Genital Prolapse Predisposing factors Childbirth – vaginal delivery à trauma to pelvic floor, weakening of support (esp if prolonged 2nd stage) Menopause – oestrogen deficiency & loss of connective tissue strength Suprapubic surgery for urinary incontinence – burch colposuspension can à increased risk of enterocele Congenital – weakness & neurological deficiency, can be present at birth Genetics – uncommon in African population (reason unknown) Types Urethrocele & cystocele Anterior part of vaginal wall (urethrocele = first 3-4cm, cystocele = above) Can affect continence à stress incontinence Uterine descent 1st degree – descent of uterus & cervix within vagina but not reach introitus 2nd degree – to level of introitus 3rd degree – protrude from vagina Procidentia – cervix, uterus & vaginal wall all prolapses. Can à ulceration Vault Prolapse Inversion of the entire vault post hysterectomy Rectocele Weakening of rectovaginal fascia à rectum protrudes to lower vagina Enterocele Only true hernia (through pouch of Douglas) Symptoms May be asymptomatic (detected at smear) Symptoms of “something coming down”, dragging feeling, backache (improved on laying down) + those related to organ involved (incontinence, constipation relieved by digital replacement) Signs Assess obesity, motility, general well-being, Dyspnoea, nicotein stains, cough & abnormal chest signs point to chronic cough Part labia & ask to cough – look for incontinence & buldging Lie on side and assess using sims speculum Management Conservative Pelvic floor exercises (if mild or not suitable for surgery) – also help with incontinence Ring Pessary – behind pubic symphysis & posterior fornix. Supports the vault & will help with cystocele. Change every 4-6 months (check for ulceration etc) Shelf Pessary – useful in procidentia Surgical Mostly performed vaginally – must consider calibre of vagina if woman wishes to remain sexually active Anterior colporrhaphy – places supporting sutures in place to elevate bladder neck Vaginal hysterectomy – definitive treatment for uterine descent Machester/Fothergill repair – shortening of uterosacral ligaments (uterus left in place) Posterior colpo-perineorrhaphy – similar to anterior repair Sacrocolpoplexy – suturing the vault to the body of sacrum Sacrospinious fixation – suture top of vault to sacrospinious ligament