Unfortunately, prolapse pelvic organs– this is not only an anatomical problem. Complaints are almost never limited to "feelings" foreign body protruding from the vagina." Abnormal position of the pelvic organs leads to pronounced violations in bladder function ( frequent urge, difficulty urinating, chronic urinary retention, recurrent infections), rectum (constipation, difficulty defecating, incontinence of gas and stool), creates difficulties during sexual activity up to complete refusal of the latter, and is the cause of chronic pain syndrome.
Modern women want to live a full life, including sexual life, even in old age.
And with the main manifestations of pelvic organ prolapse, there is no need to talk about a normal, fulfilling life, including sexual life.
Fortunately, today most of the problems outlined above are curable with surgery. Technologies for pelvic floor reconstruction for urinary incontinence and pelvic organ prolapse will be described below.
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Prolapse of the pelvic organs occurs due to damage or weakening of the supporting fascial-ligamentous apparatus, for a number of the above reasons. The cervix is the apex of the pelvic floor and when it descends, a tractional displacement of the anterior and posterior walls of the vagina occurs, followed by its complete eversion. The anterior and posterior walls of the vagina are separated from the bladder and rectum only by layers of the intrapelvic fascia. With its defects, the bladder and/or rectum begin to descend into the lumen of the vagina - forming prolapse and prolapse of the vaginal walls.
Figure 1. “Normal” organ anatomy female pelvis.
Pelvic organ prolapse can occur in the anterior (34%) (Fig. 2), middle (14%) (Fig. 3), and posterior (19%) (Fig. 4). sections of the pelvic floor.
To prolapse anterior section include:
Figure 2. Anatomy of the female pelvic organs with prolapse of the anterior vaginal wall (Cystocele).
Middle segment prolapse includes:
Figure 3. Anatomy of the female pelvic organs with combined prolapse of the walls of the vagina and uterus (Apical prolapse).
Posterior prolapse includes:
Figure 4. Anatomy of the female pelvic organs with prolapse of the posterior vaginal wall (Rectocele)
It is worth noting that isolated prolapse in one section is quite rare; it is often accompanied by prolapse into the vaginal walls in neighboring sections.
There are 2 most common and generally accepted classifications:
First Baden-Walker. According to this classification, there are four stages of pelvic prolapse:
The second is the ICS-1996 classification, POP-Q, which also distinguishes 4 stages. At stage 1, the maximum prolapsed point of the vagina is 1 centimeter above the hymenal ring. At the 2nd stage, the maximum prolapsed point is located below the ring, but not less than 1 centimeter. The 3rd stage occurs when the vagina falls out, but not completely, while at least 2 centimeters must remain inside. Stage 4 - complete vaginal prolapse.
Figure 5. Baden-Walker classification
The frequency of certain types of pelvic organ prolapse in women in our country varies and ranges from 15 to 30 percent. And by the age of fifty, this indicator increases to 40 percent. Among older women, pelvic organ prolapse and prolapse are even more common. Their frequency reaches an impressive 50 - 60 percent.
Recent studies show a very depressing picture.
By the age of fifty, virtually every tenth woman needs surgical treatment of pelvic organ prolapse, and by the age of eighty, this figure doubles.
Pelvic organ prolapse ranks third as an indication for surgical intervention in gynecological institutions, after benign tumors (uterine fibroids), as well as endometriosis. This situation forces the medical community to make the most drastic decisions; in particular, the problem of pelvic organ prolapse has been brought into a separate branch of medicine - pelvioperineology.
All over the world today there are clinics specializing in the treatment of prolapse and prolapse of the pelvic organs, disorders of the urinary system, etc. In particular, at the urology department of the Clinic of High Medical Technologies named after. N.I. Pirogov of St. Petersburg State University, the North-Western Center for Pelvioperineology has been successfully operating for more than five years. The center’s specialists have enormous experience in eliminating POP – pelvic organ prolapse, performing more than 900 operations per year.
✓ Expert level of doctors - high rates of effectiveness and safety of treatment
✓ Treatment of most patients according to compulsory medical insurance policy without bureaucratic delays: collecting certificates, directions, etc.
✓ To organize treatment, call us or write a letter stating your question.
Pelvic organ prolapse does not pose an immediate threat to life, but significantly worsens its quality. The fact is that anatomical disorders, which are a consequence of damage to the structures of the pelvic floor, lead to numerous, sometimes painful, complaints.
Patients with minor pelvic organ prolapse may not seek treatment. medical care for many years and not have any complications, however, numerous studies have confirmed the fact that pelvic organ prolapse is tolerated by patients worse than such serious illnesses, How diabetes and coronary heart disease. In advanced forms, pelvic organ prolapse (especially bladder prolapse) can cause chronic urinary retention and, as a consequence, bilateral hydronephrosis and the subsequent development of chronic renal failure.
To make a diagnosis, collecting complaints and anamnesis of the disease is not enough. Conducting a vaginal examination is a mandatory diagnostic point and is carried out primarily to identify the type of prolapse of the vaginal walls, because the visual picture for Cystocele, Rectocele and uterine prolapse (Uterocele) may be similar.
There are two main directions of treatment for prolapse of the vaginal walls: conservative and surgical
Unfortunately, the window of therapeutic opportunity for most conservative methods (i.e., the period when treatment has the greatest effect) is quite narrow and concerns mainly prevention or treatment initial forms omissions.
Figure 6. Pessary inserted into the vagina.
Surgical treatment is the only effective and at the modern level quite safe method of combating prolapse, prolapse of the uterus and vagina.
At present, traditional surgical interventions for SEVERE forms of cystocele, rectocele or uterine prolapse, which involve plastic surgery with one’s own tissues without the use of “meshes” (Anterior colporrhaphy, perineolevatoroplasty, etc.), cannot be considered the optimal choice.
The reason is extremely high risk relapse (at least percent) with a sufficiently large number of complications (sexual dysfunction, pain syndrome, etc.). Unfortunately, in Russia and the CIS traditional methods still remain the main operations performed for pelvic organ prolapse. And hysterectomy (removal of the uterus) is often used to “treat” pelvic organ prolapse, which in most cases is completely unjustified and even harmful. The common belief that if you remove the uterus, then “nothing will fall out” is a misconception.
The uterus itself does not have any effect on prolapse, being the same hostage to the situation (defect of the pelvic floor ligaments), like other pelvic organs (bladder, rectum, loops of the small intestine). For some reason, no one suggests deleting the latter. Hysterectomy (removal of the uterus) healthy organ using modern technologies is completely unnecessary and has no basis (including oncological ones). However, you need to understand that removing this organ can lead to damage nerve structures regulating urination, disrupt the blood supply to all pelvic organs and, finally, lead to prolapse of the vaginal dome (when the uterus has already been removed) in every fourth woman.
Figure 7. “Hybrid” reconstruction of the pelvic floor using mesh implants for stage 3 pelvic organ prolapse.
With this approach, there is a summation of the pros and leveling of the cons of both methods. Our clinic is one of the pioneers in this area. In our practice, we most often use materials produced by the domestic enterprise Lintex (St. Petersburg), since we have already been convinced of high quality these implants and have the opportunity to directly influence the improvement of all elements of these products through long-term scientific and technical cooperation.
