Prolapse and prolapse of the internal genital organs (genital prolapse). What is genital prolapse and what are the treatments? Symptoms of prolapse and prolapse of the genital organs

In women over 50, genital prolapse occurs in almost 50% of cases. Severe forms of this pathology require surgical intervention, which helps to significantly improve the quality of life of a woman.

What is genital prolapse

Genital prolapse is a prolapse of the internal genital organs in women. This pathology is common, and more than 15% of operations in gynecology are carried out precisely because of genital prolapse.

Notably, the prevalence of genital prolapse varies by geography. So, for example, in India, this problem is too common (almost epidemic), and in the United States, according to various estimates, genital prolapse occurs in 15 million women.

With age, the likelihood of developing genital prolapse increases, but not only elderly women suffer from this pathology. According to statistics, among women under 30 years of age, genital prolapse occurs in 10% of cases; in women from 30 to 45 years old - in 40%; in women after 50 years, genital prolapse is diagnosed in every second.

Often the disease begins in the reproductive age and, as a rule, is progressive. At first, women often do not pay attention to this, however, with the development of the pathological process, functional disorders also deepen, which cause physical problems. Pathology is complicated to the point that a woman can become partially or completely disabled.

Prolapse of the genitals - the main causes

In the development of genital prolapse, both physical and genetic and psychological factors play an important role. Among the causes and factors that negatively affect the state of the pelvic floor, the following can be distinguished:

age;
heredity;
heavy physical work;
pelvic injury;
birth trauma;
increased intraperitoneal pressure;
scars after surgical interventions;
inflammatory diseases;
changes in the production of sex hormones;
failure of the pelvic floor muscles;
other reasons.

The leading factors in the development of genital prolapse are increased intraperitoneal pressure and failure of the pelvic floor muscles. There are four main reasons for this problem, namely:

pelvic floor injury (most often during childbirth);
systemic insufficiency of connective tissues, which manifests itself in the form of hernias or prolapses of other internal organs;
hormonal changes (impaired synthesis of steroid hormones);
chronic metabolic diseases.

With an increase in intraperitoneal pressure, the organs begin to be squeezed out of the pelvic floor. If any organ is located entirely inside the extremely expanded pelvic floor, then, having lost any support, it is squeezed out through the pelvic floor.

With the omission of the anterior wall of the vagina and bladder, a cystocele is formed, which increases under the influence of its own internal pressure. Thus, a vicious circle is formed, and over time, the woman develops urinary incontinence (it is noted in every second woman with genital prolapse).

Similarly, a cystocele is formed rectocele - a combination of prolapse of the posterior wall of the vagina and rectum. Complications from the rectum and colon are formed in every third woman with genital prolapse.

Classification of genital prolapse

There is the following classification of genital prolapse:

I degree- the cervix descends no more than half the length of the vagina.
II degree- the cervix and / or the walls of the vagina descend to the entrance to the vagina.
III degree- the cervix and / or the walls of the vagina descend beyond the entrance to the vagina, and the body of the uterus is located above it.
IV degree- the entire uterus and / or the walls of the vagina are outside the entrance to the vagina.

There is also a more modern standardized classification of genital prolapse POP-Q (Pelvic Organ Prolapse Quantification). It has been adopted by many urogynecological societies around the world. It is used in the description of most studies that are devoted to this topic. This classification is quite difficult to understand, but it has a number of advantages in establishing an accurate diagnosis and prescribing the optimal treatment regimen.

Symptoms of genital prolapse

At the initial stage, genital prolapse may not manifest itself in any way. Women do not experience any uncomfortable or painful conditions that would make her seek medical help.

With the progression of pelvic organ prolapse, women may feel a foreign body in the area of the vulvar ring, they are worried about the feeling of discomfort and heaviness in the perineum and lower abdomen. As a rule, in the evening the feeling of discomfort intensifies, and after rest and repositioning of the organs, it disappears.

The main symptoms of genital prolapse include:

painful intercourse;
vaginal pain;
feeling of pressure;
pain in the perineum when standing up;
discomfort when sitting for a long time;
frequent aching pain in the lower back, radiating to the groin;
bleeding or bleeding;
irritation;
protrusion from the gap of the vaginal wall;
heaviness (in the vaginal area);
urinary retention;
difficulty urinating;
weak jet pressure;
Urinary incontinence with small emotional or physical exertion.

