Prolapse and Urogynaecology

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Chapter 12 Prolapse and Urogynaecology

Retroversion of the Uterus 214

Symptoms and Treatment of Displacement 215
Uterovaginal Prolapse 216
Vaginal Prolapse 218

Anterior Prolapse 218
Prolapse of the Posterior Wall 219
Clinical Features of Prolapse 220
Differential Diagnosis of Prolapse 221
Pessary Treatment 222

Alternative-Shaped Pessaries 222
Indications for Pessary Treatment 222
Anterior Colporrhaphy (and Repair of Cystocele) 223

Anterior Repair 223
Manchester Repair 225
Posterior Colpoperineorrhaphy (Including Repair of Rectocele) 227
Repair of Enterocele 228
Vaginal Hysterectomy 229

Indications 229
Operative and Postoperative Complications 230
Late Complications 230
Urogynaecology 231

The Anatomy of the Urinary Tract 231
Blood Supply of the Ureter 233

Histology of the Ureter 233
Physiology of Micturition 234

Intravesical Pressure 234
Intraurethral Pressure 234
Innervation of Bladder and Urethra 235
Mechanism of Voiding 236
Detrusor Instability 237

Symptoms 237
Genuine Stress Incontinence 238

Symptoms 238
Genuine Stress Incontinence 238
Other Incontinence Mechanisms 239

Overflow Incontinence 239
Neurological Disease 239
Other Symptoms and Signs Associated with Incontinence 239
The Urethral Syndrome 240
Investigation of Incontinence 241

Examination 241
Demonstrations of Stress Incontinence 241
Urodynamic Investigation of Bladder Function 242

Cystometry 242
Abnormal Cystometry 242
Indications for Urodynamic Assessment 243

Other Investigations 243
Treatment of Stress Incontinence 244

Conservative Treatment of Stress Incontinence 244
New Surgical Developments in the Treatment of Stress Incontinence 244
Surgical Treatment of Stress Incontinence 245
Marshall–Marchetti–Krantz Urethropexy 246
Burch’s Colposuspension Operation 247

Stamey Needle Suspension Procedure 247
Sling Procedures 248
Treatment of Detrusor Instability 249

Bladder Retraining 249
Drug Treatment 249

Retroversion of the uterus

An alteration from the usual anteverted position of the uterus often with a change in the curve of the uterine axis. Most of the so-called displacements are merely variations of the normal and are of little clinical significance.

Anteverted Uterus

The uterus is approximately at right angles to the vagina and has a slight forward curve.

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Retroversion

The long axis of the uterus is directed backwards. The uterus is displaced backwards and this is simply a physiological variation for the vast majority of women. It occurs in approximately 20–30% of women.

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Retroflexion

This is a variation of retroversion but the uterus is curved backwards. The cervix may remain in the normal position but is usually positioned as in retroversion.

Causes of Displacement

Displacement may be due to the presence of some other condition such as a cyst or fibroid or endometriosis.

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Diagnosis is by bimanual palpation. The vaginal hand palpates a mass in the Pouch of Douglas, the abdominal hand detects the absence of a uterine corpus in the expected place. The possibility of pelvic pathology should be considered and ultrasound may be used to confirm the clinical findings.

Symptoms and treatment of displacement

Consequences of Uncomplicated Displacement

Usually none. However, if there is pelvic pathology present, the woman may complain of deep dyspareunia. If such pain occurs, it can easily be reproduced by pressing with the examining fingers. It is quite possible for the patient to present with a complaint of dyspareunia and to have a retroverted uterus which has nothing to do with her complaint.

Uterovaginal prolapse

Herniation of the genital tract through the pelvic diaphragm.

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The uterus and vagina are held in the pelvis by the cardinal and uterosacral ligaments and by the pelvic floor musculature, mainly the levatores ani.

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When these ligaments and muscles become ineffective, the uterus and vagina descend (prolapse) through the gap between the muscles.

The causes of prolapse are the following:

• The stretching of muscle and fibrous tissue which occurs with childbirth and damage to the innervation of the pelvic floor.
• Age and menopausal changes lead to changes in connective tissue support.
• Increased intra-abdominal pressure, for example, chronic cough, heavy manual work; congenital predisposition to stretch the ligaments.
• Distortion of pelvic anatomy by previous surgery, for example, vault prolapse after hysterectomy or entercoele after colposuspension.

The incidence of this condition in the United Kingdom has been greatly reduced because of smaller families and higher caesarean section rates.

Uterovaginal prolapse

The uterus gradually descends in the axis of the vagina taking the vaginal wall with it. It may present clinically at any level, but is usually classified as one of three degrees.

First degree: cervix still inside vagina.

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Second degree: the cervix appears at the level of the introitus.