Currently, the North-Western Center for Pelviperineology is based at the Clinic of High Medical Technologies named after. N.I. Pirogov St. Petersburg State University annually provides assistance to more than 1,500 patients with various pathologies pelvic floor from all regions of Russia, the CIS and neighboring countries.
Our clinic performs more than 600 operations per year for urinary incontinence in women and also for prolapse (prolapse) of the pelvic organs (also in combination with urinary incontinence).
Data about all women who received help within our walls are entered into a single register, which allows us to reliably track the results of treatment on different terms(1 month, 6 months, 1 year and then annually). There is already 7-year follow-up data indicating that the effectiveness surgical treatment In our patients, the frequency of erosions exceeding 90 percent when using “synthetics” is 0.2%, and relapses occur in no more than 9% of cases.
But, of course, there is also unresolved problems. We continue to develop and strive to achieve the best results in each specific clinical case. One of our main principles is to constantly monitor the best world trends, exchange experiences and quickly implement achievements into practice.
Pelvic floor reconstructive surgery is a very specialized field that requires a thorough understanding of the anatomy and function of the pelvic organs, as well as proficiency in both “mesh” and “traditional” procedures. Knowledge makes the doctor free to choose a treatment method, and the patient happy with the results.
190121, St. Petersburg, Fontanka River embankment no. 154
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The multidisciplinary urological center operates as part of the High Medical Technologies Clinic named after. N.I. Pirogov St. Petersburg State University.
On the basis of the hospital complex of the clinic, more than 17 thousand patients are treated annually and more than 16 thousand operations of surgical, oncological, cardiac surgery, orthopedic and other profiles are performed.
Our center provides patients with the opportunity for free surgical treatment in accordance with the state program for high-tech medical care and compulsory medical insurance/high-tech medical care. Most patients are treated free of charge (under compulsory medical insurance).
The prolapse or loss of a woman's internal genital organs is commonly called cysto-rectocele. This term refers to a violation of the position of the uterus and vaginal walls relative to the vaginal opening. Strictly speaking, pathologies associated with cysto-rectocele should be considered as a type of pelvic floor hernia.
Sometimes a synonym is used for terminology - genital prolapse. For isolated prolapse of the anterior wall, the term cystocele should be used, and for the posterior wall, rectocele.
As a rule, the disease occurs during reproductive age, developing at a relatively high speed. Of course, as the pathology develops, the functions of certain pelvic organs worsen. Unfortunately, cysto-rectocele causes not only physical suffering; there are often cases when the development of the disease led to complete disability. Failure of the pelvic floor muscles is always accompanied by an increase in intra-abdominal pressure.
There are four main causes of this pathology:
1. Malfunction of the genital organs, namely their synthesis. In addition, too much or too little estrogen also leads to the development of the disease;
2. Failure of connective tissues, which thereby form insufficiency of woven structures;
3. Injuries and other physical damage to the pelvic floor;
4. Various chronic diseases that to one degree or another affect intra-abdominal pressure.
As a result, under the influence of one or more of the above factors, failure of the ligamentous apparatus begins to develop. As a result, intra-abdominal pressure increases and pushes out the pelvic floor organs.
The main symptoms of this pathology are the sensation of a foreign body in the vagina. In addition, patients are always harassed nagging pain in the lower abdomen. Of course, cysto-rectocele affects the entire urinary system. And all this happens against the background of severe constipation.
Diagnosis of cysto-rectocele should be comprehensive and include the following tests:
Vaginal culture;
Ultrasound of all pelvic organs;
Oncocytology of the cervix.
After determining the stage of the disease, doctors will formulate a further course of treatment. If the initial stage is present, the patient will be offered physical therapy, consisting of exercises that are designed to restore normal functionality of the pelvic floor muscles.
In other cases, either drug treatment, or surgical. Typically, the goal of medication is to restore normal estrogen levels. Concerning surgical intervention, then its goal is not so much to eliminate the incorrect position of organs as to correct and restore the functioning of adjacent organs: the bladder and rectum.
The Republican Center for Human Reproduction and Family Planning has excellent doctors who have extensive experience in dealing with these diseases. Come to us for diagnostics and we will answer all your questions.
Select your symptoms:
Official website of the Republican Center for Human Reproduction and Family Planning Moscow, Baumanskaya metro station, Friedrich Engels street, building 23. It is also conveniently accessible by transport from the Kurskaya, Komsomolskaya, Krasnoselskaya, Krasnye Vorota metro stations. By car - convenient access to the medical center from the Third Transport Ring (TTK)
Elena, good afternoon. Please help me figure it out. I am 30 years old. First natural birth 08/01/2014. The child is large, 4240 kg. They did an episiotomy. During childbirth they said there were no cervical ruptures. A month after giving birth they said slight erosion, treat after the end of lactation. Recently I went to a good gynecologist. He also operates in gynecology. As a result, cervical ruptures and failure of the pelvic floor muscles (cystocele 2nd degree, rectocele 2nd degree, prolapse of the walls of the vagina and uterus 2nd degree, NMTD. He said that my genital slit is not closed, there is no natural barrier from microbes. After the incision in childbirth, it turns out to me Only the skin was sewn together, without muscles. I also often pick up the child. The only complaint is air in the vagina (rarely happens during intercourse) and I have started to urinate a little more often. Question 1) how necessary is the operation. If I want another child, is there a high probability of intrauterine infection without surgery (due to an open genital gap) and will the muscles support the fetus without surgery? 2) is it true that such a diagnosis can be made without any special symptoms? 3) after the operation only cesarean? At a later date they may
will the stitches come apart?4) are cervical ruptures really not visible during childbirth? And the fact that only the skin without muscles is sewn together? Thank you very much.
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Weakness (incompetence) of the pelvic floor muscles
Fig 1. Pelvic floor muscles in women
Even in ancient times, it became clear that the muscles of the perineum are no less important for a woman than the main skeletal muscles. At the same time, the first exercises for their development appeared in the East - first to introduce new, more acute sensations into sexual relationships, and then it became clear that these exercises also help to bear and give birth to children more easily, and to quickly restore health after childbirth.
It is wrong to think that weakness of the pelvic floor muscles is only for the elderly; this is far from true. It all starts in adulthood, and for some women even in youth, and in old age due to a decrease in hormone levels the process progresses. The vast majority of scientists assign an important role to pregnancy and childbirth in the development of this condition. Weakness of the pelvic floor muscles is a condition that not only patients, but also many doctors are embarrassed to talk about. Therefore, the degree of its severity is often advanced, and a woman seeks help only when prolapse of the uterus and vagina (prolapse) appears, and treatment is only possible with surgery. The risk of prolapse is significantly higher in women who have given birth, and its degree is associated with the number of births and complications associated with pregnancy and childbirth, such as surgical aids during childbirth, rapid labor, perineal ruptures, large fetuses, etc. Hereditary defects of the connective tissue also play an important role fabrics.
Meanwhile, the transition of pelvic floor muscle weakness to prolapse can be prevented and the risk can be minimized in a simple and natural way.
Symptoms of weak pelvic floor muscles:
Women are most in need of pelvic floor muscle training in the first year after childbirth and during menopause. But exercises are also useful for everyone else, since maintaining muscles in tone is easier than correcting existing disorders.
The pelvic floor musculature is a voluntary striated muscle, and therefore amenable to conscious training, and all the principles and methodology of training muscle strength and endurance apply to it.
