Vaginal prolapse after removal of the uterus: causes, symptoms, treatment, surgery. Features of surgical operations for uterine prolapse

Is uterine prolapse surgery or medication? The operation for the prolapse of the uterus allows you to more efficiently and fully cure the disease, as well as normalize the health of the patient. However, it is not always surgical treatment that is used in the treatment of pathology - often the treatment regimen for uterine prolapse includes taking medications, using physiotherapy, and performing therapeutic exercises that strengthen the muscles of the pelvic floor. Surgery for uterine prolapse is rarely prescribed, but for some women this method of treatment is necessary. So - how is the scheme of surgical treatment of uterine prolapse performed?

What is the prolapse of the reproductive organ

As gynecology says, uterine prolapse or prolapse is a pathological prolapse of the uterine cavity, as well as the cervix, which has unpleasant consequences for the patient.

Not only women of advanced and advanced age suffer from the disease, but also young girls. Most often, pathology is diagnosed in women whose age varies between 30-45 years.

However, the definition of prolapse refers to the prolapse of not only the uterine cavity, but also the intestines and bladder. For a certain number of reasons, the pelvic floor, or rather its layers, are no longer able to contain the internal organs.

At the same time, when contacting a doctor, the gynecologist notices that the genital organ and its neck are located much lower than their natural presentation, and sometimes even fall out into the vaginal cavity. Of course, in this case, the woman needs urgent treatment, otherwise this pathology will cause a large number of complications for the patient's health.

What causes partial or complete prolapse of the uterus? The uterine fundus may begin to sink for a number of reasons, which are important to pay special attention to when making a diagnosis.

• diseases associated with metabolism;
• damage to the pelvic floor, which appear as a result of injuries;
• violation of the production of steroid types of hormones by the female body;
• systemic underdevelopment of the base of the connective tissue (for example, the development of a hernia in a woman, varicose veins, joint dysplasia, and so on);
• tribal activity;
• the age of the patient;
• genetic predisposition;
• frequent and prolonged constipation;
• excessive obesity.

It is known that prolapse of the uterus causes serious complications for women's health. Therefore, it is recommended to start treating the disease immediately after the discovery of its signs, otherwise the consequences of uterine prolapse will be deplorable.

Symptoms

Uterine prolapse is considered a progressive disease, but in some cases it happens quickly and in others slowly. Even the first and minor signs, if left untreated, will eventually cause prolapse of the reproductive organ, so a woman should not hesitate.

Symptoms that characterize the course of the disease can be called:

1. Pain and discomfort in the lower abdomen. This symptom can be noticed immediately, since the appearance of pulling pain and discomfort in the abdomen, as well as stretching of the lower back, is difficult to miss. According to their characteristics, these symptoms resemble the onset of menstruation, so if they do not appear in the near future, you must be wary. Also, if the patient has prolapse, she is attacked by severe pain while walking or lifting weights (even minor ones). In addition, such a patient should not have sexual intercourse, since not only will it not be pleasurable, but it will also become almost impossible.
2. Sensation of a foreign object inside. A woman, when the uterus is lowered, will feel as if something is interfering with her inside. In addition, this phenomenon will be accompanied by the release of whites, blood or blood clots. Also at this time, the lady will be able to feel the prolapsed neck, and sometimes the uterus itself through the vagina.
3. Violation of menstruation. During the prolapse of the genital organ, the patient notices a long and heavy menstruation.
4. Violation of urination. As the uterus descends into the vagina, it compresses the urinary tract. This leads to incomplete emptying of the bladder, difficulty urinating, urinary incontinence during exertion or laughter.
5. Ulcers at the base of the vagina. Due to constant pressure on the vagina, it becomes dry, and its surface is covered with small cracks that appear as a result of frequent injury to the membrane.

If the integrity of the vascular network is violated, bleeding is possible even after the passage of the menstrual cycle. In this case, it can appear during an overstrain of the body, lifting weights or performing light gymnastic exercises.

How is the operation performed

If wearing a bandage, following physical therapy and taking certain types of medications do not help get rid of the pathology, the doctor decides to perform an operation to return the uterus to a normal and natural state.

It is important to note that the operation to prolapse of the reproductive organ has certain pros and cons. However, if the woman's condition is critical, the doctor, without hesitation, decides to perform surgery.

• operations that can strengthen the pelvic muscles (as a rule, this is a two-stage operation called colpoperineolovatoroplasty);
• an operation performed on the uterine ligaments (it is a hemming and shortening of the ligaments of the uterus, which are located on its front wall);
• strong fixation of the uterine cavity to the walls or the pelvic floor;
• strengthening the ligaments of the uterus, which fix this reproductive organ;
• if the lowering is strong, which has a negative impact on the state of health, endoprostheses are used that fix the organ in the correct position;
• narrowing of the vaginal cavity, through which the uterus cannot descend;
• removal of the uterus, which can only be prescribed by the attending physician.

