organ prolapse Prevention consists in reducing injuries, restoring the integrity of the pelvic floor muscles after childbirth, good nutrition, rest and sleep. All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines. Prolapse or prolapse of the genital organs (vagina, uterus) is observed when the abdominal and pelvic muscles are weakened. This pathology can develop for a number of reasons: multiple births, hard work associated with lifting weights, inflammation, or endocrine disorders. Prolapse of the uterus and vagina is a pathology that inevitably progresses over the years. With conservative methods, its course can only be slowed down, but not stopped. So in the manual on gynecology by V.I. Duda notes: The clinical picture [of this disease] is characterized by a protracted course and a steady progression of the process”.
The type of operation for uterine prolapse largely depends on the desire and ability of a woman to become a mother. The presence of other diseases in the anamnesis also influences the patient's plans for sexual activity in the future. For patients planning childbearing, organ-preserving operations are used, in which the plastic of the vagina is performed, and the muscles of the pelvis (levators) are strengthened. Women over 45 years of age are shown to have the uterus removed (hysterectomy), which is naturally associated with the loss of childbearing function. Some doctors prefer surgery to suture the ligaments that hold the uterus in place. A necessary condition for such an intervention is the absence of atrophic processes in the genitals. Vaginal closure surgery is recommended for women who no longer plan to be sexually active.(mainly the elderly). It is the most effective and minimally invasive. As contraindications, the presence of common diseases and the absence of suspicion of oncological processes in the uterus can be noted. When the omission affects neighboring organs (intestine, bladder), during the operation, their position and the muscles holding them are corrected. Sometimes it is required to combine the vaginal access with the laparoscopic one to achieve the maximum effect of the surgical intervention. In case of prolapse of the cervical stump after a radical operation, the use of a mesh prosthesis is recommended. It will perform the function of ligaments and will allow you to fix the organ in the required position. anterior colporrhaphy This type of surgical treatment of uterine prolapse is performed on the anterior wall of the vagina. For its implementation, the surgeon needs an assistant. It helps in visualizing the internal organs with the help of mirrors. The woman is on the gynecological chair, the doctor or assistant treats her perineum and inner thighs with an antiseptic (alcohol is usually used). The cervix is exposed. The surgeon removes the anterior wall of the vagina. The flap of excess tissue is grasped with clamps and cut off. After that, the surgeon dissects the subcutaneous tissue to gain access to the fascia (connective tissue membranes of organs). They are sutured to give the uterus and, if necessary, the bladder the correct position and their subsequent fixation. After that, sutures are placed directly on the mucosa. In the ureter of the patient for some time there will be a catheter to monitor the condition of the bladder. Preparation for surgery is similar. The surgeon grasps the posterior wall of the vagina with a toothed clamp. After that, the shape of the future vaginal vault is determined, and 3 more clamps are applied. The width equal to two fingers is considered optimal, which leaves the possibility for sexual activity in the future. posterior colporrhaphy As a result, a diamond-shaped flap is formed, which the surgeon cuts off when the mucosa is stretched. With the help of scissors, he cleans the surface of subcutaneous tissue. Levators are exposed into the wound, which are sutured for a more durable subsequent fixation of the uterus and vagina. In parallel, constant monitoring of the state of the vessels is carried out, if necessary, bleeding is stopped. The surgeon connects the edges of the wound with a continuous suture. The affected areas of the skin are also sutured. The vagina is dried and wiped with alcohol. A swab with a disinfectant ointment is inserted for a day. Important! Getting out of bed is allowed 1-2 days after the operation. The operation is reduced to fixing the lowered organs. It can be done through transvaginal or abdominal access. The object of attachment is the abdominal wall, the sacrum. In some cases, a mesh prosthesis is used, which bears the function of ligaments. It is made of polypropylene or prolene. The prosthesis does not cause an allergic reaction and are durable. The mesh is placed inside the organ and sewn with silk or nylon threads; its ends are brought out through the formed channel and fixed to the peritoneum or bone. Layer-by-layer stitching of fabrics is carried out. During the procedure, the surgeon exposes and pulls the cervix to the perineum. After that, mucosal flaps approximately 4 * 6 cm in size are separated from the anterior and posterior walls of the vagina. The exposed surfaces are pressed against each other. Seams are applied. In this case, it turns out that the uterus rests on the sewn areas and, accordingly, cannot fall out or fall. This is followed by plastic surgery of the vagina and levators. It comes down to partial excision of the labia and their stitching, as well as shortening of the muscles. The best way to correct prolapse with this method is to remove the uterus and part of the vagina. With a large excision area of the latter, a so-called vaginal shaft of connective tissue is formed in place of the canal, which prevents the formation of a hernia and strengthens the pelvic floor. With partial removal of the vagina (the Elkin method), the stump is fixed on a ligament or prosthesis. Important!