The first (and still not outdated) scientific system of intimate gymnastics was developed 60 years ago - in 1950 - by the American gynecologist Arnold Kegel. Since then, “Kegel exercises,” “Kegel complex,” “Kegel exercises” have been recommended by doctors around the world.
A woman can identify the pelvic floor muscles as follows:
The muscles that are used to stop the flow of urine are the pelvic floor muscles. If you can't find them on the first try, you need to try several times.
If the first method did not help to detect exactly those same muscles, then you can try the following: place your finger in the vaginal opening and try to squeeze it. The muscles we need must contract around the finger. In this case, neither the buttock muscles nor the abdominal or back muscles should be involved.
Once you learn to determine the right muscles, go directly to the exercises.
Performing exercises only to compress the pelvic floor muscles at different paces.
Step 1: Clench and unclench your muscles quickly for 10 seconds, then rest for 10 seconds. Perform this exercise in 3 sets.
Step 2. Squeeze and unclench your muscles for 5 seconds, then rest for 5 seconds, repeat squeezing and unclenching 9 times.
Step 3. Squeeze the muscles, hold for 30 seconds and relax for 30 seconds, repeat 2 more times. And repeat step number 1 again.
Step 1: Squeeze your muscles and hold for 5 seconds, then release, repeat 10 times.
Step 2: Quickly clench and unclench your muscles 10 times, repeat 3 times. Squeeze your muscles and hold them for as long as possible (maximum 120 seconds). Rest for 2 minutes and repeat the exercise from the beginning.
Step 1: Squeeze and unclench your muscles 30 times. Then proceed to step 2, gradually the number of compressions in the first step should reach 100 times.
Step 2: Squeeze your muscles as hard as you can and hold for 20 seconds, then relax for 30 seconds. Repeat 5 times.
Start by simply squeezing and relaxing your muscles for 2 minutes, gradually increasing the time to 20 minutes. This exercise must be performed at least 3 times a day.
So, the main thing. If you want to achieve good results, do not forget to do the exercises regularly, and the more often the better. Choose the exercise that is most convenient for you. To maintain constant tone throughout the day, it is necessary to do compressions of varying durations. After this, you will achieve automatic exercise throughout the day. There is no need to set aside special time for this; the exercises can be performed at work, at home, in transport, wherever is convenient for you.
After you learn to squeeze your muscles and they get stronger (after 2-3 months), you can add pushing exercises. In order to feel the perineal muscles and check their enlargement, a woman can insert one or two lubricated fingers into the vagina during a compression exercise.
Performing not only muscle compressions, but also “pushing” exercises.
Exercise 5. pushing out:
Push down moderately, as if you were having a bowel movement or childbirth, 3-5 times.
This exercise alternates with any compression exercise, gradually the number of push-outs increases to 10 at a time, dose per day.
Performing a set of Kegel exercises will strengthen the muscles of the perineum and prevent the occurrence of many female problems.
Prolapse and prolapse of the internal genital organs is a violation of the position of the uterus or vaginal walls, manifested by displacement of the genital organs to the vaginal opening or their prolapse beyond it.
Genital prolapse should be considered as a type of pelvic floor hernia that develops in the area of the vaginal opening. In the terminology of prolapse and prolapse of the internal genital organs, synonyms are widely used, such as “genital prolapse”, “cystorectocele”; The following definitions are used: “prolapse,” incomplete or complete “prolapse of the uterus and vaginal walls.” For isolated prolapse of the anterior vaginal wall, it is appropriate to use the term “cystocele,” and for prolapse of the posterior wall, “rectocele.”
N81.2 Incomplete prolapse of the uterus and vagina.
N81.3 Complete prolapse of the uterus and vagina.
N81.8 Other forms of female genital prolapse (pelvic floor muscle failure, old pelvic floor muscle ruptures).
N99.3 Prolapse of the vaginal vault after hysterectomy.
Epidemiological studies in recent years show that 11.4% of women in the world have a lifetime risk of surgical treatment of genital prolapse, i.e. One in 11 women will undergo surgery in their lifetime due to prolapse and prolapse of the internal genital organs. It should be noted that due to relapse of prolapse, more than 30% of patients are re-operated.
As life expectancy increases, the incidence of genital prolapse increases. Currently, in the structure of gynecological morbidity, prolapse and prolapse of the internal genital organs account for up to 28%, and of the so-called major gynecological operations 15% are carried out specifically for this pathology. In the United States, patients with genital prolapse are operated on annually at a total cost of treatment of $500 million, which is 3% of the healthcare budget.
Basic preventive measures:
I degree - the cervix descends no more than half the length of the vagina.
II degree - the cervix and/or vaginal walls descend to the entrance to the vagina.
III degree - the cervix and/or vaginal walls descend beyond the entrance to the vagina, and the body of the uterus is located above it.
IV degree - the entire uterus and/or vaginal walls are located outside the vaginal opening.
The standardized classification of genital prolapse POP-Q (Pelvic Organ Prolapse Quantification) should be recognized as more modern. It has been accepted by many urogynecological societies around the world (International Continence Society, American Urogynecologic Society, Society or Gynecologic Surgeons, etc.) and is used to describe most studies on this topic. This classification is difficult to learn, but has several advantages.
It should be noted that prolapse means prolapse of the vaginal wall, and not adjacent organs (bladder, rectum) located behind it, until they are accurately identified using additional research methods. For example, the term “posterior wall prolapse” is preferable to the term “rectocele”, since other structures besides the rectum can fill this defect.
In Fig. Figure 27-1 shows a schematic representation of all nine points used in this classification in the sagittal projection of the female pelvis in the absence of prolapse. Measurements are carried out with a centimeter ruler, uterine probe or forceps with a centimeter scale with the patient lying on her back with the maximum severity of prolapse (usually this is achieved by performing the Valsalva maneuver).
Rice. 27-1. Anatomical landmarks for determining the degree of pelvic organ prolapse.
The hymen is a plane that can always be accurately visually determined and relative to which the points and parameters of this system are described. The term "hymen" is preferred to the abstract term "introitus". The anatomical position of six defined points (Aa, Ap, Ba, BP, C, D) is measured above or proximal to the hymen, and a negative value (in centimeters) is obtained. When these points are located below or distal to the hymen, a positive value is recorded. The plane of the hymen corresponds to zero. The remaining three parameters (TVL, GH and PB) are measured in absolute values.
POP-Q staging. The stage is determined by the most prolapsing part of the vaginal wall. There may be prolapse of the anterior wall (point Ba), the apical part (point C) and the posterior wall (point BP).
Simplified POP–Q classification scheme.
Stage 0 - no prolapse. Points Aa, Ar, Ba, Vr - all 3 cm; Points C and D have a minus sign.
Stage I - the most prolapsing part of the vaginal wall does not reach the hymen by 1 cm (value >–1 cm).
Stage II - the most prolapsing part of the vaginal wall is located 1 cm proximal or distal to the hymen.
Stage III - most protruding point more than 1 cm distal to the hymenal plane, but total length vagina (TVL) decreases by no more than 2 cm.
Stage IV - complete loss. The most distal part of the prolapse protrudes more than 1 cm from the hymen, and the total vaginal length (TVL) is reduced by more than 2 cm.
The disease often begins during reproductive age and is always progressive. Moreover, as the process develops, functional disorders also deepen, which, often layered on top of each other, cause not only physical suffering, but also make these patients partially or completely disabled.