The operation is most often performed through the vaginal cavity, or using laparoscopy.

When a woman feels heaviness in the pubic region and pain in the vagina, in most cases gynecologists diagnose prolapse of the reproductive organ - prolapse.

This pathology can be insignificant, and then you can get by with conservative methods of eliminating the problem - gymnastics, hormonal drugs, wearing a bandage, and so on.

But in some cases, such a therapeutic tactic is not successful, and then surgical intervention is necessary.

Treatment of prolapse is necessary, because without it, the genital organ can completely fall out of the genital gap. In addition, the pathology can be complicated, and the consequences can be very serious.

What is it and why does it occur

The uterus is held in its natural position thanks to the muscles of the pelvic floor and its own ligamentous apparatus.

When muscle tone weakens, the genital organ shifts downward. Together with the uterus, the bladder and rectum can descend. In this case, signs of a violation of the excretory system are also added to the clinical picture of uterine prolapse - problems with urination, constipation, as well as urinary and fecal incontinence are possible.

For a more detailed picture of the disease, the following diagnostic measures will be required:

• hysterosalpingoscopy;
• bacterial culture of vaginal discharge;
• urine culture;
• excretory urography;

In addition to a gynecologist, a woman should consult a urologist and a proctologist to determine whether a cystocele or a rectocele is present.

It is important to differentiate prolapse from cystic formations in the vagina, fibroids, uterine eversion.

Types of surgery

To date, there are the following surgical interventions that are performed with prolapse:

• colporrhaphy. This operation consists in suturing a part of the vagina, as a result of which the vaginal canal narrows, and, consequently, the prolapse of the organs is inhibited. However, this type of surgery is not considered effective, since relapses after colporrhaphy account for 40% of all cases. There are three types of such an operation - anterior, posterior and Lefort-Neigebauer operation;
• vaginopexy(colpopexy). A minimally invasive procedure in which the vaginal wall is sutured to the abdomen. There are two types of this intervention - anterior and posterior. The first is carried out if there is a prolapse of the front wall, the second - respectively, when the back wall prolapses. It is also impossible to call this method effective, since relapses occur quite often;
• rigid fixation of the uterus. The essence of this intervention is the fixation of the lowered organs to the sacral bone or to the peritoneum. This operation can be performed abdominally or transvaginally. In some cases, a mesh prosthesis is used during the operation. The prosthesis is placed on the reproductive organ, and its ends are attached to the bone or to the peritoneum. The organ is fixed securely, and relapse is excluded;
• laparoscopy. The surgeon gets access to the internal organs through punctures in the abdominal cavity. The doctor sutures the reproductive organ to more fixed organs or shortens the muscle tissue by suturing the muscle fibers. For a stronger fixation in this case, a mesh can also be used;
• cervical plastic. This intervention can be carried out in different ways - cryodestruction, laser removal, radio wave method, surgical intervention. The doctor removes (for example, with a laser) the wedge-shaped part of the neck, forms the desired size and fixes it;
• hysterectomy. Removal of the uterus through the vagina. It is carried out most often in relation to women who have left the reproductive age. After this intervention, sexual activity remains possible;
• laparotomy. The uterus is pulled up by the surgeon through an abdominal incision. Scars after the operation remain not only on the uterus, but also on the woman's stomach.

For those women who have not yet fulfilled their reproductive function, it is better to consider colpography. This technology will ensure high chances for pregnancy in the future.

Women with already extinct reproductive function most often undergo surgery with the complete removal of the reproductive organ.

Preparation for the procedure

The preparatory period for prolapse surgery is not difficult, it consists of:

• consultations with specialists - gynecologist, urologist, proctologist, cardiologist;
• tests that will show the presence or absence of inflammation and infections in the genitourinary system, in the presence of infections, they should be treated;
• in the evening before the operation, it is necessary to clean the intestines;
• on the morning of the operation day, it is necessary to refuse breakfast, the intervention is carried out on an empty stomach.

How is the uterus sutured?

With prolapse, the uterus is sutured to the muscles to which it is attached.

In the past, such an intervention was fraught with re-stretching of muscle fibers. Currently, to prevent recurrence, I use a special mesh that will hold the uterus and prevent the muscles from stretching again.

The material from which the mesh is made is organic for the human body, therefore it does not cause side effects, and it also does not react with body fluids.

The operation to suture the uterus is most often performed using laparoscopy, so no adhesions, no scars, or other negative phenomena are observed.

The intervention is performed under general anesthesia, while the effect on the reproductive organs is insignificant, and recovery is quick and rarely accompanied by complications.

Recovery period

If we talk about how long the recovery after the operation lasts, then the rehabilitation period takes about a month and a half.

