Vaginal prolapse

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Eman Alademi, M.D.[2]

Synonyms and keywords: Female genital prolapse, procidentia and ptosis.

Overview

Vaginal prolapse is characterized by a portion of the vaginal canal protruding from the opening of the vagina. The condition usually occurs when the pelvic floor collapses as a result of childbirth and is inherent among tall Caucasian women.

Types of vaginal prolapse

• Cystocele (bladder into vagina)
• Enterocele (small intestine into vagina)
• Rectocele (rectum into vagina)
• Urethrocele (urethra into vagina)
• Uterine prolapse (uterus into vagina)
• Vaginal vault prolapse (roof of vagina, after hysterectomy)

Historical Perspective

Vaginal prolapse was first discovered in era of the pharaohs, about 1500 years before Christ. Then MRI/surgery was developed by Hippocrates to treat/diagnose vaginal prolapse over the centuries, different treatment modalities, some of which we can currently seem strange

Classification

Vaginal prolapse may be classified according to Uterine cervical elongation that found in patients undergoing hysterectomy for pelvic organ prolapse, Cervical elongation grades and prolapse stages are correlated. Vaginal prolapse is classified as physiological uterine cervical elongation based on corpus/cervix ratio to (grade 0, CCR>1.5) grade I (CCR>1 and ≤1.5) grade II (CCR>0.5 and ≤1), and grade III (CCR≤0.5)

Pathophysiology

The pathogenesis of Pelvic organ prolapse like vaginal prolapse is not fully understood. It is thought that vaginal prolapse is characterized by two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated, Pelvic organ prolapse is a hernia of the vaginal wall. The utero-sacral ligaments and the arcus tendineus of the pelvic fascia lose their elasticity. Atrophic levator anii muscles do not play their trempoline, active support anymore To the pelvic floor. That is related to the aging of these structures but also to excessive mechanical strains -pregnancy, delivery, dyschesia, physical practices-. Moreover, postural disorders lead to a direct orientation of these strains on the genital slit

Prolapse and urinary incontinence often occur concomitantly and cystocele, rectocele, enterocele, uterine descent or vaginal vault prolapse may also be present. The pathophysiology of prolapse encompasses direct and indirect injury, metabolic abnormalities and chronic high intra-abdominal pressure. Anterior vaginal wall prolapse may present as stress incontinence

Differentiating vaginal prolapse from other Diseases

• Vaginal prolapse must be differentiated from other diseases that cause urethral prolapse, cystocele, enterocele, urethral diverticulum, and Gartner duct cyst. such as:

• Urethral prolapse
• Cystocele
• Enterocele
• Gartner duct cyst
• Urethral diverticulum

Epidemiology and Demographics

Age

• vaginal prolapse is more commonly observed among patients aged 25-64 years old.older women .

Gender

• Females are more commonly affected with vaginal prolapse.

Race

• vaginal prolapse usually affects individuals of the African Americans and Caucasians race.

Risk Factors

• Common risk factors in the development of vaginal prolapse are genetic contribution which decrease in the expression of the genes HOXA13 ,sex steroids, pregnancy, parity, vaginal delivery, age, obesity (increase BMI), vaginal hysterectomy ,vaginal birth, menopausal status and measurement of total vaginal length , pelvic floor muscle weakness.

Natural History, Complications and Prognosis

• The majority of patients with vaginal prolapse remain asymptomatic .
• Common complications of vaginal prolapse include [bladder incarceration], [consecutive irreducible rectal prolapse],
• Prognosis is generally [excellent], and No serious perioperative complications

Diagnosis

Symptoms

• vaginal prolapse is usually asymptomatic.
• Symptoms of vaginal prolapse may shown feeling of bulge in the vagina But When it’s demonstrate greater degrees of pelvic , and include the following:

• Bowel symptoms (constipation)
• Urinary(Incontinence and voiding difficulties)
• Sexual dysfunction

Physical Examination

• Patients with vaginal prolapse usually appear like vaginal/vestibular masses , or bulge in the vagina

Laboratory Findings

• There are no specific laboratory findings associated with vaginal prolapse.

Imaging Findings

• Pelvic MRI is the imaging modality of choice for vaginal prolapse. It has the ability to identify changes related to uterosacral ligament disruption and to document the corrective changes after surgical repair of this ligament. In the future, pelvic MR imaging is help to document and advance knowledge of surgical repair methodology. Dynamic pelvic MRI (D-MRI ) provides an accurate diagnostic evaluation of the pelvis,which seems an appropriate tool in pre-operative assessment of cases with vaginal prolapse. It will help in focusing our surgical strategy, especially in cases that present post-hysterectomy and in cases with residual or recurrent prolapse.
• On Pelvic MRI, vaginal prolapse is characterized by Defects of musculofascial component of the pelvic floor with Offten demonstrate combination of defects MLA( musculus levator ani ), EF ( sacrouterine ligaments  ) and SUL ( sacrouterine ligaments)

Other Diagnostic Studies

• Vaginal prolapse may also be diagnosed using Ultrasound imaging of the perineal body, which is associated strongly with posterior compartment prolapse
• Findings on Ultrasound imaging of the perineal body include a small perineal body was strongly associated with posterior compartment prolapse.

Treatment

Vaginal prolapses must be treated according to the severity of symptoms.

Non-Surgical Therapy

• With conservative measures (changes in diet and fitness, Kegel exercises, etc.)
• With a pessary, to provide support to the weakened vaginal walls

Surgical Therapy

A new minimally invasive surgical procedure is effective in restoring a woman's anatomy to the condition before childbirth with a two weeks recovery period. It is performed vaginally using a laparoscope and surgical mesh to repair the cystocele and rectocele and a laser to tighten the vaginal canal, which create a natural support for the uterus[35][./Vaginal_prolapse#cite_note-pmid:_8934045-35 [35]]

Related Chapters

• Prolapse
• Enterocele

References

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