With the development of this pathology, there is always an increase in intra-abdominal pressure of an exo or endogenous nature and incompetence of the pelvic floor. There are four main reasons for their occurrence:
Under the influence of one or more of these factors, functional failure of the ligamentous apparatus of the internal genital organs and the pelvic floor occurs. Increased intra-abdominal pressure begins to squeeze the pelvic organs beyond the pelvic floor. The close anatomical connections between the bladder and the vaginal wall contribute to the fact that, against the background of pathological changes in the pelvic diaphragm, including the genitourinary diaphragm, a combined prolapse of the anterior vaginal wall and bladder occurs. The latter becomes the contents of the hernial sac, forming a cystocele. The cystocele also increases under the influence of its own internal pressure in the bladder, resulting in a vicious circle.
A special place is occupied by the problem of the development of urinary incontinence during tension in patients with genital prolapse.
Urodynamic complications are observed in almost every second patient with prolapse and prolapse of the internal genital organs.
A rectocele is formed in a similar way. Proctological complications develop in every third patient with the above pathology.
A special place is occupied by patients with prolapse of the vaginal dome after a hysterectomy. The incidence of this complication ranges from 0.2 to 43%.
Most often, pelvic organ prolapse occurs in elderly and senile patients.
Main complaints: sensation of a foreign body in the vagina, nagging pain in lower sections abdomen and lumbar region, the presence of a hernial sac in the perineum. In most cases, anatomical changes are accompanied by functional disorders of adjacent organs.
Urinary disorders manifest themselves in the form of obstructive urination up to episodes acute delay, urgent urinary incontinence, overactive bladder, urinary incontinence under tension. However, in practice, combined forms are more often observed.
In addition to urination disorders, dyschezia (violation of the adaptive capabilities of the rectal ampulla), constipation, more than 30% of women with genital prolapse suffer from dyspareunia. This led to the introduction of the term “pelvic descent syndrome” or “pelvic dysynergia.”
Apply the following types examination of patients with prolapse and prolapse of the internal genital organs:
When collecting an anamnesis, the peculiarities of the course of labor are clarified, the presence of extragenital diseases, which may be accompanied by an increase in intra-abdominal pressure, and the operations undergone are specified.
The basis for diagnosing prolapse and prolapse of the internal genital organs is a correctly performed two-manual gynecological examination. The degree of prolapse of the walls of the vagina and/or uterus, defects in the urogenital diaphragm and peritoneal perineal aponeurosis are determined. It is imperative to carry out stress tests (Valsalva maneuver, cough test) for prolapsed uterus and vaginal walls, as well as the same tests when modeling the correct position of the genitals.
When conducting a rectovaginal examination, information is obtained about the condition of the anal sphincter, peritoneal-perineal aponeurosis, levators, and the severity of the rectocele.
A transvaginal ultrasound of the uterus and appendages is necessary. Detection of changes in the internal genital organs can expand the scope of the operation during surgical treatment of prolapse before their removal.
Modern ultrasound diagnostic capabilities make it possible to obtain additional information about the state of the bladder sphincter and paraurethral tissues. This must also be taken into account when choosing a method of surgical treatment. Ultrasound for assessing the urethrovesical segment is more informative than cystography, and therefore X-ray methods examinations are used for limited indications.
A combined urodynamic study is aimed at studying the state of detrusor contractility, as well as the closing function of the urethra and sphincter. Unfortunately, in patients with severe prolapse of the uterus and vaginal walls, the study of urination function is difficult due to simultaneous dislocation of the anterior wall
vagina and posterior wall of the bladder beyond the vagina. Conducting a study during the reduction of a genital hernia significantly distorts the results, so it is not necessary in the preoperative examination of patients with pelvic organ prolapse.
Examination of the uterine cavity, bladder, rectum using endoscopic methods is performed according to indications: suspicion of GPE, polyp, endometrial cancer; to exclude diseases of the mucous membrane of the bladder and rectum. For this purpose, other specialists are involved - a urologist, a proctologist. Subsequently, even with adequate surgical treatment, conditions may develop that require conservative treatment by specialists in related fields.
The data obtained are reflected in the clinical diagnosis. For example, with complete prolapse of the uterus and vaginal walls, the patient was diagnosed with UI due to tension. In addition, a vaginal examination revealed a pronounced bulging of the anterior vaginal wall, a defect of the peritoneal perineal aponeurosis of 3x5 cm with prolapse of the anterior wall of the rectum, and levator diastasis.
IV degree prolapse of the uterus and vaginal walls. Cystorectocele. Incompetence of the pelvic floor muscles. NM under tension.
Restoration of the anatomy of the perineum and pelvic diaphragm, as well as normal function adjacent organs.
Conservative treatment can be recommended for uncomplicated forms of the initial stages of pelvic organ prolapse (prolapse of the uterus and vaginal walls of degrees I and II). Treatment is aimed at strengthening the pelvic floor muscles with the help of physical therapy according to Atarbekov (Fig. 27-2, 27-3). The patient needs to change living and working conditions, if they contributed to the development of prolapse, and treat extragenital diseases that affect the formation of a genital hernia.
Rice. 27-2. Therapeutic exercise for genital prolapse (in a sitting position).
Rice. 27-3. Therapeutic exercise for genital prolapse (in a standing position).
In the conservative management of patients with prolapse and prolapse of the internal genital organs, the use of vaginal applicators for electrical stimulation of the pelvic floor muscles can be recommended.
Estrogen deficiency must be corrected, especially by local administration in the form of vaginal products, for example estriol (Ovestin©) in suppositories, in the form of vaginal cream).
For III–IV degrees of prolapse of the uterus and vaginal walls, as well as for complicated forms of prolapse, surgical treatment is recommended.
The purpose of surgical treatment is not only (and not so much) the elimination of violations of the anatomical position of the uterus and vaginal walls, but also the correction functional disorders adjacent organs (bladder and rectum).
The formation of a surgical program in each specific case involves performing a basic operation to create reliable fixation of the vaginal walls (vaginopexy), as well as surgical correction available functional disorders. In case of urinary incontinence with tension, vaginopexy is supplemented with urethropexy using a transobturator or retropubic approach. In case of failure of the pelvic floor muscles, colpoperineolevatoplasty (sphincteroplasty according to indications) is performed.
Prolapse and prolapse of the internal genital organs are corrected using the following surgical approaches.
Vaginal access involves performing vaginal hysterectomy, anterior and/or posterior colporrhaphy, various options for sling (loop) operations, sacrospinal fixation, vaginopexy using synthetic mesh (MESH) prostheses.
Vaginopexy operations are widespread with laparotomy access. own ligaments, aponeurotic fixation, less commonly sacrovaginopexy.
Some types of laparotomy interventions have been adapted to the conditions of laparoscopy. These are sacrovaginopexy, vaginopexy with your own ligaments, suturing of paravaginal defects.
When choosing a method of vaginal fixation, you should take into account the recommendations of the WHO Committee on the Surgical Treatment of Genital Prolapse (2005):
Type of anesthesia: conduction, epidural, intravenous, endotracheal. Position on operating table typical for perineal surgery with intensely adducted legs.
After the introduction of permanent urinary catheter and hydropreparation, an incision is made in the vaginal mucosa, 2–3 cm proximal to the external opening of the urethra, through the dome of the vagina to the skin of the perineum. It is necessary to cut not only the vaginal mucosa, but also the underlying fascia. The posterior wall of the bladder is widely mobilized, opening the cellular spaces of the obturator spaces. The bony tubercle of the ischium is identified.