In order for him to go without complications, a woman must adhere to the following rules:

• exclude physical activity;
• do not take baths and do not visit baths and saunas;
• on the recommendation of a doctor, wear a bandage;
• do not lift weights - the maximum allowed weight during the recovery period is 1.5 kg;
• refuse from intimate contacts for the entire recovery period;
• Eat right to prevent constipation.

Prevention of postoperative complications depends on the discipline of the woman and her strict implementation of all doctor's recommendations.

Possible consequences

As a rule, operations to eliminate prolapse are not accompanied by complications and negative consequences, but in some cases the following difficulties may arise:

• problems with urination;
• scar inflammation (after laparotomy);
• bleeding;
• peritonitis;
• hematomas in the area of ​​the postoperative suture.

NOTE!

In the first two weeks after the intervention, spotting is considered normal and does not require treatment.

Maca prolapse is a pathology in which the uterus descends below the entrance to the vagina. In addition to problems with the genitals, this brings disruption of the bladder and rectum. With prolonged malposition of the pelvic organs, complications from the kidneys, intestines and other abdominal organs can often develop.

How difficult is it: surgery for uterine prolapse?

Nowadays, surgical interventions are increasingly being performed to restore the anatomical position of the pelvic floor organs through vaginal access. What does it mean? The surgeon makes an incision on the wall of the vagina, and through the resulting hole he can work with the muscles, ligaments and walls of the organs. According to indications, either the anterior or posterior wall of the vagina is dissected. Laparoscopic access (through holes in the abdominal wall), or laparotomy (dissection of the abdominal wall) can also be used.

Depending on the intended extent of the surgical intervention, local, epidural or general anesthesia may be used. Most often, surgeons make a choice in favor of the epidural method of anesthesia.

The volume of the operation is always associated with the degree of dysfunction of the pelvic organs, as well as the state of the muscles of the pelvic floor. Early surgical intervention is considered optimal, while the muscles have not yet lost their ability to contract. In this case, you can restore the anatomy by plasty with your own tissues.

With severe disorders, complete failure of the pelvic floor muscles, an operation using mesh implants and slings is indicated. The attitude of surgeons to these materials is ambiguous: with an active sexual life, late complications often occur. However, when this is the only way to restore the normal position of the uterus, bladder and rectum, there is no choice.

Full recovery after surgery is completed after 6 weeks, but after 2 weeks the woman is allowed to sit and conduct moderate physical activity. Lifting more than 6 kg is prohibited. Sex during the recovery period (6 weeks) should also be abstained, including without penetration into the vagina.

Types of operations and technique

The goal of surgical treatment is to firmly fix the walls of the vagina in a normal position, and, depending on the disturbed functions, additional fixation of the bladder and rectum.

Older women who do not plan to be sexually active often have colporrhaphy. During the operation, the walls of the vagina are sutured, the entrance is simply sewn up, which prevents the uterus from coming out. The advantage of this operation is technical simplicity. This relieves the patient of the need for complex anesthesia, and virtually eliminates blood loss. Recovery after colporrhaphy is also fast. Therefore, this treatment is chosen for patients with concomitant diseases of the heart and blood vessels, in the absence of an alternative.

Modern surgical treatment today is operations with Profit and TVT systems. The first is used to restore the strength of the pelvic floor, the second - to fix the bladder with. TVT is the use of an artificial (polypropylene) sling that supports the bladder without tension.

The Profit system is a polypropylene mesh and features of its location. It is installed either on the front wall of the vagina from the side of the internal organs, or on the back, or the vagina is completely wrapped around the outside with a mesh. The upper free sections of the mesh are attached to the pelvic floor muscles and ligaments of the pelvis.

The ligaments on which the uterus is suspended can also be shortened. In this case, the ligaments are also reinforced with mesh.

If uterine prolapse appeared immediately after childbirth, then plastic surgery can be performed without the use of strengthening materials. Reducing the size of the vagina is often enough for younger patients. But if necessary, the schemes described above can also be used.

Natalia Trohimets

One of the most difficult types of prolapse of the pelvic organs, in terms of surgical treatment, is prolapse of the dome of the vagina(posthystrectomy prolapse) Fig.1. This condition is often a consequence of the treatment of pelvic organ prolapse, which consists in the removal (extirpation) of the prolapsed uterus.

Figure 1. Prolapse of the dome of the vagina after removal of the uterus.

LECTURE FOR WOMEN WITH PROBLEM Vaginal prolapse after hysterectomy

Symptoms and causes of vaginal prolapse

The main and common symptom of prolapse of the walls of the vagina is the sensation of a foreign body in the perineum. When talking about their complaints, patients often use the following phrases: “something comes out of me”, “some kind of ball sticks out of the vagina”, “when I sit down, it seems to me that I am sitting on something”, “ something comes out of my vagina and rubs against my underwear”, etc. After removal of the uterus, the prolapse of the vaginal walls occurs gradually, two to four months after the operation is enough for the following specific manifestations and characteristic symptoms to appear:

Dysuric disorders:

• Weak urine stream
• Urination in several stages
• Feeling of incomplete emptying of the bladder (up to the complete absence of independent urination)
• The need to reduce prolapse to start urination
• Frequent urination (including having to get up at night)
• Sharp urge to urinate.

