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Staging and Management of Genital Prolapse

Staging and Management of Genital Prolapse. Dr. V.P.Paily MD; FRCOG Professor Jubilee Mission Medical College, Thrissur, Kerala. Consultant, Mother Hosp and Raji Nursing Home , Thrissur, Kerala. Prolapse. Very common problem.

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Staging and Management of Genital Prolapse

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  1. Staging and Management of Genital Prolapse

  2. Dr. V.P.Paily MD; FRCOG Professor Jubilee Mission Medical College, Thrissur, Kerala. Consultant, Mother Hosp and Raji Nursing Home , Thrissur, Kerala

  3. Prolapse • Very common problem. • Confusion regarding assessing degree / stage

  4. Conventional Staging • Cervix is the main point.

  5. Conventional staging • Difference between British and American System.

  6. Baden Walker Halfway System

  7. Prolapse quantification • Pelvic organ prolapse quantification(POP-Q) • Recommended by ICS, society of Gyn.Surgeons &Amer. Urogyn. Surgeons

  8. Pelvic organ prolapse • Quantification • POP Q

  9. Quantification • Vault, Cx or Posterior fornix • Anterior & Posterior walls • Introitus • Perineal body • Length of vagina

  10. Quantification • Anterior (a) -- Point A & B • Posterior (p) -- Point A & B • Point C -- Lips of Cervix • Point D -- Post.fornix

  11. Quantification • Length of vagina • Diameter of introitus • Perineal body

  12. POP- Q

  13. Quantification

  14. POP-Q Drawbacks • Appears complicated • Doesn’t include lateral prolapse.

  15. Comprehensive pattern required incorporating defects at various levels & compartments

  16. Look for defects At 3 levels Upper Middle Lower

  17. Look for defects At two compartments • Anterior • Posterior

  18. Compartmental approach Level 1 • Descent of cervix • Descent of vault • Enterocele

  19. Compartmental Approach Level 2 • Anterior segment – cystocele • Posterior segment – rectocele • Lateral detachment

  20. Compartmental Approach Level 2 • High rectocele can extend up to post fornix and has to be differentiated from enterocele.

  21. Compartmental Approach Level 2 • Midline defects are due to tear or weakness of fascial envelope – pubo vesico cervical fascia and rectovaginal fascia ( Denonvilliers).

  22. Compartmental Approach Level 3 • Anteriorly – Urethrocele • Posteriorly – Detached perineal body

  23. Compartmental Approach Level 3 • Detached Perineal body • Reattach to recto vaginal fascia

  24. Practical approach to Level 3 defects • Common complaint Sound of air being sucked in

  25. Compartmental Approach Lateral detachment • Reattach to Arcus Tendineus • Fascia pelvis or Arcus Tendineus • Fascia Rectovaginalis

  26. Compartmental Approach Anterior Lateral detachment • Richardson’ s operation • Transvaginal • Transabdominal • Endoscopic

  27. Compartmental Approach Posterior Lateral detachment • Reattach to Arcus tendineus fascia rectovaginalis

  28. Symptomatology Record symptoms related to • Anatomical descent • Urinary function • Sexual function • Reproductive need • GI symptoms • Air suction

  29. Management • Restore anatomy by correcting the defect.

  30. Special Situations

  31. Nulliparous prolapse

  32. Older age with weak tissues

  33. Mesh for Repair • Concept borrowed from Hernia repair • Special mesh being developed. (Gyne mesh) • We have tried prolene mesh.

  34. Conclusions • Detailed record of defects • Detailed record of symptoms • Individualised surgery

  35. Thank you

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