Further under control index finger Percutaneously, using special conductors, the membrane of the obturator foramen is perforated in two places that are as far apart as possible from each other, with stylets being passed lateral to the arcus tendinous fascia endopelvina.
Next, the anterior wall of the rectum is widely mobilized, the ischiorectal tissue space is opened, and the bony tubercles of the ischial bones and sacrospinal ligaments are identified. Through the skin of the perineum (lateral to the anus and 3 cm below it), identical stylets are used to perforate the sacrospinal ligaments 2 cm medial from the point of attachment to the bony tubercle (safe zone).
Using conductors passed through polyethylene tubes of stylets, a mesh prosthesis of an original shape is installed under the vaginal wall, straightened without tension or fixation (Fig. 27-4).
The vaginal mucosa is sutured with a continuous suture. The polyethylene tubes are removed. Excess mesh prosthesis is cut off subcutaneously. The vagina is tightly tamponed.
Rice. 27-4. Position of the Prolift Total mesh prosthesis.
1 - lig. Uterosacralis; 2 - lig. Sacrospinalis; 3 - Arcus tendinous fascia endopelvina.
The duration of the operation does not exceed 90 minutes, the standard blood loss does not exceed 50–100 ml. The catheter and tampon are removed the next day. In the postoperative period, early activation with inclusion in the sitting position is recommended from the second day. Hospital stay does not exceed 5 days. The criterion for discharge, in addition to the general condition of the patient, is adequate urination. The average time for outpatient rehabilitation is 4–6 weeks.
It is possible to perform plastic surgery of only the anterior or only the posterior wall of the vagina (Prolift anterior/posterior), as well as vaginopexy with a preserved uterus.
The operation can be combined with vaginal hysterectomy or levatoroplasty. For symptoms of UI with tension, it is advisable to simultaneously perform transobturator urethropexy with a synthetic loop (TVT-obt).
Complications associated with the surgical technique include bleeding (the most dangerous is damage to the obturator and pudendal vascular bundles), perforation of hollow organs (bladder, rectum). Late complications include erosion of the vaginal mucosa.
Infectious complications (abscesses and cellulitis) are extremely rare.
Anesthesia: endotracheal anesthesia.
Position on the operating table with the hip joints feet.
Typical laparoscopy using three additional trocars. In case of hypermobility of the sigmoid colon and poor visualization of the promontorium, temporary percutaneous ligature sigmopexy is performed.
Next, the posterior layer of the parietal peritoneum is opened above the level of the promontorium. The latter is isolated until the transverse presacral ligament is clearly visualized. The posterior layer of the peritoneum is opened along the entire length from the promontorium to the pouch of Douglas. The elements of the rectovaginal septum are distinguished (the anterior wall of the rectum, back wall vagina) to the level of the levator ani muscles. A 3x15 cm mesh prosthesis (polypropylene, index soft) is fixed with non-absorbable sutures to the levators on both sides as distally as possible.
At the next stage of the operation, a 3x5 cm mesh prosthesis made of identical material is fixed to the pre-mobilized anterior vaginal wall and stitched with a previously installed prosthesis in the area of the vaginal dome or cervical stump. Under conditions of moderate tension, the prosthesis is fixed with one or two non-absorbable sutures to the transverse presacral ligament (Fig. 275). At the final stage, peritonization is performed. The duration of the operation ranges from 60 to 120 minutes.
Rice. 27-5. Sacrocolpopexy operation. 1 - place of fixation of the prosthesis to the sacrum. 2 - place of fixation of the prosthesis to the walls of the vagina.
When performing laparoscopic vaginopexy, amputation or extirpation of the uterus, retropubic colpopexy according to Birch (for symptoms of UI with tension), and suturing of paravaginal defects can be performed.
It should be noted early activation in the postoperative period. The average postoperative period is 3–4 days. The duration of outpatient rehabilitation is 4–6 weeks.
In addition to the complications typical for laparoscopy, injury to the rectum is possible in 2–3% of cases, bleeding (especially when levators are isolated) in 3–5% of patients. Among the late complications after sacrocolpopexy in combination with hysterectomy, erosion of the vaginal dome is noted (up to 5%).
Patients should follow the recommendations below:
Subsequently, patients should avoid lifting more than 10 kg. It is important to regulate the act of defecation, treat chronic diseases of the respiratory system, accompanied by prolonged cough. Some types are not recommended physical exercise(exercise bike, cycling, rowing). For a long period of time, local use of estrogen-containing drugs in vaginal suppositories is prescribed). Treatment of urinary disorders according to indications.
The prognosis for treatment of genital prolapse is, as a rule, favorable with adequately selected surgical treatment, compliance with the work and rest regime, and limitation of physical activity.
Kan D.V. Guide to obstetric and gynecological urology. - M., 1986.
Kulakov V.I. and others. Operative gynecology / V.I. Kulakov, N.D. Selezneva, V.I. Krasnopolsky. - M., 1990.
Kulakov V.I. and others. Operative gynecology - surgical energies / V.I. Kulakov, L.V. Adamyan, O.V. Mynbaev. - M., 2000.
Krasnopolsky V.I., Radzinsky V.E., Buyanova S.N. and others. Pathology of the vagina and cervix. - M., 1997.
Chukhrienko D.P. and others. Atlas of urogynecological operations / D.P. Chukhrienko, A.V. Lyulko, N.T. Romanenko. - Kyiv, 1981.
Bourcier A.P. Pelvic floor disorders / A.P. Bourcier, E.J. McGuire, P. Abrams. - Elsevier, 2004.
Abrams P., Cardozo L., Khoury S. et al. 2nd International Consultation on Incontinence. - 2nd ed. - Paris, 2002.
Chapple C.R., Zimmern P.E., Brubaker L. et al. Multidisciplinary management of female pelvic floor disorders - Elsevier, 2006.
Petros P.E. The female pelvic floor. Function, dysfunction and management according to the integral theory. - Springer, 2004.
The prolapse or loss of a woman's internal genital organs is commonly called cysto-rectocele. This term refers to a violation of the position of the uterus and vaginal walls relative to the vaginal opening. Strictly speaking, pathologies associated with cysto-rectocele should be considered as a type of pelvic floor hernia.
Sometimes a synonym is used for terminology - genital prolapse. For isolated prolapse of the anterior wall, the term cystocele should be used, and for the posterior wall, rectocele.
As a rule, the disease occurs during reproductive age, developing at a relatively high speed. Of course, as the pathology develops, the functions of certain pelvic organs worsen. Unfortunately, cysto-rectocele causes not only physical suffering; there are often cases when the development of the disease led to complete disability. Failure of the pelvic floor muscles is always accompanied by an increase in intra-abdominal pressure.
There are four main causes of this pathology:
1. Malfunction of the genital organs, namely their synthesis. In addition, too much or too little estrogen also leads to the development of the disease;
2. Failure of connective tissues, which thereby form insufficiency of woven structures;
3. Injuries and other physical damage to the pelvic floor;
4. Various chronic diseases that to one degree or another affect intra-abdominal pressure.
As a result, under the influence of one or more of the above factors, failure of the ligamentous apparatus begins to develop. As a result, intra-abdominal pressure increases and pushes out the pelvic floor organs.