As a rule, with such a pathology, patients do not feel severe pain. Only pronounced forms of rectocele, enterocele can give episodic pain in the abdomen due to traction of the mesentery. With acute urinary retention, a woman has severe pain in the lower abdomen. Most women with severe genital prolapse have sexual dysfunction.

With genital prolapse, the likelihood of developing infectious diseases increases, so patients often complain of recurrent colpitis, the appearance of leucorrhoea. A prolapsed uterus, which is often in contact with linen, can lead to the formation of ulcers on the mucous membranes.

Diagnosis of genital prolapse

Diagnosis of prolapse of the female genital organs includes the following activities:

collection of anamnesis;
gynecological examination;
transvaginal ultrasound;
urodynamic study;
instrumental research.

Consider the diagnostic procedures for this pathology in more detail.

When collecting an anamnesis, doctors are interested in the features of the course of childbirth, as well as the presence of extragenital diseases, which may be accompanied by an increase in intra-abdominal pressure. The surgeries, injuries and other diseases that could adversely affect the woman's health are specified.

During the physical examination, the main diagnostic method is a two-handed gynecological examination. During the examination, the doctor determines the degree of prolapse of the walls of the vagina or uterus and the presence of defects in the urogenital diaphragm. In case of prolapse of the uterus and vaginal walls, stress tests are mandatory, as well as tests when modeling the correct position of the genitals. During a rectovaginal examination, the doctor receives information about the condition of the anal sphincter and the severity of the rectocele.

Instrumental studies for genital prolapse include the following activities:

Transvaginal ultrasound. It is necessary to conduct a transvaginal ultrasound of the uterus and appendages. Detection of changes in the internal genital organs can expand the scope of the operation in the surgical treatment of prolapse before their removal. Modern possibilities of ultrasound diagnostics allow obtaining additional information about the state of the sphincter of the bladder, paraurethral tissues. This should also be taken into account when choosing a method of surgical treatment. Ultrasound for assessing the urethrovesical segment is superior in informativeness to cystography, and therefore, radiological examination methods are used for limited indications.
Urodynamic study. A combined urodynamic study in genital prolapse is performed to study the contractility of the detrusor, as well as the closing ability of the urethra and sphincter. In women with severe prolapse of the uterus and vaginal walls, an adequate study of the functions of urination is difficult due to the simultaneous dislocation of the anterior vaginal wall and the posterior wall of the bladder. When conducting a comprehensive urodynamic study, the patient is located in the gynecological chair. Special sensors are attached to show the pressure in the bladder and intra-abdominal pressure. After some time, the patient is transferred to the uroflowmeter, where the study begins, which lasts 20-30 minutes. This procedure does not require special preparation and is performed on an empty bladder. Immediately before or immediately after the study, an antibiotic is always prescribed to prevent urinary infection. A comprehensive urodynamic study for patients with genital prolapse reveals latent urinary incontinence, overactive bladder, and the degree of damage to the lower urinary tract, which is useful for predicting the results of surgery and other treatments for genital prolapse. As a result of this study, clearly form the patient's expectations - to explain how the process of urination will occur after the restoration of the anatomy of the pelvic organs
Endoscopic research methods. Instrumental diagnostics for genital prolapse includes the performance of endoscopic examinations of the uterus, bladder and rectum. For these purposes, other specialists can be involved - a urologist and a proctologist. Depending on the suspicion of the causes of the development of genital prolapse, the patient undergoes hysteroscopy, cystoscopy and rectoscopy.

After performing all types of research, a council of doctors carefully examines the information received and establishes a diagnosis, on the basis of which it prescribes an acceptable treatment regimen.

Treatment of genital prolapse

The main goal of treatment is to restore the anatomy of the perineum and pelvic diaphragm, as well as the normal functioning of adjacent organs. Indications for hospitalization of a woman are a violation of the functions of adjacent organs, prolapse of the vaginal walls of the 3rd degree, complete prolapse of the uterus and vaginal walls, as well as a pronounced progression of the disease, which requires medical intervention.

Treatment of genital prolapse is non-drug, medical and surgical.