Problems with defecation:

• Chronic constipation, with the need to massage the prolapsed part of the rectum for its complete emptying;
• Feeling of incomplete emptying of the rectum;
• Frequent urge to defecate;

Discomfort during intercourse;

The reasons for the development of vaginal prolapse after removal of the uterus and why a “healthy” but prolapsed uterus does not need to be removed

In the United States, 433,000 surgeries are performed annually to remove (extirpate) the uterus. Fig.2. And according to studies performed in Russia, the share of such operations is about 40 percent of the total number of gynecological operations. Unfortunately, one of the indications for surgical treatment in these patients, surgeons consider prolapse of the vagina or uterus.

However, these operations in themselves lead to repeated prolapse (already of the vaginal stump) on average in every fifth - seventh woman. Patients are far from always well informed about this by specialists who suggest "remove everything so that once and for all ...".

The fact is that the uterus, or rather, the cervix, is the main fixing point of the entire ligamentous apparatus of the pelvic floor. Its removal is impossible without the intersection of the uterine arteries, which feed many important structures of this anatomical region (not only the uterus itself).

In addition, during an organ-removing operation, inevitable damage to the nerve structures that pass through the thickness of the sacro-uterine ligaments occurs. These are predominantly components of the sympathetic innervation of the bladder, the lack of which increases the risk of overactive bladder and urinary incontinence. In accordance with all modern guidelines for pelvioperineology, the uterus should be preserved if possible.

Figure 2. Types of hysterectomy.

It is also important to note that it is at least incorrect to talk about the prevention of cervical cancer and uterine cancer by removing the latter for PTO. Guided by this logic, it is better to remove the mammary glands or the rectum, since in old age they are much more often affected by the oncological process. After the age of 60, cervical cancer and uterine cancer are quite rare diseases that are easily detected in the early stages at the annual gynecological examination.

Diagnostics and prevention

Diagnosis of vaginal prolapse after removal of the uterus

To make a diagnosis of prolapse of the vagina, a mandatory vaginal examination is necessary. This type of examination is aimed primarily at identifying the nature of the prolapse of the walls of the vagina:

• Vaginal examination is carried out in a horizontal position on a special gynecological chair without the use of gynecological mirrors - to reduce discomfort during examination. During the examination, the doctor may ask you to strain or cough to better assess the prolapse of the walls of the vagina.
• Filling in specific questionnaires before and after surgery is necessary to objectify your complaints and subsequent comparison, to evaluate the effectiveness of the treatment.
• Ultrasound of the bladder with the determination of residual urine, ultrasound of the pelvic organs, Uroflowmetry, Urine culture for flora and sensitivity to antibiotics. When the walls of the vagina are lowered, it is recommended to perform a determination of the volume of residual urine after urination, in order to assess the adequacy of emptying the bladder.
• In case of chronic urinary retention or suspected infection of the lower urinary tract (cystitis), the so-called "urine culture" can be performed, this analysis will determine the causative agent of the infection and select the necessary antibacterial drug for its eradication (destruction).

Prevention of vaginal prolapse after hysterectomy

To cure vaginal prolapse/uterine prolapse/cystocele/rectocele, etc. it is not necessary to remove the uterus, especially if there are no other indications for this. There are much safer and more effective treatments for the aforementioned pathologies. Feel free to seek a second or even third opinion. The doctors of our center have helped thousands of women with this problem, while preserving the uterus.

Conservative treatment

Unfortunately, most conservative methods for this type of vaginal prolapse and prolapse are not effective. The fact is that the structures to which the vagina should be fixed are removed, which makes all attempts at treatment without surgery unsuccessful.

Operations

The goal of reconstructive pelvic floor surgery is not only to restore the normal anatomy and physiology of the pelvic organs, but also to improve the quality of life, including sexual life. To date, various approaches to the correction of posthysterectomy prolapse, both original and their modifications, have been described. The most common and studied are: sacrocolpopexy (open and laparoscopic access), sacrospinous fixation, McCall culdoplasty.

These approaches have a number of limitations, such as the duration of the operation or high cost (laparoscopic / robotic sacrocolpopexy), and are also often accompanied by serious intraoperative (massive blood loss requiring transfusion of blood components) and postoperative (high incidence of erosions of the vaginal walls, defecation disorders, postoperative ileus ( intestinal obstruction), obstruction of the ureters, dyspareunia (pain during sex)) complications.