The main symptoms of this pathology- feeling of a foreign body in the vagina. In addition, patients are always haunted by nagging pain in the lower abdomen. Of course, cysto-rectocele affects the entire urinary system. And all this happens against the background of severe constipation.
Diagnosis of cysto-rectocele should be comprehensive and include the following tests:
- vaginal smear;
- vaginal culture;
- colposcopy;
- Ultrasound of all pelvic organs;
- oncocytology of the cervix.
After determining the stage of the disease, doctors will formulate a further course of treatment. If there is an initial stage, the patient will be offered physiotherapy, consisting of exercises that are designed to restore normal functionality of the pelvic floor muscles.
In other cases, either drug treatment, or surgical. Typically, the goal of medication is to restore normal estrogen levels. As for surgical intervention, its goal is not so much to eliminate the incorrect position of organs, but to correct and restore the functioning of adjacent organs: the bladder and rectum.
Prolapse and prolapse of the internal genital organs is a violation of the position of the uterus or vaginal walls, manifested by displacement of the genital organs to the vaginal opening or their prolapse beyond it.
Genital prolapse should be considered as a type of pelvic floor hernia that develops in the area of the vaginal opening. In the terminology of prolapse and prolapse of the internal genital organs, synonyms are widely used, such as “genital prolapse”, “cystorectocele”; The following definitions are used: “prolapse,” incomplete or complete “prolapse of the uterus and vaginal walls.” For isolated prolapse of the anterior vaginal wall, it is appropriate to use the term “cystocele,” and for prolapse of the posterior wall, “rectocele.”
ICD-10 CODE
N81.1 Cystocele.
N81.2 Incomplete prolapse of the uterus and vagina.
N81.3 Complete prolapse of the uterus and vagina.
N81.5 Enterocele.
N81.6 Rectocele.
N81.8 Other forms of female genital prolapse (pelvic floor muscle failure, old pelvic floor muscle ruptures).
N99.3 Prolapse of the vaginal vault after hysterectomy.
Epidemiological studies in recent years show that 11.4% of women in the world have a lifetime risk of surgical treatment of genital prolapse, i.e. One in 11 women will undergo surgery in their lifetime due to prolapse and prolapse of the internal genital organs. It should be noted that due to relapse of prolapse, more than 30% of patients are re-operated.
As life expectancy increases, the incidence of genital prolapse increases. Currently, in the structure of gynecological morbidity, prolapse and prolapse of the internal genital organs account for up to 28%, and of the so-called major gynecological operations, 15% are performed specifically for this pathology. In the United States, about 100,000 patients with genital prolapse are operated on annually at a total treatment cost of $500 million, which is 3% of the health care budget.
Basic preventive measures:
I degree - the cervix descends no more than half the length of the vagina.
II degree - the cervix and/or vaginal walls descend to the entrance to the vagina.
III degree - the cervix and/or vaginal walls descend beyond the entrance to the vagina, and the body of the uterus is located above it.
IV degree - the entire uterus and/or vaginal walls are located outside the vaginal opening.
The standardized classification of genital prolapse POP-Q (Pelvic Organ Prolapse Quantification) should be recognized as more modern. It has been accepted by many urogynecological societies around the world (International Continence Society, American Urogynecologic Society, Society or Gynecologic Surgeons, etc.) and is used to describe most studies on this topic. This classification is difficult to learn, but has several advantages.
It should be noted that prolapse means prolapse of the vaginal wall, and not adjacent organs (bladder, rectum) located behind it, until they are accurately identified using additional research methods. For example, the term “posterior wall prolapse” is preferable to the term “rectocele”, since other structures besides the rectum can fill this defect.
In Fig. Figure 27-1 shows a schematic representation of all nine points used in this classification in the sagittal projection of the female pelvis in the absence of prolapse. Measurements are carried out with a centimeter ruler, uterine probe or forceps with a centimeter scale with the patient lying on her back with the maximum severity of prolapse (usually this is achieved by performing the Valsalva maneuver).
Rice. 27-1. Anatomical landmarks for determining the degree of pelvic organ prolapse.
The hymen is a plane that can always be accurately visually determined and relative to which the points and parameters of this system are described. The term "hymen" is preferred to the abstract term "introitus". The anatomical position of six defined points (Aa, Ap, Ba, BP, C, D) is measured above or proximal to the hymen, and a negative value (in centimeters) is obtained. When these points are located below or distal to the hymen, a positive value is recorded. The plane of the hymen corresponds to zero. The remaining three parameters (TVL, GH and PB) are measured in absolute values.
POP-Q staging. The stage is determined by the most prolapsing part of the vaginal wall. There may be prolapse of the anterior wall (point Ba), the apical part (point C) and the posterior wall (point BP).
Simplified POP–Q classification scheme.
Stage 0 - no prolapse. Points Aa, Ar, Ba, Vr - all 3 cm; Points C and D have a minus sign.
Stage I - the most prolapsing part of the vaginal wall does not reach the hymen by 1 cm (value >–1 cm).
Stage II - the most prolapsing part of the vaginal wall is located 1 cm proximal or distal to the hymen.
Stage III is the most protruding point more than 1 cm distal to the hymenal plane, but the total vaginal length (TVL) is reduced by no more than 2 cm.
Stage IV - complete loss. The most distal part of the prolapse protrudes more than 1 cm from the hymen, and the total vaginal length (TVL) is reduced by more than 2 cm.
The disease often begins during reproductive age and is always progressive. Moreover, as the process develops, functional disorders also deepen, which, often layered on top of each other, cause not only physical suffering, but also make these patients partially or completely disabled.
With the development of this pathology, there is always an increase in intra-abdominal pressure of an exo or endogenous nature and incompetence of the pelvic floor. There are four main reasons for their occurrence:
Under the influence of one or more of these factors, functional failure of the ligamentous apparatus of the internal genital organs and the pelvic floor occurs. Increased intra-abdominal pressure begins to squeeze the pelvic organs beyond the pelvic floor. The close anatomical connections between the bladder and the vaginal wall contribute to the fact that, against the background of pathological changes in the pelvic diaphragm, including the genitourinary diaphragm, a combined prolapse of the anterior vaginal wall and bladder occurs. The latter becomes the contents of the hernial sac, forming a cystocele. The cystocele also increases under the influence of its own internal pressure in the bladder, resulting in a vicious circle.
A special place is occupied by the problem of the development of urinary incontinence during tension in patients with genital prolapse.
Urodynamic complications are observed in almost every second patient with prolapse and prolapse of the internal genital organs.
A rectocele is formed in a similar way. Proctological complications develop in every third patient with the above pathology.
A special place is occupied by patients with prolapse of the vaginal dome after a hysterectomy. The incidence of this complication ranges from 0.2 to 43%.
Most often, pelvic organ prolapse occurs in elderly and senile patients.
The main complaints: sensation of a foreign body in the vagina, nagging pain in the lower abdomen and lumbar region, the presence of a hernial sac in the perineum. In most cases, anatomical changes are accompanied by functional disorders of adjacent organs.
Urinary disorders manifest themselves in the form of obstructive urination, up to episodes of acute retention, urgent urinary incontinence, overactive bladder, and urinary incontinence under stress. However, in practice, combined forms are more often observed.