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Third degree: complete prolapse. In the picture, the uterus is retroflexed and the outline of bladder can be seen. There may be a rectal prolapse as well. This is sometimes called complete procidentia. The vaginal mucosa is non-keratinised and the tissues can become very dry and ulcerated with a 3rd degree uterine prolapse. Bleeding and infection can also occur.

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Vaginal prolapse

The prolapse involves the vaginal walls and the related viscera. Prolapse of several sites may co-exist and a uterine prolapse may also be present.

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Anterior prolapse

When the upper part of the anterior wall prolapses, there is an underlying failure of the investing fascia, and the bladder base also descends. This is called a cystocele.

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Sometimes the lower part of the vaginal wall prolapses and the urethra also descends. This is called a urethrocele.

Vaginal prolapse

Prolapse of the posterior wall

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If the prolapse is at the level of the middle third of the vagina, the rectovaginal septum is often involved and rectum prolapses with vaginal wall. This is called a rectocele. If the lowest part of the vagina prolapses, the perineal body is involved rather than the rectum.

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If the upper part of the posterior vaginal wall prolapses, the Pouch of Douglas is elongated and small bowel or omentum may descend. This is called an enterocele. Enterocele is often associated with uterine prolapse, as in the picture.

Where the uterus has been removed, prolapse of this region is known as a vault prolapse. This is a difficult condition to treat. The technique depends on suspending the vaginal vault from fixed ligaments within the pelvic and often requires insertion of a non-absorbable mesh.

Clinical features of prolapse

• Asymptomatic. It is not uncommon for women to palpate a prolapse, for example, during washing or attempting to insert a tampon. For some women, simple reassurance that there is no sinister cause is all that is required. It can also be identified during routine smear, etc., and if asymptomatic no treatment is required.
• ‘Something coming down’ within the vagina is the commonest symptom. It tends to be worse when the woman has been on her feet and it disappears when she lies down.
• Backache. Some women will experience a dragging feeling or bearing down sensation. This is sometimes resolved with treatment of the prolapse, but mechanical back pain is very common and it may be unrelated to prolapse.
• Coital problems. This is relatively unusual but the woman may admit to difficulties with intercourse, only on direct questioning.
• Increased frequency of micturition. This can be due to anatomical changes that make it difficult to empty the bladder fully. Detrusor instability is also common in older women and may co-exist. A careful urinary history should be taken including fluid and caffeine intake.
• Stress incontinence. This is by no means always present. Sometimes, it is found that reduction of the prolapse causes stress incontinence.
• Difficulty in voiding urine and defecating. The patient may find that it is impossible to initiate micturition except by pushing up the cystocele with her finger. In the same way, the rectocele must be pushed back to allow emptying of the rectum.

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The onset may be gradual or quite sudden and is commoner after the menopause when the genital tract tissues begin to atrophy.

Differential diagnosis of prolapse

Prolapse should be confirmed by vaginal examination. The following conditions resemble prolapse on superficial examination; however, careful examination will detect the difference.

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Pessary treatment

There are a number of different shapes of vaginal pessaries, the simplest to insert is a ring pessary. This is usually made of semi-rigid plastic and is inserted into the vagina so that the vaginal walls are stretched and they cannot prolapse through the introitus.

The pessary is compressed into a long ovoid shape, lubricated and gently pushed into the vagina, where it resumes its circular shape and takes up a position in the coronal plane. It must not be too tight; and correct fitting is learnt by experience. To an extent, pessary fitting is trial and error and the woman should be warned that the pessary may dislodge. A point of contact should be given so that she can be seen again without delay if this is the case.

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Alternative-shaped pessaries

The ‘shelf’ pessary can be particularly useful for uterine prolapse but it is slightly less malleable and insertion can be more difficult.

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Indications for pessary treatment

• The patient prefers a pessary. Pelvic surgery with its unavoidable risks should only be applied to a willing patient.
• The prolapse is amenable to pessary support. If the perineal muscles are very deficient they will not hold a pessary and the pessary will fall out. If too big a ring is required, the vaginal wall or cervix will prolapse through it. Posterior vaginal wall prolapses are poorly supported by pessaries.
• The patient is not fit for surgery.
• The patient wishes to delay operation temporarily (e.g., another pregnancy is anticipated).

Plastic rings should be changed once or twice a year, and if it has been properly fitted, the patient will be unaware of its presence in her vagina even during coitus. An ill-fitting pessary is ineffective and may cause dyspareunia and discomfort. If it is too tight or left too long, ulceration of the vaginal wall will occur, and malignant change has been reported. Vaginal oestriol cream or vaginal oestradiol tablets (0.025 mg) help prevent atrophic vaginitis.

Anterior colporrhaphy (and repair of cystocele)

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