Lumbosacral spondylodiscitis is one of the specific complications of sacrocolpopexy. This iatrogenic pathology occurs infrequently and is often described as individual cases, however, it requires repeated surgical intervention, cutting off the prosthesis from the fixation site, and long-term antibiotic therapy. An obvious limitation in the spread of laparoscopic/robotic sacrocolpopexy is the technical capacity of the hospital, as well as the duration of training.

Method of surgical treatment of vaginal prolapse, developed in our center

Compared to traditionally performed techniques, the technique we developed does not involve the use of expensive equipment, is relatively simple to perform, is characterized by a short duration of an average of 35 minutes, and a low rate of complications.

Figure 3. A - technique for applying a subfascial suture: a - fixing ligatures of the apical sling, b - purse-string suture on the inner surface of the fascia, c - UroSling-1, d - the suture passes over the fixing ligatures; B - formation of neocervix: a - tightened purse-string suture, b - ligatures are tied together over a conglomerate of tissues, c - neocervix; C - Diagram of the position of the apical sling: a - UroSling-1, b - sacrospinous ligament, c - dome of the vagina

The above facts are confirmed by the data of a clinical study conducted on the basis of the North-West Center for Pelvioperineology (pelvic floor surgery) - not a single case of endoprosthesis erosion was detected, both as a result of the use of modern mesh material, and due to the unique method of fixing the dome of the vagina to it. The main advantage of the proposed technique is the absence of direct contact of the sling and its fixing ligatures with the vaginal wall.

The neocervix formed with a purse-string suture is used as a support structure for fixing the vaginal fornix to the endoprosthesis. Often, in posthysterectomy prolapse, there are concomitant defects of the endopelvic fascia, which forces surgeons to supplement the apical correction with restoration of the anterior/posterior vaginal wall. However, traditionally performed colporrhaphy is accompanied by a high recurrence rate, reaching 70 percent in the case of cystocele correction, according to some authors.

Below is a video of an advanced procedure performed at our clinic for vaginal prolapse

Elimination of post-hysterectomy prolapse of the vagina

Our operation for the reconstruction of the dome of the vagina involves the imposition of a continuous suture on the inner surface of the fascia, due to which this suture material is isolated from the vaginal mucosa, which allows the use of non-absorbable sutures with a sufficient thickness of the fascia, thereby increasing strength.

Summarizing the above, we can state that a good anatomical result in all three compartments, obtained in our study, is achieved due to the creation of a single structure consisting of a neocervix (a conglomerate of tissues from the restored endopelvic fascia and other structures of the vaginal wall), fixed to a synthetic apical sling. Vaginal reconstruction according to our technique has all the advantages of traditional plasty (colporrhaphy) - (minimal risks for the patient) and the reliability of pelvic floor reconstruction using synthetic material.

At present, the North-Western Center for Pelvioperineology on the basis of the Urological Department of the Clinic of High Medical Technologies named after N.I. Pirogov St. Petersburg State University annually provides assistance to more than 1,500 patients with various pelvic floor pathologies from all regions of Russia, the CIS and neighboring countries.

More than 600 operations per year for urinary incontinence in women and more 900 - with prolapse (omission) of the pelvic organs (also in combination with urinary incontinence).

Treatment in KVMT them. N.I. Pirogov St. Petersburg State University

Northwestern Center for Pelvioperineology(SZTsPP), founded in 2011 on the basis of the Department of Urology of the Clinic of High Medical Technologies named after. N.I. Pirogov of St. Petersburg State University, specializes in modern low-traumatic methods for the treatment of prolapse of the vagina and pelvic organs, its leader is Doctor of Medical Sciences, Urologist Shkarupa Dmitry Dmitrievich. The specialists of the Center undertake to correct the consequences of unsuccessful reconstructive operations, complications, combined functional disorders.

Pelvic floor reconstructive surgery is a very specific field that requires a deep understanding of the anatomy and function of the pelvic organs, as well as a strong command of both “mesh” and “traditional” operations. Knowledge makes the doctor free to choose the method of treatment, and the patient - satisfied with the results.

Every year more than 900 operations are performed in our Center for prolapse (omission) of the pelvic organs (also in combination with urinary incontinence).

We consider the monitoring of long-term results of treatment to be the most important element of our work. More than 80% of our patients are regularly examined by specialists of the Center in the late postoperative period. This allows you to see a real picture of the effectiveness and safety of the treatment.

The cost of treatment of vaginal prolapse, including after removal of the uterus:

Most of the patients receive help free of charge as part of compulsory health insurance(according to the OMS policy).

It is possible and treatment for cash. The price depends on the volume and complexity of the operation. Average: from 50,000 to 80,000 rubles. (The price includes: surgery, anesthesia, hospital stay, mesh implant and other expenses).