Non-drug treatment of genital prolapse. Uncomplicated stages of genital prolapse can be treated and non-drug methods (in particular, we are talking about the prolapse of the uterus 1 and 2 degrees). With the help of physical therapy, special exercises, you can significantly strengthen the muscles of the pelvic floor. As a rule, the doctor prescribes to the patient a set of exercises that must be performed regularly to achieve the goal. In addition, a woman may be advised to use special vaginal applicators for electrical stimulation of the pelvic floor muscles.
Medical treatment. With an imbalance of hormones, control of estrogen in the blood is necessary. With its shortage, a woman is prescribed local estrogens, for example, in the form of suppositories or a vaginal cream. In case of problems with the work of the intestines, a woman is prescribed drugs that normalize peristalsis.

With the prolapse of the uterus 3 and 4 degrees and the walls of the vagina, the treatment of genital prolapse is surgical. The goal of surgical treatment is to eliminate the violation of the anatomical and functional disorders of the pelvic organs.

When forming a surgical program, in each case, a basic surgical operation is performed to create fixation of the walls of the vagina, as well as surgical correction of functional disorders.

The operation for genital prolapse is performed using the following surgical approaches:

vaginal access. In this case, a vaginal hysterectomy is performed.
laparotomy access. The operations of vaginopexy with own ligaments, aponeurotic fixation, and sometimes sacrovaginopexy are common.

Types of surgical treatment of genital prolapse

Depending on the degree of prolapse of the reproductive organs, a woman is offered the following types of surgical intervention:

Vaginal extraperitoneal colpopexy. This operation is performed under conduction, epidural, intravenous or endotracheal anesthesia. The doctor inserts a urinary catheter, and then an incision is made in the vaginal mucosa. During the operation, the anterior wall of the rectum is mobilized, and a mesh prosthesis of the original form is installed under the wall of the vagina. Then the vaginal mucosa is sutured with a continuous suture, and the excess mesh prosthesis is cut off subcutaneously, after which the vagina is tightly packed. The duration of such an operation does not exceed 90 minutes, and blood loss is 50-100 ml. The tampon and catheter are removed the next day.
Laparoscopic sacrocolpopexy. In this case, endotracheal anesthesia is used for anesthesia. The posterior peritoneum is opened all the way from the promontorium to the Douglas space. The elements of the rectovaginal septum (the anterior wall of the rectum, the posterior wall of the vagina) are isolated to the level of the muscles that lift the anus. With laparoscopic intervention, early activation in the postoperative period is possible. As a rule, the average postoperative period is 3-4 days, and the duration of outpatient rehabilitation is up to 6 weeks.

After treatment, patients should follow the following recommendations:

restriction of weight lifting no more than 5-7 kg for 6 weeks;
avoid sexual intercourse for 6 weeks;
rest for 2 weeks, after which light physical activity is allowed.

In the future, women should avoid lifting more than 10 kg, and also treat respiratory diseases accompanied by cough in a timely manner. In addition, cycling, exercise bike, rowing is not recommended. For a long time, a woman is prescribed estrogen-containing drugs in the form of vaginal suppositories. Depending on the situation, treatment of urination disorders is prescribed.

All materials on the site are prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative and are not applicable without consulting the attending physician.

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.
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

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, 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, one can note the presence of common diseases and the absence of suspicion of oncological processes in the uterus.

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.

Types of operations and course of surgical intervention

Anterior colporrhaphy

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.

Posterior colporrhaphy

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.

Fixation of the uterus

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.

Median colporrhaphy (Lefort-Neigebauer operation)

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.

Removal of the uterus (hysterectomy)

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.

Recovery period

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:

Sitting up to 3-4 weeks;
Push during bowel movements (it is necessary to avoid constipation, in the first days the stool should be liquid);
Be sexually active for 2 months;
Go in for sports, lift weights, go to the pool until full recovery;
Within 2 months, take a bath or visit a sauna, a bath.

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.

Operation cost

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.

Figure 1 shows the anatomy of the pelvis, providing adequate work of muscles and ligaments. If they 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. A schematic representation of various types of prolapse is shown in Figure 2.
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.
Reasons for development
genital prolapse
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.
Symptoms of genital prolapse
The most common complaint with genital prolapse is the sensation 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.
Genital prolapse treatment methods
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 treatment
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.
Surgical treatments
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.
Complications of surgical treatment
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. It was described in detail earlier in this issue of the journal.
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.
In conclusion, it should be noted that the development of modern medical technologies makes it possible to provide highly effective assistance in the treatment of almost any genital prolapse. 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.

