Vaginal prolapse is a pathological condition in which a woman’s genitals shift from their normal anatomical position or completely fall out. At first, it is manifested by discomfort and a feeling of a foreign body in the perineum when straining or sneezing. Later, a violation of outflow and urinary incontinence, constipation, painful sensations are added. In advanced cases, total prolapse of the uterus and vagina occurs. The basis of the diagnosis is a gynecological examination, a Valsalva test, ultrasound of the genitals. Treatment in the initial stage is conservative, with the progression of pathology, surgical correction is indicated.
ICD 10
N81 Loss of female genital organs
General information
Vaginal prolapse (genital prolapse, pelvic organ distention) is the cause of 15% of operations in surgical gynecology. Often there is an isolated omission of the anterior vaginal wall. If the pathological process has affected the posterior wall, the rectum protrudes, a rectocele is formed. 50-60% of cases are elderly and senile women, in 26% of cases pelvic organ prolapse is diagnosed before the age of 40.
Causes
Vaginal prolapse is considered as a kind of pelvic hernia, which has its own sac, hernial gates and contents. Its appearance is associated with the failure of the pelvic floor. Pathology is the result of a combination of several provoking factors. The following reasons are distinguished:
- Birth injuries. Any full-term pregnancy increases the risk of vaginal prolapse. The disease is provoked by rapid childbirth, soft tissue injuries, obstetric benefits in childbirth, a large fetus. The probability of developing genital prolapse is directly associated with the duration of the second period of labor.
- Increased intra-abdominal pressure. In women, with a violation of the bowel with frequent constipation, flatulence and increased intra-abdominal pressure, there is a displacement of the pelvic organs. The ligamentous apparatus is stretched and gradually weakens. Heavy physical labor, lifting weights, working in a standing position, abdominal tumors lead to the lowering of the vagina.
- Connective tissue dysplasia. Congenital anomalies of connective tissue development provoke rapid prolapse and prolapse of the genitals after the first birth without the action of other trigger factors. In this situation, the need for surgical treatment arises in the next 5 years after the onset of symptoms.
- Estrogen deficiency. In the sacro-uterine ligaments there are receptors for estrogens, with a lack of hormone, connective tissues become loose, easily stretch. When menopause approaches, as well as as a result of taking drugs that block the function of the ovaries, the production of sex steroids is suppressed, vaginal prolapse is constantly progressing.
- Operations on the small pelvis. Surgical interventions on the bladder, rectum or reproductive organs cause injuries to soft tissues, ligamentous apparatus, which together with other factors can potentiate vaginal prolapse. The risk increases if you are overweight.
Pathogenesis
The pelvic floor in women is formed by muscles and ligaments that support the reproductive organs, bladder and distal colon in a suspended position. Under the influence of one or more factors, the pelvic organs are squeezed down. A hernial sac is formed, the contents of which are the uterus, bladder or rectum. Anatomical proximity of organs leads to a violation of their topography.
When the anterior region of the vagina is lowered, it drags the bladder with it, urination disorders appear. The external opening of the urethra gapes, closes poorly, so when sneezing, coughing, laughing, urine leaks. In severe cases, the inflection of the neck of the bladder causes acute urinary retention. The omission of the vagina in the back displaces the rectum, defecation disorders develop.
The lowering of the vaginal dome may form after hysterectomy. Pathology is associated with a violation of the normal location of the ligaments of the uterus after removal of the organ, damage to the fascia during surgery. In this case, the contents of the hernial sac can be both the rectum and the bladder, a cystorectocele is detected.
Classification
Several classifications of genital prolapse have been developed, but the most modern is the ROR-Q staging. Its results are easily reproduced, they are not affected by the patient’s position, several anatomical landmarks are used, which allow us to quantify the omission. One of these points is the remains of the hymen. According to the measurement results, the following variants are distinguished:
- Stage 0. There is no vaginal prolapse.
- Stage 1. The most protruding part of the vagina is 1 cm or more above the hymen.
- Stage 2. The vagina is lowered, its lower point is less than one cm above or below the hymen.
- Stage 3. The drop-down point of up to 1 cm or more is shifted down relative to the hymen, but the total length of the vagina is reduced by no more than 2 cm.
- Stage 4. Complete prolapse, which is accompanied by a shortening of the vagina to 2 cm or more.