Prolapse of the uterus is one of the forms of prolapse (displacement, prolapse) of the pelvic organs. It is characterized by a violation of the position of the uterus: the organ is shifted down to the entrance to the vagina or even falls out of it. In modern practice, this disease is considered as a variant of the hernia of the pelvic floor, which develops in the area of ​​the vaginal entrance.

Doctors in the description of this disease and its varieties use the concepts of "omission", "prolapse", "genital prolapse", "cystorectocele". The prolapse of the anterior wall of the uterus, accompanied by a change in the position of the bladder, is called a "cystocele". The prolapse of the posterior wall of the uterus with the capture of the rectum is called "rectocele".

Prevalence

According to modern foreign studies, the risk of prolapse requiring surgical treatment is 11%. This means that at least one in 10 women will undergo surgery for this disease during their lifetime. In women after surgery, in more than a third of cases, a recurrence of genital prolapse occurs.

The older the woman, the more likely she is to have this condition. These conditions occupy up to a third of all gynecological pathology. Unfortunately, in Russia, after the onset, many patients do not go to the gynecologist for many years, trying to cope with the problem on their own, although every second of them has this pathology.

Surgical treatment of the disease is one of the frequent gynecological operations. Thus, in the United States more than 100 thousand patients are operated on annually, spending 3% of the entire healthcare budget on this.

Classification

Normally, the vagina and cervix are tilted back, and the body of the organ itself is tilted forward, forming an angle open to the front with the axis of the vagina. The bladder is adjacent to the anterior wall of the uterus, the posterior wall of the cervix and vagina is in contact with the rectum. From above the bladder, the upper part of the body of the uterus, the intestinal wall are covered with peritoneum.

The uterus is held in the pelvis by the force of its own ligamentous apparatus and by the muscles that form the perineal region. With the weakness of these formations, its omission or loss begins.

There are 4 degrees of the disease.

1. The external uterine os descends to the middle of the vagina.
2. The cervix, along with the uterus, moves down to the entrance to the vagina, but does not protrude from the genital gap.
3. The external pharynx of the cervix moves outside the vagina, and the body of the uterus is higher without going out.
4. Complete prolapse of the uterus into the perineum.

This classification does not take into account the position of the uterus, it determines only the most prolapsed area, often the results of repeated measurements differ from each other, that is, there is poor reproducibility of the results. These shortcomings are deprived of the modern classification of genital prolapse, adopted by most foreign experts.

Appropriate measurements are taken with the woman lying on her back during straining, using a centimeter tape, uterine probe or forceps with a centimeter scale. Point prolapse is evaluated relative to the plane of the hymen (the outer edge of the vagina). Measure the degree of prolapse of the vaginal wall and shortening of the vagina. As a result, uterine prolapse is divided into 4 stages:

• Stage I: the most drop-down zone is more than 1 cm above the hymen;
• Stage II: this point is within ±1 cm of the hymen;
• Stage III: the area of ​​maximum prolapse is more than 1 cm below the hymen, but the length of the vagina is reduced by less than 2 cm;
• Stage IV: complete prolapse, reduction in the length of the vagina by more than 2 cm.

Causes and mechanism of development

The disease often begins at the woman's fertile age, that is, before the onset of menopause. Its course is always progressive. As the disease develops, there are dysfunctions of the vagina, uterus, and surrounding organs.

For the appearance of genital prolapse, a combination of two factors is necessary:

• increased pressure in the abdominal cavity;
• weakness of the ligamentous apparatus and muscles.

Causes of uterine prolapse:

• a decrease in estrogen production that occurs during menopause and postmenopause;
• congenital weakness of the connective tissue;
• trauma to the muscles of the perineum, in particular, during childbirth;
• chronic diseases accompanied by impaired blood circulation in the body and increased intra-abdominal pressure (intestinal diseases with constant constipation, respiratory diseases with prolonged severe cough, obesity, kidney, liver, intestines, stomach).

These factors in various combinations lead to weakness of the ligaments and muscles, and they become unable to hold the uterus in a normal position. Increased pressure in the abdominal cavity "squeezes" the organ down. Since the anterior wall is connected to the bladder, this organ also begins to follow it, forming a cystocele. The result is urological disorders in half of the women with prolapse, for example, urinary incontinence when coughing, physical effort. The posterior wall, when lowered, "pulls" the rectum behind it with the formation of a rectocele in a third of patients. Often there is a prolapse of the uterus after childbirth, especially if they were accompanied by deep muscle ruptures.

Increase the risk of disease multiple births, intense physical activity, genetic predisposition.

Separately, it is worth mentioning the possibility of vaginal prolapse after amputation of the uterus for another reason. According to different authors, this complication occurs in 0.2-3% of operated patients with a removed uterus.

Clinical picture

Patients with pelvic organ prolapse are mostly elderly and senile women. Younger patients usually have early stages of the disease and are in no hurry to see a doctor, although the chances of successful treatment in this case are much greater.