Omissions and prolapses of the internal genital organs belong to the pathology with which the doctor often encounters, but does not always correctly and timely resolve the issue of treatment and rehabilitation of such patients. 15% of gynecological operations are performed specifically for this pathology.

The prevalence of genital prolapse is striking: in India, this disease is, one might say, the nature of an epidemic, and in America, about 15 million women suffer from this disease.

There is a generally accepted opinion that genital prolapse is a disease of the elderly. This is not at all true if we consider that out of 100 women under the age of 30, this pathology occurs in every tenth. At the age of 30 to 45 years, it occurs in 40 cases out of 100, and after 50 years it is diagnosed in every second woman.

The disease often begins in reproductive age and is always progressive. Moreover, as the process develops, functional disorders also deepen, which often cause not only physical suffering, but also make these patients partially or completely disabled.

For ease of understanding, the omission and prolapse of the internal genital organs should be considered as a “hernia”, which is formed when the closing apparatus - the pelvic floor - has lost the ability to contract so much that individual organs or their parts do not fall into the projection of the supporting apparatus.

It is generally accepted that in the normal position, the uterus is located along the wire axis of the pelvis. At the same time, the body of the uterus is tilted forward, its bottom does not protrude above the plane of the entrance to the small pelvis, the cervix is at the level of the interspinous line. The angle between the body of the uterus and the cervix is more than a straight one and is open anteriorly. The second angle between the cervix and the vagina is also directed anteriorly and is equal to 70-100°. Normally, the uterus and its appendages retain a certain physiological mobility, which contributes to the creation of conditions for their normal functioning, as well as the preservation of the architectonics of the pelvic organs.

You will get acquainted with the causes of this disease, clinical manifestations and treatment options for genital prolapse by flipping through the pages of our website. In the "Make" section, the methods of plastic surgery performed with the prolapse and prolapse of the internal genital organs are widely and clearly presented.

Causes of genital prolapse

Prolapse of the genitals- the disease is polyetiological and physical, genetic and psychological factors play an important role in its development.

Of the reasons that affect the state of the pelvic floor and the ligamentous apparatus of the uterus, the following can be especially distinguished: age, heredity, childbirth, birth injuries, hard physical work and increased intraperitoneal pressure, scars after inflammatory diseases and surgical interventions, changes in the production of sex steroids that affect the response of smooth muscles, the inability of the striated muscles to ensure the full value of the pelvic floor, etc. An always present factor in the development of this pathology is an increase in intra-abdominal pressure and insolvency of the pelvic floor muscles, in the occurrence of which 4 main causes can be distinguished, although their combination is also possible.

Post-traumatic pelvic floor injury (most common during childbirth).
Insolvency of connective tissue structures in the form of "systemic" insufficiency (manifested by the presence of hernias of other localizations, prolapse of other internal organs).
Violation of the synthesis of steroid hormones.
Chronic diseases, accompanied by a violation of metabolic processes, microcirculation.

Under the influence of one or more of these factors, functional failure of the ligamentous apparatus of the internal genital organs and the muscles of the pelvic floor occurs. With an increase in intraperitoneal pressure, the organs begin to be squeezed out of the pelvic floor. If any organ is located entirely inside the extremely expanded pelvic floor, then, having lost any support, it is squeezed out through the pelvic floor. If part of the organ lies inside, and part is outside the hernial orifice, then the first part of it is squeezed out, while the other is pressed against the supporting base. Thus, the part that is still outside the hernial orifice keeps the other from being squeezed out - and the more, the stronger the intra-abdominal pressure.

Close anatomical connections between the bladder and the vaginal wall contribute to the fact that against the background of pathological changes in the pelvic diaphragm, including, of course, the urogenital one, the anterior vaginal wall prolapses, which entails the bladder wall. The latter becomes the contents of the hernial sac, forming a cystocele.

The cystocele also increases under the influence of its own internal pressure in the bladder, resulting in a vicious circle. Similarly, a rectocele is formed. However, if the prolapse of the anterior vaginal wall is almost always accompanied by a cystocele, expressed to one degree or another, then the rectocele may be absent even if the vaginal walls prolapse, which is due to a looser connective tissue connection between the vaginal wall and the rectum.

