Pelvic organ prolapse Etiology of pelvic organ prolapse Vaginal vault prolapse Etiological factors of vault prolapse Signs and symptoms of vaginal vault prolapse Diagnosis of vaginal vault prolapse Treatment measures

1. Vaginal vault prolapse
Prepared by: Nabina Bhasima
Bsc.Nursing 3rd year

2. Overview:
- Pelvic organ prolapse
- Etiology of pelvic organ prolapse
- Vaginal vault prolapse
- Etiological factors of vault prolapse
- Signs and symptoms of vaginal vault
prolapse
- Diagnosis of vaginal vault prolapse
- Treatment measures

3. Pelvic Organ Prolapse
• Pelvic organ prolapse is one of the common
clinical conditions met in day to day
gynaecological practice especially among the
parous women.
• The entity includes descent of the vaginal
wall and/or the uterus.

4. Etiology of pelvic organ prolapse
• The genital prolapse occurs due to weakness
of the structures supporting the organs in
position.
• These factors may be anatomical or clinical.

5. 1. Acquired
• Vaginal delivery with consequent injury to
the supporting structures is the single most
important acquired predisposing factor in
producing prolapse.
• The prolapse is unusual in cases delivered by
caesarean section.

6. Contd..
• The injury is caused by:
- Overstretching of the Mackenrodts’s and
uterosacral ligaments
a. Premature bear down efforts prior to full
dilatation of the cervix.
b. Delivery with forceps or ventouse with
forceful traction.

7. Contd..
c. Prolonged second stage of labor
d. Downward pressure on the uterine fundus in
an attempt to deliver the placenta.
e. Precipitate labor
In all these conditions, the uterus tends to be
pushed down into the flabby distended vagina.
- Overstretching and breaks in the endopelvic
fascial sheath.

8. Contd..
- Overstretching of the perineum
- Imperfect repair of the perineal injuries.
Poor repair of collagen tissue.
- Loss of levator function
- Neuromuscular damage of levator ani during
childbirth
- Subinvolution of the supporting structures.

9. Contd..
This is particularly noticeable in:
i) Ill-nourished and asthenic women.
ii) Early resumption of activities which greatly
increase intra-abdominal pressure before
the tissues regain their tone.
iii) Repeated childbirths at frequent intervals.

10. 2. Congenital
• Congenital weakness of the supporting
structures is responsible for nulliparous
prolapse or prolapse following an easy
vaginal delivery.
• One should be on the look out for an occult
spina bifida and associated neurological
abnormalities.

11. Clinical types of pelvic organ
prolapse
1. Vaginal prolapse
2. Uterine prolapse
While prolapse can occur independently
without uterine descent, the uterine prolapse
is usually associated with variable degrees of
vaginal descent.

12. Vaginal Vault Prolapse
Vaginal Prolapse
• Anterior Wall
- Cyctocele
- Urethrocele
• Posterior Wall
- Relaxed perineum
- Rectocele

13. Vault Prolapse
1. Enterocele
2. Secondary vault prolapse

14. 1. Enterocele:
Laxity of the upper-third of the posterior
vaginal wall results in herniation of the pouch
of Douglas. It may contain omentum or even
loop of small bowel and hence called
enterocele.
Traction enterocele is secondary to
uterovaginal prolapse. Pulsion enterocele is
secondary to chronically raised intra-
abdominal pressure.

15. Contd..
• Secondary Vault Prolapse
This may occur following either vaginal or
abdominal hysterectomy. Undetected
enterocele during initial operation or
inadequate primary repair usually results in
secondary vault prolapse.

16. Aetiology
• Attenuation of the support mechanisms may
occur as a results of:
1. Childbirth: Prolapse is uncommon in
nulliparous women. Prolonged labours with
difficult vaginal deliveries may predispose to
the development of prolapse subsequently.

17. Contd..
• Precipitate labour may indicate some degree
of deficiency of pelvic floor which may later
express itself as prolapse.
• Postmenopausal atrophy
• Chronic elevation of intra-abdominal
pressure due, for example: obesity or a
chronic cough

18. Symptoms and signs
- The commonest symptoms are:
• A feeling of something coming down
• Awareness of a lump protruding from vulva
• Discomfort and backache

19. Contd..
• Possible stress incontinence because the
urethra lies caudal to the pelvic floor and not
primarily because of loss of the posterior
urethra-vesical angle.
• Urinary retention of difficulty with
defecation occur occasionally in severe
vaginal wall prolapse.

20. Contd..
• Examination is best carried out with the
patient in the left lateral position using a
sims speculum.
- A vasellum may be applied to the cervix so
that traction will demonstrate the severity of
prolapse.
- Discomfort

21. Diagnosis
1. History: Ask and record of chief complaints,
obstetric history and aggravating factors.
2. Physical examination, which will include a
pelvic examination. She is made to cough
and strain and nature, degree or prolapse
noted. The vulva is examined for evidence
of any perineal laceration.

22. Contd..
3. Stress incontinence should be looked for by
asking the patient to strain.
4. Speculum examination determines the
vaginal prolapse, the degree of uterine
descent and the condition of the vagina and
cervix.