• feeling that there is some kind of formation in the vagina or perineum;
• prolonged pain in the lower abdomen, in the lower back, tiring the patient;
• protrusion of a hernia in the perineum, which is easily injured and infected;
• painful and prolonged menstruation.

Additional signs of uterine prolapse arising from the pathology of neighboring organs:

• episodes of acute urinary retention, that is, the inability to urinate;
• urinary incontinence;
• frequent urination in small portions;
• constipation;
• in severe cases, fecal incontinence.

More than a third of patients experience pain during sexual intercourse. This worsens the quality of their life, leads to tension in family relationships, negatively affects the woman's psyche and forms the so-called pelvic descent syndrome, or pelvic dysynergy.

Often develops varicose veins with swelling of the legs, cramps and a feeling of heaviness in them, trophic disorders.

Diagnostics

How to recognize uterine prolapse? To do this, the doctor collects an anamnesis, examines the patient, prescribes additional research methods.

A woman needs to tell the gynecologist about the number of births and their course, surgeries, diseases of internal organs, mention the presence of constipation, bloating.

The main diagnostic method is a thorough two-handed gynecological examination. The doctor determines how much the uterus or vagina has sunk, finds defects in the muscles of the pelvic floor, performs functional tests - a test with straining (Valsalva test) and cough. A rectovaginal examination is also carried out to assess the condition of the rectum and structural features of the pelvic floor.

To diagnose urinary incontinence, urologists use a combined urodynamic study, but when organs are prolapsed, its results are distorted. Therefore, such a study is optional.

If necessary, endoscopic diagnostics is prescribed: (examination of the uterus), cystoscopy (examination of the bladder), sigmoidoscopy (study of the inner surface of the rectum). Typically, such studies are necessary if cystitis, proctitis, hyperplasia, or cancer are suspected. Often, after the operation, a woman is referred to a urologist or proctologist for conservative treatment of identified inflammatory processes.

Treatment

Conservative treatment

Treatment of uterine prolapse should achieve the following goals:

• restoration of the integrity of the muscles that form the bottom of the small pelvis, and their strengthening;
• normalization of the functions of neighboring organs.

Prolapse of the uterus of the 1st degree is treated conservatively on an outpatient basis. The same tactic is chosen for uncomplicated genital prolapse of the 2nd degree. What to do with the prolapse of the uterus in mild cases of the disease:

• strengthen the muscles of the pelvic floor with the help of therapeutic exercises;
• refuse heavy physical activity;
• get rid of constipation and other problems that increase intra-abdominal pressure.

Is it possible to pump the press when the uterus is lowered? When lifting the body from a prone position, intra-abdominal pressure increases, which contributes to further pushing the organ out. Therefore, therapeutic exercises include tilts, squats, leg swings, but without straining. It is carried out in a sitting and standing position (according to Atarbekov).

At home

Treatment at home includes a diet rich in vegetable fiber, reduced in fat. It is possible to use vaginal applicators. These small devices produce electrical stimulation of the muscles of the perineum, strengthening them. There are developments in SCENAR therapy aimed at improving metabolic processes and strengthening ligaments. Can be performed.

Massage

Gynecological massage is often used. It helps to restore the normal position of the organs, improve their blood supply, and eliminate discomfort. Usually, 10 to 15 massage sessions are performed, during which the doctor or nurse, with the fingers of one hand inserted into the vagina, lifts the uterus, and with the other hand, circular massage movements are made through the abdominal wall, as a result of which the organ returns to its normal place.

However, all conservative methods can only stop the progression of the disease, but not get rid of it.

Is it possible to do without surgery? Yes, but only if the prolapse of the uterus does not lead to its prolapse outside the vagina, does not impede the function of neighboring organs, does not cause the patient trouble associated with an inferior sex life, and is not accompanied by inflammatory and other complications.

Surgery

How to treat uterine prolapse III-IV degree? If, despite all conservative methods of treatment or due to the patient's late request for medical help, the uterus has gone beyond the vagina, the most effective method of treatment is prescribed - surgical. The purpose of the operation is to restore the normal structure of the genital organs and correct the disturbed functions of neighboring organs - urination, defecation.

The basis of surgical treatment is vaginopexy, that is, fixing the walls of the vagina. With urinary incontinence, the strengthening of the walls of the urethra (urethropexy) is simultaneously performed. If there is weakness of the muscles of the perineum, they are plastic (recovered) with strengthening of the neck, peritoneum, supporting muscles - colpoperineolevathoroplasty, in other words, suturing of the uterus during prolapse.

Depending on the required volume, the operation can be performed using transvaginal access (through the vagina). This is how, for example, removal of the uterus, suturing the walls of the vagina (colporrhaphy), loop operations, sacrospinal fixation of the vagina or uterus, strengthening the vagina with the help of special mesh implants are performed.