The hernial sac, in certain cases, with a wide recto-uterine or vesico-uterine space, may also include intestinal loops.

Classification of displacement of the vagina and uterus

Downward displacement of the vagina:

prolapse of the anterior wall of the vagina, posterior or both together; in all cases, the walls do not extend beyond the entrance to the vagina;
partial prolapse of the anterior vaginal wall and part of the bladder, posterior and part of the anterior wall of the rectum, or a combination of both; the walls go outward from the vaginal entrance;
complete prolapse of the vagina, often accompanied by prolapse of the uterus.

Downward displacement of the uterus:

prolapse of the uterus or its cervix - the cervix is lowered to the level of the entrance to the vagina;
partial (beginning) prolapse of the uterus or its cervix; the cervix, when straining, protrudes beyond the genital slit, and such a beginning prolapse of the uterus most often manifests itself with physical exertion and an increase in intra-abdominal pressure (straining, coughing, sneezing, lifting weights, etc.);
incomplete prolapse of the uterus: outside the genital slit, not only the cervix, but also part of the body of the uterus is determined;
complete prolapse of the uterus: outside the genital gap (between the fallen walls of the vagina), the entire uterus is determined, while you can bring the index and middle fingers of both hands over the bottom of the uterus.

Symptoms of genital prolapse

The course of prolapse and prolapse of the vagina and internal genital organs is characterized by a slow progression of the process, although it can be observed relatively quickly. Recently, there has been some "rejuvenation" of patients.

In almost all cases, there are functional disorders of almost all organs of the small pelvis, which necessarily requires their identification and treatment.

When the genital organs are prolapsed, a symptom complex often develops, where, along with violations of the functions of the genital organs, urological and proctological complications come to the fore, which in some cases force patients to seek help from doctors of related specialties (urologists, proctologists). But the main symptom of prolapse of the uterus or its cervix, the walls of the vagina and neighboring organs is the formation detected by the patient herself, protruding from the genital slit.

The surface of the prolapsed part of the genital organs takes the form of dull-shiny, dry skin with cracks, abrasions, and then deep ulcerations (bedsores) appear in a number of patients. This happens due to the constant trauma to which the prolapsed vaginal wall is exposed when walking.

In the presence of trophic ulcers, infection of the adjacent tissue is possible, with the ensuing consequences. When the uterus is displaced downward, normal blood circulation in the small pelvis is disturbed, congestion occurs, then pain develops, a feeling of pressure in the lower abdomen, discomfort, pain in the lower back, sacrum, which increase during and after walking. Stagnation is characterized by a change in the color of the mucous membrane up to cyanosis, swelling of the underlying tissues.

Characteristic are changes in menstrual function (algomenorrhea, hyperpolymenorrhea), as well as hormonal disorders. Often these patients suffer from infertility, although the onset of pregnancy is considered quite possible.

With prolapse of the genital organs, sexual life is possible only after the reduction of the prolapsed organ.

Concomitant urological disorders are extremely diverse, which cover almost all types of urinary disorders. With pronounced degrees of omission and prolapse of the genital organs with the formation of a cystocele, the most characteristic is difficult urination, the presence of residual urine, stagnation in the urinary system and, as a result, infection of the lower, first, and with the progression of the process, its upper sections. Long-term complete prolapse of the internal genital organs can cause obstruction of the ureters, hydronephrosis, hydroureter. A special place is occupied by the development of stress urinary incontinence. More often develop, already for the second time, pyelonephritis, cystitis, urolithiasis, etc. Urological complications are observed in almost every second patient.

Quite often, the disease is manifested by proctological complications that develop in every third patient. The most frequent of them are constipation, and in some cases they are the cause of the disease, in others - a consequence and manifestation of the disease. The characteristic symptoms include dysfunction of the large intestine, mainly by the type of colitis. A painful manifestation of the disease is incontinence of gases and feces, which occur either as a result of traumatic damage to the tissues of the perineum, the wall of the rectum and its sphincter, or as a result of deep functional disorders of the pelvic floor.

This group of patients often has varicose veins, especially of the lower extremities, which is explained, on the one hand, by a violation of venous outflow as a result of changes in the architectonics of the small pelvis, and on the other hand, by insufficiency of connective tissue formations, manifested as "systemic" insufficiency.