Symptoms of vaginal prolapse
The first sign of pathology is the sensation of an extraneous body in the perineum area. The woman complains to the doctor about the feeling of bursting, the presence of a rounded object. There are pulling pains in the lower abdomen, radiating to the lumbar region. With straining, physical exertion, gases can involuntarily escape, the tendency to constipation increases, which further worsens well-being. Dyspareunia develops in 30% of patients with prolapse.
Urination disorders are of a mixed nature. At the initial stage of vaginal prolapse, stress urinary incontinence joins, which leaks when sneezing, strong coughing, laughing. At first the portions are small, later they increase. Urgent incontinence develops, the urge to go to the toilet appears suddenly and is accompanied by the leakage of a portion of urine. Some women are concerned about enuresis, urine is released during sexual intercourse. Manifestations may increase before menstruation.
With pronounced omission of the pelvic organs, residual urine accumulates in the bladder. In the advanced stages of the disease, complete obstruction may occur, the bladder cannot be emptied independently. The symptoms of delay develop rapidly and require emergency measures. Worried about the feeling of bursting over the pubis, the desire to urinate, which is impossible to realize, acute pain.
Complications
If there is a violation of the outflow of urine and its stagnation, the risk of infection and the development of cystitis increases, which is difficult to treat due to residual urine and the inability to establish normal urination. The infection can spread in an ascending way, leading to pyelonephritis. If urgent urinary retention occurs, it is necessary to constantly wear a Foley catheter to prevent relapses.
If treatment is refused, vaginal prolapse progresses, a prolapse of the uterus is formed, which is constantly located on the perineum, which worsens the quality of life, leads to an infectious lesion of the genitals. Trophic ulcers appear on the vaginal mucosa. The condition is accompanied by dyschesia – the muscles of the pelvic floor and anal sphincters work uncoordinated, so defecation is extremely painful, requires manual assistance.
Diagnostics
If symptoms of vaginal prolapse appear, a woman should consult an obstetrician-gynecologist. A consultation with a urologist may be required, if the rectum is involved in the pathological process, a proctologist is prescribed. Minimally invasive examination methods are sufficient for diagnosis, laboratory tests are uninformative and are used at the stage of preoperative preparation. The following methods are used:
- Gynecological examination. The doctor determines the visual displacement of the vaginal walls, the protrusion of one of them or a uniform omission. The ROR-Q stage is being established. With a bimanual examination, pain in the small pelvis is possible. A Valsava test is carried out, in which urine leaks during straining.
- A smear for oncocytology. It is mandatory for patients with trophic ulcers and erosions on the vaginal mucosa. The material is taken from the areas of ulceration. If atypical cells are detected, an oncologist’s consultation is necessary.
- Transvaginal ultrasound. Allows you to determine the size of the uterus, the location of the pelvic organs. Sometimes vaginal prolapse is differentiated from uterine fibroids by sonography results. The condition of the ovaries and fallopian tubes is also being investigated.
- Combined urodynamic study. Method of evaluation of urination function. A special diary is kept in which the peculiarities of visiting the toilet are noted. According to urofluometry, a decrease in the flow rate of urine, a change in the duration of urination, an increase in the volume of residual urine is detected. The procedure is supplemented by cystometry and profilometry.
- MRI of the pelvis. The procedure is prescribed to women with combined forms of vaginal prolapse, with a relapse of the disease after surgical treatment. MRI is performed with filling the vagina with gel for ultrasound examination, which increases the contrast of the image. Special preparation of the intestine allows you to increase the accuracy of the study.
Treatment of vaginal prolapse
The goals of treatment depend on the patient’s age and the state of her reproductive system. In young patients, the main task is to preserve fertility and improve the quality of sexual contacts. In elderly women, therapy is aimed at improving the quality of life. At the initial stages, conservative methods are used under the supervision of a doctor of a women’s consultation. Hospitalization in the gynecological department is carried out for planned surgical treatment.
Conservative therapy
In women suffering from the initial degree of vaginal prolapse, it is possible to use complex conservative treatment to slow the progression of pathology. Conservative methods are also indicated for elderly women in the presence of absolute contraindications to surgery. The following approaches are used:
- Kegel exercises. Performed when the vagina is lowered 1-2 degrees. The essence of the exercises consists in alternating compression and relaxation of the pelvic floor muscles. Classes are held in a supine or sitting position, with good muscle training, you can practice in any position.