With laparotomy (an incision of the anterior abdominal wall), the operation for prolapse of the uterus consists in fixing the vagina and cervix with its own tissues (ligaments, aponeurosis).

Sometimes laparoscopic access is also used - a low-traumatic intervention, during which it is possible to strengthen the walls of the vagina and suture defects in the surrounding tissues.

Laparotomy and vaginal access do not differ in long-term results. Vaginal is less traumatic, with less blood loss and the formation of adhesions in the pelvis. Application may be limited due to lack of necessary equipment or qualified personnel.

Vaginal colpopexy (strengthening the cervix with access through the vagina) can be performed under conduction, epidural anesthesia, intravenous or endotracheal anesthesia, which expands its use in the elderly. This operation uses a mesh-like implant that strengthens the pelvic floor. The duration of the operation is about 1.5 hours, the blood loss is insignificant - up to 100 ml. Starting from the second day after the intervention, the woman can already sit down. The patient is discharged after 5 days, after which she undergoes treatment and rehabilitation in the clinic for another 1-1.5 months. The most common long-term complication is erosion of the vaginal wall.

Laparoscopic surgery is performed under endotracheal anesthesia. During it, a mesh prosthesis is also used. Sometimes amputation or extirpation of the uterus is performed. The field of operation requires early activation of the patient. An extract is carried out on the 3-4th day after the intervention, outpatient rehabilitation lasts up to 6 weeks.

Within 6 weeks after the operation, a woman should not lift weights of more than 5 kg, sexual rest is required. Within 2 weeks after the intervention, physical rest is also necessary, then you can already do light housework. The average period of temporary disability is from 27 to 40 days.

What to do in the long term after the operation:

• do not lift weights more than 10 kg;
• normalize stool, avoid constipation;
• treat respiratory diseases accompanied by cough in time;
• long-term use of estrogen suppositories (Ovestin) as prescribed by a doctor;
• do not engage in certain sports: cycling, rowing, weightlifting.

Features of the treatment of pathology in the elderly

Gynecological ring (pessary)

Treatment of uterine prolapse in the elderly is often difficult due to comorbidities. In addition, often this disease is already in an advanced stage. Therefore, doctors face significant difficulties. To improve the results of treatment, at the first signs of pathology, a woman should contact a gynecologist at any age.

Therefore, a bandage will provide significant assistance to a woman when the uterus is lowered. It can also be used by younger patients. These are special supportive panties that tightly cover the abdominal area. They prevent prolapse of the uterus, support other organs of the small pelvis, reduce the severity of involuntary urination and pain in the lower abdomen. Choosing a good bandage is not easy, a gynecologist should help with this.

A woman must perform therapeutic exercises.

With a significant prolapse, a surgical operation is performed, often this is the removal of the uterus through a vaginal access.

Effects

If the disease is diagnosed in a woman of fertile age, she often has the question of whether it is possible to become pregnant with the prolapse of the walls of the uterus. Yes, there are no special obstacles to conception in the early stages if the disease is asymptomatic. If the omission is significant, then before the planned pregnancy it is better to be operated on 1-2 years before conception.

Preservation of pregnancy with proven uterine prolapse is fraught with difficulties . Is it possible to bear a child with this disease? Of course, yes, although the risk of pregnancy pathology, miscarriage, premature and rapid birth, bleeding in the postpartum period is significantly increased. In order for the pregnancy to develop successfully, you need to constantly be observed by a gynecologist, wear a bandage, use a pessary if necessary, engage in physiotherapy exercises, and take medications prescribed by a doctor.

What threatens the prolapse of the uterus in addition to possible problems with carrying a pregnancy:

• cystitis, pyelonephritis - infections of the urinary system;
• vesicocele - saccular dilation of the bladder, in which urine remains, causing a feeling of incomplete emptying;
• urinary incontinence with irritation of the skin of the perineum;
• rectocele - expansion and prolapse of the ampulla of the rectum, accompanied by constipation and pain during defecation;
• infringement of intestinal loops, as well as the uterus itself;
• eversion of the uterus with its subsequent necrosis;
• deterioration in the quality of sexual life;
• a decrease in the overall quality of life: a woman is embarrassed to go out into a public place, because she is constantly forced to run to the toilet, change incontinence pads, she is exhausted by constant pain and discomfort when walking, she does not feel healthy.

Prevention

The prolapse of the walls of the uterus can be prevented in this way:

• minimize prolonged traumatic childbirth, if necessary, excluding the straining period or performing a caesarean section;
• timely identify and treat diseases accompanied by increased pressure in the abdominal cavity, including chronic constipation;
• in the event of ruptures or dissection of the perineum during childbirth, carefully restore the integrity of all layers of the perineum;
• recommend women with estrogen deficiency hormone replacement therapy, in particular, with menopause;
• assign patients at risk of genital prolapse special exercises to strengthen the muscles that form the pelvic floor.