Treatment of choice for uterine prolaspe in a 40-year- old married female with completed family?
Ans. C. Vaginal hysterectomy with pelvic floor repair. (Ref. Shaw Gynecology 15th/pg. 340; Novak's Gynecology 13th/pg. 290; Stenchever Gynecology 4,h/pg.580)UTERINE PROLAPSE# Woman < 20 yr old.unmarried=Sling Operation# Young Woman (20-40 yrs) of child bearing age = FothergilFs operation.# Woman > 40 yrs with completed family & not desirous of keeping childbreaing and menstrual function = Vaginal hysterectomy with pelvic floor repair.# Older women who are no longer sexually active = Le Fort's operation.A prolapse into the upper barrel of the vagina is called first degree. If the prolapse is through the vaginal barrel to the region of the introitus, it is second degree. If the cervix and uterus prolapse out through the introitus, it is called third degree or total. In total prolapse the vagina is everted around the uterus and cervix and completely exteriorized. When this occurs, the patient is in danger of developing dryness, thickening, and chronic inflammation of the vaginal epithelium. Stasis ulcers may result as edema and interference with blood supply to vaginal wall occur. These ulcers rarely become cancerous.The treatment for prolapse is:Conservative management of prolapse usually involves fitting the patient with a pessary.A. Conservative:Abdominal and perineal exercises, massage vaginal pessaryAsymptomatic prolapse does not need treatment. An exception is a woman with stress incontinence and prolapse who is about to undergo surgical bladder neck suspension.Symptomatic prolapse can be treated conservatively or surgically, depending on the individual. Pelvic muscle exercises may be of benefit to women with stress incontinence.B. Surgical: Vaginal hysterectomy with pelvic floor repairAnterior colporrhaphyPosterior colporraphy and colpoperineorrhaphyFotehrgill's repair (Manchester operation)Shirodkar's procedureLeforf s repairAbdominal sling operationsOperations for Vaginal ProlapseVaginal Hysterectomy:Operative repair for prolapse of the uterus and cervix generally involves a vaginal hysterectomy with anterior and posterior colporrhaphy. The advantage of vaginal hysterectomy is that it allows other vaginal surgery (e.g., anterior and posterior colporrhaphy or enterocele repair) to be performed at the same time, without the need for a separate incision or for repositioning the patient.F other gill Operation:This operation combines an anterior and posterior colporrhaphy with the amputation of the cervix and the use of the cardinal ligaments to support the anterior vaginal wall and bladder. In this operation, the bladder is dissected off the cervix, which is then amputated. The cardinal ligaments are sewn to the anterior cervical stump, and the posterior vagina is closed over the rest of the opening. This operation is usually performed in conjunction with an anteroposterior colporrhaphy, and it is usually done for the sake of expediency in patients who are poor surgical risks and who do not desire future fertility. The loss of the cervix may interfere with fertility or lead to incompetence of the internal cervical os. The operation has value in older women who have an elongated cervix and well-supported uterus because it is technically easier and has a shorter operative time.Manchester/Fothergill Operation -Operation of choice in third degree prolapse of uterus in patients who are poor surgical risks and who do not desire future fertility.Uteropexy (Abdominal sling operation) :In a young nullipara who desires to retain her fertility. If prolapse cannot be managed successfully with a pessary, such patients present a surgical challenge. The older abdominal uterine suspension operations (Baldy-Webster, Gilliam, ven- trofixation, or hysteropexy) do not work for patients with significant uterine prolapse. Abdominal sling operations include:# Abdominocervicopexy# Shirodker's abdominal sling operation# Khanna abdominal sling operationParavaginal Defect Repair Operation:Anterior vaginal prolapse has been treated with anterior colporrhaphy, plicating the endopelvic fascia in the midline under the bladder neck. If the anterior vaginal prolapse results from a lateral detachment of the endopelvic fascia from the lateral pelvic sidewall, however, better results will be obtained by performing a lateral repair. In this technique, the endopelvic fascia is reattached to the arcus tendineus fasciae pelvis through what is referred to as a paravaginal defect repair operation.Posterior Colporrhaphy:Repair of posterior vaginal prolapse for rectocele and enterocele is also performed vaginally using posterior colporrhaphy. In a rectocele repair, the posterior vagina is opened, the rectum is dissected away from the pararectal fascia, and the levator ani muscles are plicated over the rectum in the midline, after which the vaginal epithelium is closed. Because of concern over postoperative dyspareunia, recent modifications of posterior colporrhaphy have included site-specific repair.Le Fort's operationIn older women who are no longer sexually active a simple procedure for reducing prolapse is a partial colpocleisis. The classic procedure was described by Le Fortand involves the removal of a strip of anterior and posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other.The Goodall-Power modification of the Le Fort operation allows for the removal of a triangular piece of vaginal wall beginning at the cervical reflection or 1 cm above the vaginal scar at the base of the triangle, with the apex of the triangle just beneath the bladder neck anteriorly and just at the introitus posteriorly. This procedure works well for relatively small prolapses, whereas the Le Fort is best for larger ones.
Fothergill's operation
Abdominal Sling operation
Vaginal hysterectomy with pelvic floor repair
Ring pessary
Miscellaneous (Gynae)