- Gymnastics according to Atarbekov. A set of exercises aimed at strengthening the muscles of the pelvis and the anterior abdominal wall. Various types of bending, twisting, and leg dilution are produced. It provides a load on the press, squats with legs wide apart.
- Diet. Food is prescribed to eliminate constipation. A woman is not recommended flour, food rich in simple carbohydrates. To relax the stool, dried apricots, prunes, fresh apricots or plums, beets are included in the diet daily. The amount of plant food is increased, excluding products that contribute to gas formation.
- Estrogen preparations. Indicated for the therapy of vaginal prolapse in combination with other methods. Effective in older women. For treatment, cream or candles are used in an individual dosage. Initially, the saturation of the body is carried out, after which they switch to a maintenance mode.
- Gynecological pessary. A ring or other form of silicone is selected individually, inserted into the vagina and serves to support the genitals. It does not eliminate prolapse, but reduces its severity. With prolonged use, it can contribute to the progression of omission, the appearance of bedsores and the addition of infectious complications.
Surgical treatment
The main method of correction of vaginal prolapse. Indications are 3-4 degrees of pathology, dysfunction of neighboring organs, complete prolapse of the uterus or rapid progression of the disease. The type of intervention depends on the age of the woman and her desire to preserve reproductive function. Operations with vaginal and abdominal access can be used. Treatment through the perineum is carried out by the following methods:
- Colporaphia. Reconstructive surgery aimed at reducing the volume of the vagina at the expense of its own tissues. It is recommended for young women with a sufficiently preserved fascial ligamentous apparatus. In other cases, the risk of recurrence of vaginal prolapse reaches 50%.
- Sacrospinal fixation. This method of treatment is indicated after removal of the uterus when the stump of the vagina is lowered. The operation takes place without the use of synthetic materials. The dome of the vagina is fixed to the right sacro-spinous ligament.
- Vaginopexy with MESH prosthesis. A synthetic polypropylene mesh is introduced by vaginal access, the shape of which repeats the defect on the fascia of the pelvis. The technique returns the anatomical position to the genitals, reduces the risk of recurrence of vaginal prolapse. Fixation is performed by attaching to its own ligaments, which provides elasticity and a low probability of vaginal erosions.
- TVT and TVT-O sling operations. Methods using synthetic tape, which is carried out by vaginal access. Eliminates the omission of the anterior part of the vagina, relieves a woman of the symptoms of urinary incontinence. The risk of relapse is minimal.
- Colpocleesis. Stitching of the front and back walls of the vagina. It is performed for elderly patients when it is impossible to use other methods. The advantages of the operation are minimally invasive, simplicity and speed. After treatment, sexual activity is excluded.
When using vaginal access, removal of the uterus may be required. The operation can be combined with the subsequent installation of a mesh prosthesis. According to indications, laparoscopic or abdominal approaches are applicable for the correction of vaginal prolapse, but these methods are less preferable due to the long recovery period. The following types of operations have been developed:
- Sacrovaginopexy. Performed laparoscopically. It is recommended for isolated uterine prolapse. The neck and vagina are fixed to the presacral ligament of the sacrum. To improve the results, the operation is complemented by the use of mesh implants.
- Vaginopexy with own ligaments. The intervention is performed by laparoscopy and laparotomy. The vagina is sewn to the abdominal wall due to its own ligaments, which are slightly shortened. The disadvantage of the technique is the risk of postoperative complications, bleeding and recurrence of omission due to sprains.
- Aponeurotic fixation. It is rarely carried out due to high traumatism and the likelihood of complications. The operation is performed by laparotomic access, muscle aponeuroses are used to fix the vagina and uterus. After treatment, a long recovery period is required.
Prognosis and prevention
With timely access to a doctor and compliance with the recommendations, it is possible to stop the progression of vaginal prolapse, but complete elimination of pathology by conservative methods is impossible. Modern operations using implants allow you to restore the anatomical position of organs and get rid of unpleasant symptoms. The risk of relapse depends on the surgical technique and method of surgical treatment.
Prevention of vaginal prolapse consists in the proper organization of labor, restriction of lifting weights, careful management of childbirth. It is necessary to control the work of the intestines, to avoid the appearance of constipation. In premenopausal women, it is possible to reduce the likelihood of rapid vaginal prolapse with hormone replacement therapy.