In this case, the opportunity for sexual activity remains. When using the latest modification, vaginal access is used. In this case, the uterus and vagina are completely everted and removed outside. They are fixed with special clamps. Produce separation at the level of three transverse fingers from the vaginal pharynx. The ligaments coming from the appendages are fixed on the stump of the organ with the help of ligatures. Seams are applied. Depending on the complexity of the operation and the chosen access method, it is allowed to get up for 1-3 days after the procedure. Hospitalization can last from 2-3 days to a week. At first, the patient will receive anti-inflammatory drugs. Some may be prescribed suppositories containing estrogen. With a strong pain syndrome, a woman will receive analgesics. If the access was vaginal, then she is not allowed to: Showering is allowed 5-6 days after the operation. Prior to this, the toilet is performed by a nurse when staying in a hospital or by a woman on her own upon receipt of appropriate instructions. A follow-up examination is carried out a week after the operation (usually still in the hospital) and a month later. In case of bleeding, it is necessary to notify the clinic in which the treatment was carried out and call an ambulance. Surgical intervention for uterine prolapse can be performed free of charge in a hospital under a compulsory medical insurance policy. When using a prosthesis, the patient pays for it on her own - 20,000 - 25,000 rubles. The cost of colporrhaphy in a private clinic will be 25,000 - 50,000 rubles. The average prices for the removal of an organ are 30,000 - 90,000 rubles. If additional tests and studies are required, as well as hospitalization, then the price may increase by 50,000 - 100,000 rubles in both cases.
Causes of genital prolapse
Symptoms of genital prolapse
Genital prolapse treatment methods
Conservative treatment of genital prolapse
Surgical treatments
Complications of surgical treatment
- obesity;
- chronic cough of smoking women;
- heavy physical labor in the postpartum period;
- incorrect position of the uterus (back bend);
- birth defects;
- hereditary muscle weakness;
- weakening of the muscles as a result of previous operations.
Gradually, the genitals move down. The ligaments on which the internal genital organs are suspended are greatly stretched, as are the vessels. Because of this, there is a violation of blood circulation and lymph circulation in the genital organs, stagnation of blood and lymph occurs.
o prolapse of the wall of the vagina or uterus (its part);
o the appearance of heaviness or pain in the lower back, sacrum, sensation of a "foreign body" in the perineum;
o the appearance of symptoms from adjacent organs (frequent urination, urinary incontinence or difficulty urinating, constipation, pain during sexual activity).
o the uterus is displaced downward, but the cervix is within the vagina (determined during a gynecological examination),
o the body of the uterus is in the vagina, and the cervix is in the vestibule of the vagina or even slightly lower (sometimes this condition is called partial prolapse),
o the entire uterus and everted walls of the vagina are below the genital gap (this condition is also called complete prolapse).
The prolapse of the genital organs is dangerous by the formation of hernias of the anterior and posterior walls of the vagina. With complete prolapse of the uterus, the vagina turns outward, the bladder descends lower, as does the anterior wall of the rectum, intestinal loops.
If you need surgical treatment for genital prolapse, call us at the numbers listed on the website and make an appointment with a doctor.
All recommendations are indicative and are not applicable without consulting the attending physician.
At the initial stages of the disease, a special diet, a certain daily routine, and exercises aimed at strengthening certain muscle groups are prescribed. Surgery for uterine prolapse is the most effective and radical way to solve the problem.Indications for surgery
Types of operations and course of surgical intervention
Anterior colporrhaphy
Posterior colporrhaphy
Fixation of the uterus
Median colporrhaphy (Lefort-Neigebauer operation)
Removal of the uterus (hysterectomy)
Recovery period
Operation cost