More often than with other gynecological diseases, pathology of the respiratory organs, endocrine disorders are noted, which can be considered as a predisposing background.

Diagnosis of prolapse and prolapse of internal genital organs

A colposcopic examination is mandatory.

The presence of a cysto- or rectocele is determined. A preliminary assessment of the functional state of the sphincter of the bladder and rectum is carried out (i.e., is there urinary incontinence, gases during stress, for example, when coughing).

Research should include:

general urine analysis;
bacteriological examination of urine;
excretory urography;
urodynamic study.

Patients with prolapse and prolapse of the internal genital organs should undergo a rectal examination, in which attention is paid to the presence or severity of the rectocele, the state of the rectal sphincter.

In cases where organ-preserving plastic surgery is supposed to be performed, as well as in the presence of concomitant uterine pathology, special methods should be included in the research complex:

hysteroscopy with diagnostic curettage,
hormonal research,
examination of smears to determine the flora and degree of purity, as well as atypical cells,
analysis of cultures of vaginal discharge, etc.

Treatment of prolapse and prolapse of the internal genital organs

Of particular difficulty is the choice of treatment tactics, the determination of a rational method of surgical assistance. It is determined by a number of factors:

the degree of prolapse of the internal genital organs;
anatomical and functional changes in the organs of the reproductive system (the presence and nature of concomitant gynecological pathology);
the possibility and necessity of maintaining or restoring reproductive, menstrual function;
features of dysfunction of the colon and rectal sphincter;
age of patients;
concomitant extragenital pathology and the degree of risk of surgical intervention and anesthesia.

Conservative treatment of prolapse and prolapse of the internal genital organs

With prolapse of the internal genital organs, when the latter do not reach the vestibule of the vagina and in the absence of dysfunction of neighboring organs, conservative management of patients is possible, including:

kegel exercises,
physiotherapy according to Yunusov (voluntary contraction of the pelvic floor muscles during urination until the flow of urine stops),
lubrication of the vaginal mucosa with an ointment containing estrogens, metabolites,
use of pessaries, medical bandage.

Surgical treatment of prolapse and prolapse of the internal genital organs

With more severe degrees of prolapse and prolapse of the internal genital organs, the treatment is surgical. It should be noted that for no other pathology, so many methods of surgical aid have been proposed as with this one. There are several hundred of them, and each has, along with certain advantages, disadvantages, which is mainly expressed in relapses of the disease. The latter most often occur during the first 3 years after the intervention and reach 30-35%.

All methods of treatment can be combined into groups according to one main feature - which anatomical formation is used and strengthened to correct the position of the internal genital organs.

The most common surgical options.

Group I. Operations aimed at strengthening the pelvic floor - colpoperineolevathoroplasty. Given that the pelvic floor muscles are always pathogenetically involved in the process, colpoperineolevathoroplasty should be performed in all cases of surgical intervention as an additional or basic benefit. This also includes plastic surgery on the anterior wall of the vagina, aimed at strengthening the vesico-vaginal fascia.
II group. Operations with the use of various modifications of shortening and strengthening of the round ligaments of the uterus and fixation of the uterus using these formations. The most typical and frequently used is the shortening of the round uterine ligaments with their fixation to the anterior surface of the uterus. Shortening of the round ligaments with their fixation to the posterior surface of the uterus according to Webster-Bundy-Dartig, shortening of the round ligaments of the uterus through the inguinal canals according to Alexander-Adams, ventrosuspension of the uterus according to Dolery-Gilliams, ventrofixation of the uterus according to Kocher, etc.

However, this group of operations is considered ineffective, since it is after them that the highest percentage of relapses of the disease is observed. This is due to the fact that obviously insolvent tissue is used as a fixing material - the round ligaments of the uterus.