In addition to urination disorders, dyschezia (violation of the adaptive capabilities of the rectal ampulla), constipation, more than 30% of women with genital prolapse suffer from dyspareunia. This led to the introduction of the term “pelvic descent syndrome” or “pelvic dysynergia.”
The following types of examination of patients with prolapse and prolapse of the internal genital organs are used:
When collecting an anamnesis, the peculiarities of the course of labor are clarified, the presence of extragenital diseases, which may be accompanied by an increase in intra-abdominal pressure, and the operations undergone are specified.
The basis for diagnosing prolapse and prolapse of the internal genital organs is a correctly performed two-manual gynecological examination. The degree of prolapse of the walls of the vagina and/or uterus, defects in the urogenital diaphragm and peritoneal perineal aponeurosis are determined. It is imperative to carry out stress tests (Valsalva maneuver, cough test) for prolapsed uterus and vaginal walls, as well as the same tests when modeling the correct position of the genitals.
When conducting a rectovaginal examination, information is obtained about the condition of the anal sphincter, peritoneal-perineal aponeurosis, levators, and the severity of the rectocele.
A transvaginal ultrasound of the uterus and appendages is necessary. Detection of changes in the internal genital organs can expand the scope of the operation during surgical treatment of prolapse before their removal.
Modern ultrasound diagnostic capabilities make it possible to obtain additional information about the condition of the bladder sphincter and paraurethral tissues. This must also be taken into account when choosing a method of surgical treatment. Ultrasound for assessing the urethrovesical segment is more informative than cystography, and therefore X-ray examination methods are used for limited indications.
A combined urodynamic study is aimed at studying the state of detrusor contractility, as well as the closing function of the urethra and sphincter. Unfortunately, in patients with severe prolapse of the uterus and vaginal walls, the study of urination function is difficult due to simultaneous dislocation of the anterior wall
vagina and posterior wall of the bladder beyond the vagina. Conducting a study during the reduction of a genital hernia significantly distorts the results, so it is not necessary in the preoperative examination of patients with pelvic organ prolapse.
Examination of the uterine cavity, bladder, rectum using endoscopic methods is performed according to indications: suspicion of GPE, polyp, endometrial cancer; to exclude diseases of the mucous membrane of the bladder and rectum. For this purpose, other specialists are involved - a urologist, a proctologist. Subsequently, even with adequate surgical treatment, conditions may develop that require conservative treatment by specialists in related fields.
The data obtained are reflected in the clinical diagnosis. For example, with complete prolapse of the uterus and vaginal walls, the patient was diagnosed with UI due to tension. In addition, a vaginal examination revealed a pronounced bulging of the anterior vaginal wall, a 3x5 cm defect in the peritoneoperineal aponeurosis with prolapse of the anterior wall of the rectum, and levator diastasis.
IV degree prolapse of the uterus and vaginal walls. Cystorectocele. Incompetence of the pelvic floor muscles. NM under tension.
Restoration of the anatomy of the perineum and pelvic diaphragm, as well as the normal function of adjacent organs.
Conservative treatment can be recommended for uncomplicated forms of the initial stages of pelvic organ prolapse (prolapse of the uterus and vaginal walls of degrees I and II). Treatment is aimed at strengthening the pelvic floor muscles with the help of physical therapy according to Atarbekov (Fig. 27-2, 27-3). The patient needs to change living and working conditions, if they contributed to the development of prolapse, and treat extragenital diseases that affect the formation of a genital hernia.
Rice. 27-2. Therapeutic exercise for genital prolapse (in a sitting position).
Rice. 27-3. Therapeutic exercise for genital prolapse (in a standing position).
In the conservative management of patients with prolapse and prolapse of the internal genital organs, the use of vaginal applicators for electrical stimulation of the pelvic floor muscles can be recommended.
Estrogen deficiency must be corrected, especially by local administration in the form of vaginal products, for example estriol (Ovestin©) in suppositories, in the form of vaginal cream).
For III–IV degrees of prolapse of the uterus and vaginal walls, as well as for complicated forms of prolapse, surgical treatment is recommended.
The purpose of surgical treatment is not only (and not so much) the elimination of disturbances in the anatomical position of the uterus and vaginal walls, but also the correction of functional disorders of adjacent organs (bladder and rectum).
The formation of a surgical program in each specific case involves performing a basic operation to create reliable fixation of the vaginal walls (vaginopexy), as well as surgical correction of existing functional disorders. In case of urinary incontinence with tension, vaginopexy is supplemented with urethropexy using a transobturator or retropubic approach. In case of failure of the pelvic floor muscles, colpoperineolevatoplasty (sphincteroplasty according to indications) is performed.
Prolapse and prolapse of the internal genital organs are corrected using the following surgical approaches.
Vaginal access involves performing vaginal hysterectomy, anterior and/or posterior colporrhaphy, various options for sling (loop) operations, sacrospinal fixation, vaginopexy using synthetic mesh (MESH) prostheses.
With laparotomy access, vaginopexy with native ligaments, aponeurotic fixation, and less commonly sacrovaginopexy are widely used.
Some types of laparotomy interventions have been adapted to the conditions of laparoscopy. These are sacrovaginopexy, vaginopexy with your own ligaments, suturing of paravaginal defects.
When choosing a method of vaginal fixation, you should take into account the recommendations of the WHO Committee on the Surgical Treatment of Genital Prolapse (2005):
Type of anesthesia: conduction, epidural, intravenous, endotracheal. The position on the operating table is typical for perineal surgery with intensely adducted legs.
After insertion of a permanent urinary catheter and hydropreparation, an incision is made in the vaginal mucosa, 2–3 cm proximal to the external opening of the urethra, through the dome of the vagina to the skin of the perineum. It is necessary to cut not only the vaginal mucosa, but also the underlying fascia. The posterior wall of the bladder is widely mobilized, opening the cellular spaces of the obturator spaces. The bony tubercle of the ischium is identified.
Next, under the control of the index finger, the membrane of the obturator foramen is perforated percutaneously using special conductors in two places that are as far apart as possible from each other, with stylets being passed lateral to the arcus tendinous fascia endopelvina.
Next, the anterior wall of the rectum is widely mobilized, the ischiorectal tissue space is opened, and the bony tubercles of the ischial bones and sacrospinal ligaments are identified. Through the skin of the perineum (lateral to the anus and 3 cm below it), identical stylets are used to perforate the sacrospinal ligaments 2 cm medial from the point of attachment to the bony tubercle (safe zone).
Using conductors passed through polyethylene tubes of stylets, a mesh prosthesis of an original shape is installed under the vaginal wall, straightened without tension or fixation (Fig. 27-4).
The vaginal mucosa is sutured with a continuous suture. The polyethylene tubes are removed. Excess mesh prosthesis is cut off subcutaneously. The vagina is tightly tamponed.
Rice. 27-4. Position of the Prolift Total mesh prosthesis.
1 - lig. Uterosacralis; 2 - lig. Sacrospinalis; 3 - Arcus tendinous fascia endopelvina.
The duration of the operation does not exceed 90 minutes, the standard blood loss does not exceed 50–100 ml. The catheter and tampon are removed the next day. In the postoperative period, early activation with inclusion in the sitting position is recommended from the second day. Hospital stay does not exceed 5 days. The criterion for discharge, in addition to the general condition of the patient, is adequate urination. The average time for outpatient rehabilitation is 4–6 weeks.