23. Contd..
5. Tests that may be done the nature of a
prolapse, include cystoscopy, intravenous
pyelogram computed tomography scan.
Investigation include haemoglobin, urine
examination for RE/ME, urine cultures, blood
urea, blood sugar, high vaginal swab in cases
of vaginitis.
6. X-ray, ECG

24. Management
I. Preventive
II. Conservative
III. Surgery

25. I. Preventive Management
1. Reaching and staying at a weight that is
health for your height.
2. Educate women for stopping smoking and
prevent chronic cough.
3. Create awareness in the family and
community about the benefit of good
nutrition for a girl child who is a future
mother, to prevent complication of
pregnancy, delivery and postnatal period
and longterm complications like genital
prolapse.

26. Contd..
4. Correcting constipation
5. Avoiding heavy lifting and jumping
6. Educate women for nutritional supplement,
antenatal hygiene, physiotherapy, relaxation
exercises are important.
7. Doing pelvic strengthening exercises (kegal
exercises) everyday. These exercises help
strengthen the muscles of the pelvis.

27. Contd..
8. Proper supervision and management of the
second stage of labor (avoid prolonged 2nd stage
of labor)
9. A generous episiotomy in most primigravidae
and in all complicated labours eg: breech
delivery
10. A perineal tear and episiotomy must be
immediately and accurately sutured after
delivery.
11. Encourage postnatal exercises ( pelvic floor
exercises) are beneficial.

28. Contd..
12. Encourage early postnatal ambulation.
13. Provision of adequate rest for the first six
months after delivery and the availability of
home help for heavy domestic duties. Tell
women to avoid carrying heavy loads and
performing heavy work after delivery (at least
6 weeks, postpartum)

29. Contd..
14. Avoiding multiparity by using a family
planning method so that strain an the
ligamentary supports is reduced.
15. Explain to women and their families the
importance of spacing each child by at least
two years and limiting the size of the family.

30. Contd..
16. Tell women to avoid wearing a tight
putuka just after delivery.
17. Prophylactic hormone replacement
therapy (estrogen therapy either vaginal or
oral) in post menopausal women may help
maintain connective tissue and muscle tone.
Estrogen prevents drying and thinning of the
vaginal tissue (vaginal atrophy)

31. Contd..
Following interventions have suggested by
National Medical Standard Vol II to prevent
genital prolapse.
• Encourage for taking nutritious food
• Use skilled birth attendance to assist at birth
to prevent prolonged labor.
• Avoid carrying heavy loads and performing
heavy work after delivery.

32. Contd..
• Educate on importance of birth spacing and
limiting.
• Educate women to lift heavy objects properly
and without strain. Also teach not wear tight
patuka just after delivery.
• Educate women for stopping smoking and
prevent chronic cough.

33. II. Conservative Management
Decision about treatment depends on how
had symptoms present and whether other
medical conditions present or not. If
symptoms are mild, may be able to do things
at home to help feel better.

34. Contd..
1. Making lifestyle changing
• Doing pelvic floor exercise
• Eating high fiber to prevent constipation.
• Cutting down caffeine (acts as diuretic)

35. Contd..
2. Vaginal pessary:
• It is a rubber of plastic device used to
support the areas of prolapse and maintain
support of the prolapsed organ.
• Pessaries will not definitively treat prolapse
or vaginal wall defects but can restore
normal anatomy, relieve pressure and
sometimes improve incontinence.

36. Contd..
• They can provide longterm or temporary
relief until more definitive surgery can be
performed.
• The most commonly available pessary is ring
pessary, usually made of stiff latex and
available in a number of sizes, common are
6.25 – 7.5cm.

37. III. Surgical
• Transvaginal approach
1. Repair of enterocele along with PFR (Pelvic
Floor Repair)
2. Le.Fort’s operation
3. Colpocleisis ( cases following hysterectomy)
4. Sacrospinous colpopexy
• Abdominal approach
1. Vault suspension (sacral colpopexy)

38. 1. Le.Fort’s operation
• This procedure is almost obsolete. It may be
done in old age with procidentia when the
patient is unfit for longer duration of surgery as
vaginal hysterectomy with PFR.
• There should not be any uterine or pelvic
pathology.
• Cervical cytology (pap smear) should be normal.
• The operation can be done under local
anesthesia.

39. 2. Colpociesis (after hysterectomy)
• Denudation of vaginal mucosa is done all
round.
• Successive purse string absorbable sutures
are placed from above downwards to oppose
the vaginal walls.
• It is simple, safe and effective operation for a
woman who is no longer interested in coital
function.

40. 3. Sacrospinous colpopexy
• This is done under direct vision following
dissection of pararectal space.
• A special neddle (Miya Hook) is used
• Overall results are good.

41. 4. Vault suspension( sacral
colpopexy)
• Principle of the operation is to suspend the
vaginal vault to be anterior longitudinal ligament
in front of 3rd sacral vertebra.

42. References
• “ Dutta D.C”, “Textbook of gynecology”, 7th Edition,
Jaypee Publication, page 168-182
• “Livingstone C.C”, “Aids to obstetrics and
gynaecology”, 4th Edition, Gordon. M. Stirrat Page
no: 242-245
• “Dewhurst”,”Textbook of obstetrics and
gynaecology for postgraduates”, 4th Edition, C.R
Whitfield

43. Contd..
• “Current”, “Obstetric and Gynecologic Diagnosis
and Treatment”, 8th Edition, Appleton and lange,
Page no: 816-819
• “ Prasai Subedi Durga”, “ Gynaecology Nursing”, 1st
Edition, Medhavi Publication, Page no:288- 298