III group. Operations aimed at strengthening the fixing apparatus of the uterus (cardinal, sacro-uterine ligaments) by stitching them together, transposition, etc. However, these operations, despite the fact that they imply the fixation of the uterus due to the most powerful ligaments, do not completely solve the problem, since they eliminate one link in the pathogenesis of the disease. This group includes the "Manchester operation", which is considered one of the most effective methods of surgical treatment. The operation is traumatic, as it deprives patients of reproductive function.
IV group. Operations with the so-called rigid fixation of prolapsed organs to the walls of the pelvis (to the pubic bones, to the sacrum, sacrospinal ligament, etc.).
Group V. Operations with the use of alloplastic materials to strengthen the ligamentous apparatus of the uterus and its fixation. They did not justify themselves enough, since they did not reduce the number of relapses of the disease as a result of frequent rejection of the alloplast, and also led to the development of fistulas.
VI group. Operations aimed at partial obliteration of the vagina (median colporrhaphy of Lefort-Neigebauer, vaginal-perineal cleisis - Labgardt's operation).
VII group. The radical methods of surgical treatment of prolapse of the internal genital organs include vaginal extirpation of the uterus.

All of the above operations are performed through the vagina or through the anterior abdominal wall.

In recent years, combined surgical treatment is more often used, which is preferred by most gynecologists. These interventions involve strengthening the pelvic floor, plastic surgery of the vaginal walls, and fixation of the uterus, cervical stump or vaginal dome, mainly by one of the above methods. But, unfortunately, this does not always contribute to the complete recovery of patients, since sometimes functional disorders of neighboring organs remain, especially the organs of the urinary system.

Anterior colporrhaphy

Anterior colporrhaphy is an operation performed when the anterior wall of the vagina is lowered.

Anterior colporrhaphy with bladder reposition

With a significant omission of the anterior wall of the vagina, the bladder also descends over time, forming a cystocele, therefore, using only the anterior colporrhaphy, a good result cannot be achieved.

Colpoperineorrhaphy

With the omission of the posterior wall of the vagina and rectum, with long-standing ruptures of the perineum, the integrity of the pelvic floor, and sometimes the external sphincter of the anus and rectum, is broken. In such patients, the genital slit gapes, the posterior wall of the vagina, and over time, the rectum descends. In advanced cases, the vagina turns inside out and the uterus falls outside the genital gap, falls out. Prolapse and prolapse of the genital organs contribute to hard physical work (weight lifting), rapid and rapid weight loss, exhaustion and aging of the body. As the genitals prolapse, as well as the bladder and rectum, some patients develop urinary incontinence, especially when coughing, sneezing, laughing, straining, and profuse vaginal discharge appears. Allocations (leucorrhea), flowing onto the external genitalia, can cause irritation of adjacent skin areas. If the integrity of the external sphincter of the anus is violated, patients suffer from partial or complete incontinence of gases and feces. These sufferings are even more intensified if the rectum is also torn.

Consequently, the surgical restoration of the integrity of the perineum is advisable in some patients to prevent the painful symptoms of prolapse and prolapse of the genital organs, and in others to eliminate these sufferings.

Usually the prolapse of the anterior and posterior walls of the vagina occurs simultaneously with the prolapse of the bladder and rectum; while the uterus descends. Surgical treatment for prolapse of the genital organs should, as a rule, consist of three stages: anterior colporrhaphy, colpoperineorrhaphy and one of the operations that correct the position of the uterus: ventrosuspension, ventrofixation or shortening of the uterine ligaments.

Fixation of the uterus with recto-uterine ligaments

The operation of fixing the uterus with the help of recto-uterine ligaments is performed in addition to the anterior colporrhaphy of colpoperineorrhaphy.

Median colporrhaphy of Lefort-Neugebauer

Carrying out this operation is rational in case of complete prolapse of the uterus in senile women who do not live sexually, for whom a more complex operation is not indicated for health reasons.

The essence of the operation of the median colporrhaphy, as evidenced by its name, is reduced to suturing the symmetrical wound surfaces of the anterior and posterior walls of the vagina after excision of flaps of the same size and shape from them.

The operation is technically simple, it is greatly facilitated by correctly performed infiltration anesthesia.

Labgardt operation (incomplete vagina-perineal cleisis)

This operation is carried out for women of senile age who do not live sexually, both with complete and with incomplete prolapse of the uterus; it gives more stable results and is more physiological than median colporrhaphy.

The main points of the Labgardt operation after preparation of the operating field and thorough anesthesia are as follows:

cutting out a flap from the walls of the vagina;
layer-by-layer suturing of an extensive wound (stitching of the peri-vaginal and peri-rectal tissue) and the connection of the muscles that lift the anus;

connection of the edges of the skin incision of the perineum.

Vaginal extirpation of the uterus with simultaneous anterior colporrhaphy and colpoperineorrhaphy

This operation is performed for elderly women with uterine prolapse, an elongated hypertrophied cervix and everted vagina, as well as with incomplete uterine prolapse, if for some reason other methods of surgical treatment are undesirable or unreliable (obesity, glandular-muscular hyperplasia, erosion and other precancerous conditions). cervix). With complete prolapse of the uterus, extirpation of the organ is indicated for women aged 45-50 years, if the preservation of the uterus is irrational (erosion, glandular-muscular hyperplasia of the cervix, ectropion, endometrial polyposis and other precancerous diseases of the body and cervix).

The main points of the operation of vaginal extirpation of the uterus in case of its prolapse after the preparation of the surgical field are as follows:

maximum reduction of the cervix with forceps and infiltration of the perivaginal and perivesical tissue with a 0.25% solution of novocaine for the purpose of hydropreparation;
carrying out delineating incisions and separating a triangular flap from the anterior wall of the vagina;
separating the edges of the vagina to the sides and the bladder from the cervix;
opening of the peritoneum of the vesicouterine cavity;
simultaneous clamping and cutting of the fallopian tubes, own ligaments of the ovary and round ligaments of the uterus, first on one side, then on the other side;
clamping and cutting of the uterine vessels on both sides;
clamping and cutting of the recto-uterine ligaments and recto-uterine folds of the peritoneum;
dissection of the wall of the posterior part of the vaginal fornix;
replacement of clamps with ligatures;
suturing the posterior wall of the bladder;
connection of the edges of the wound of the anterior wall of the vagina;
cutting out and separating a triangular flap from the posterior wall of the vagina;
suturing the anterior wall of the rectum and the imposition of submersible sutures on the paravaginal and perirectal tissue;
connecting the muscles that lift the anus with two ligatures;
connection of the wound edges of the vagina and perineum with knotted catgut sutures.

Vaginal extirpation of the uterus with simultaneous extirpation of the vagina according to Feit-Okinchits

Panhysterectomy with preliminary complete extirpation of the vagina is performed with complete prolapse of the uterus in elderly women who are not sexually active. It is indicated for relapses after plastic surgery.

Technically, the operation is simple.

The main points of panhysterectomy with simultaneous complete extirpation of the vagina after the preparation of the surgical field are as follows:

fixing the cervix with forceps and bringing it down;
thorough infiltration anesthesia with novocaine solution in addition to the main method of anesthesia;
a circular outlining incision of the vaginal wall along the border of its opening and its separation up to the cervix;
separation of the bladder and opening of the peritoneum of the vesicouterine cavity;
removal of the uterus from the abdominal cavity;
dissection on the clamps of the ligaments of the uterus and blood vessels;
dissection of the recto-uterine fold of the peritoneum and removal of the uterus;
replacement of clamps with ligatures;
closure of the abdominal cavity with extraperitoneal location of the stumps;
stitching of the perivaginal tissue with catgut knotted circular sutures superimposed by a dotted line in 4-5 floors;
connection of the edges of the wound.

Prevention of genital prolapse

Rational mode of work and education, starting from childhood, especially puberty.
Rational tactics of conducting pregnancy and childbirth. It is known that not only the number of births, but also their nature has a decisive influence on the occurrence of prolapse and prolapse of the internal genital organs and stress urinary incontinence. During childbirth, various intrapelvic injuries of the lumbosacral plexus occur, causing paralysis of the obturator, femoral and sciatic nerves and, as a result, urinary and fecal incontinence. One should strive to use such a delivery technique in which the musculature of the pelvic floor and its innervation would be protected from damage during childbirth. Prolonged labor should not be allowed, especially in the second period. Anatomically and physiologically substantiated is the timely production of mediolateral episiotomy, predominantly right-sided, in which the integrity of the pudendal nerve is preserved and, therefore, the innervation of the pelvic floor muscles is disturbed to a lesser extent. The second important point is to restore the integrity of the perineum with the correct matching of tissues.
Prevention of purulent-inflammatory complications and rehabilitation measures aimed at a more complete restoration of the functional state of the pelvic floor and pelvic organs in the postpartum period - special physical exercises, laser therapy, electrical stimulation of the pelvic floor muscles using an anal electrode.