It is possible to perform plastic surgery of only the anterior or only the posterior wall of the vagina (Prolift anterior/posterior), as well as vaginopexy with a preserved uterus.
The operation can be combined with vaginal hysterectomy or levatoroplasty. For symptoms of UI with tension, it is advisable to simultaneously perform transobturator urethropexy with a synthetic loop (TVT-obt).
Complications associated with the surgical technique include bleeding (the most dangerous is damage to the obturator and pudendal vascular bundles), perforation of hollow organs (bladder, rectum). Late complications include erosion of the vaginal mucosa.
Infectious complications (abscesses and cellulitis) are extremely rare.
Anesthesia: endotracheal anesthesia.
Position on the operating table with legs apart and extended at the hip joints.
Typical laparoscopy using three additional trocars. In case of hypermobility of the sigmoid colon and poor visualization of the promontorium, temporary percutaneous ligature sigmopexy is performed.
Next, the posterior layer of the parietal peritoneum is opened above the level of the promontorium. The latter is isolated until the transverse presacral ligament is clearly visualized. The posterior layer of the peritoneum is opened along the entire length from the promontorium to the pouch of Douglas. The elements of the rectovaginal septum (anterior wall of the rectum, posterior wall of the vagina) are isolated to the level of the levator ani muscles. A 3x15 cm mesh prosthesis (polypropylene, index soft) is fixed with non-absorbable sutures to the levators on both sides as distally as possible.
At the next stage of the operation, a 3x5 cm mesh prosthesis made of identical material is fixed to the pre-mobilized anterior vaginal wall and stitched with a previously installed prosthesis in the area of the vaginal dome or cervical stump. Under conditions of moderate tension, the prosthesis is fixed with one or two non-absorbable sutures to the transverse presacral ligament (Fig. 275). At the final stage, peritonization is performed. The duration of the operation ranges from 60 to 120 minutes.
Rice. 27-5. Sacrocolpopexy operation. 1 - place of fixation of the prosthesis to the sacrum. 2 - place of fixation of the prosthesis to the walls of the vagina.
When performing laparoscopic vaginopexy, amputation or extirpation of the uterus, retropubic colpopexy according to Birch (for symptoms of UI with tension), and suturing of paravaginal defects can be performed.
It should be noted early activation in the postoperative period. The average postoperative period is 3–4 days. The duration of outpatient rehabilitation is 4–6 weeks.
In addition to the complications typical for laparoscopy, injury to the rectum is possible in 2–3% of cases, bleeding (especially when levators are isolated) in 3–5% of patients. Among the late complications after sacrocolpopexy in combination with hysterectomy, erosion of the vaginal dome is noted (up to 5%).
Patients should follow the recommendations below:
Subsequently, patients should avoid lifting more than 10 kg. It is important to regulate the act of defecation and treat chronic diseases of the respiratory system, accompanied by a prolonged cough. Some types of physical exercise (exercise bike, cycling, rowing) are not recommended. For a long period of time, local use of estrogen-containing drugs in vaginal suppositories is prescribed). Treatment of urinary disorders according to indications.
The prognosis for treatment of genital prolapse is, as a rule, favorable with adequately selected surgical treatment, compliance with the work and rest regime, and limitation of physical activity.
BIBLIOGRAPHY
Kan D.V. Guide to obstetric and gynecological urology. - M., 1986.
Kulakov V.I. and others. Operative gynecology / V.I. Kulakov, N.D. Selezneva, V.I. Krasnopolsky. - M., 1990.
Kulakov V.I. and others. Operative gynecology - surgical energies / V.I. Kulakov, L.V. Adamyan, O.V. Mynbaev. - M., 2000.
Krasnopolsky V.I., Radzinsky V.E., Buyanova S.N. and others. Pathology of the vagina and cervix. - M., 1997.
Chukhrienko D.P. and others. Atlas of urogynecological operations / D.P. Chukhrienko, A.V. Lyulko, N.T. Romanenko. - Kyiv, 1981.
Bourcier A.P. Pelvic floor disorders / A.P. Bourcier, E.J. McGuire, P. Abrams. - Elsevier, 2004.
Abrams P., Cardozo L., Khoury S. et al. 2nd International Consultation on Incontinence. - 2nd ed. - Paris, 2002.
Chapple C.R., Zimmern P.E., Brubaker L. et al. Multidisciplinary management of female pelvic floor disorders - Elsevier, 2006.
Petros P.E. The female pelvic floor. Function, dysfunction and management according to the integral theory. - Springer, 2004.
The pelvic floor includes groups of muscles and connective tissue membranes. When they weaken, problems appear: loss of control over bladder and intestines. A weakened pelvic floor can cause the pelvic organs to shift forward or downward. Pelvic floor muscle incompetence (PFMI) is the most painful for women. It can lead to a serious disease - cysto-rectocele (ICD 10 code - N81), which involves prolapse of the uterus and vaginal walls with their infringement. However, genital prolapse can also occur in men.
The muscular masses of the pelvic floor are almost not involved in usual training, even with systematic visits to the gym. This is the main reason for their weakness.
Other common risk factors for pelvic floor muscle and ligament insufficiency include:
Dysfunction of the pelvic muscles of a neurological nature can occur against the background of disorders nervous system. This usually happens among boys and girls.
The most common “female” factor that provokes the disease is pregnancy and childbirth. The process of labor is associated with an increase in pressure inside the peritoneum and causes overstretching of the muscles and fascia of the pelvic floor, which cannot always be restored after the baby is born. In this case, the sacrum moves forward, inside the pelvis, and the muscles attached to it sag.
In women in the postmenopausal stage, the disorder provokes a failure in the synthesis of sex hormones, especially estrogen.
Symptoms usually depend on the tone of the pelvic floor muscles. Hypotonia is a condition when the muscle mass does not contract properly, which causes urinary and fecal incontinence. Urine leaks usually occur when coughing, sneezing, laughing or physical activity.
Hypertonicity is a condition in which it is impossible to completely relax the muscles. This leads to difficulty urinating, delayed bowel movements and chronic pelvic pain syndrome. Causes pain during sexual intercourse in women, erectile dysfunction or ejaculation disorders in men. Excessive tension is accompanied by the formation of myofascial trigger points, which are clearly felt during palpation in the muscles as painful dense nodes.
Besides common features additional symptoms weakening of the pelvic floor muscles is observed in women:
After the examination, a violation is discovered vaginal microflora and urethra.
Protocol diagnostic procedures compiled by doctor. After discussing the symptoms, the attending physician will prescribe a gynecological or urological examination, based on the results of which he will try to find symptoms of muscle weakening.
Women must undergo the following tests:
Depending on the nature and severity of the symptoms, the doctor may make changes to the drawn up plan and prescribe additional procedures. This is necessary to more accurately determine the level of attenuation and indicate the appropriate treatment method.
Some procedures are aimed at assessing the quality of functioning of the bladder and urethra, others focus on the muscles of the rectum: ultrasound examination of the pelvic organs or gynecological, CT, MRI.
Treatment of pelvic floor muscle dysfunction is carried out conservatively or surgically. Conservative methods allow you to cure mild forms of the disease. Treatment procedures are selected individually, taking into account all contraindications.
Non-surgical methods include:
For representatives of the fair sex, the doctor may prescribe hormonal medications to normalize estrogen levels. Physiotherapy is also useful, for example, it is recommended to use vaginal applicators for electrical stimulation of the pelvic muscles. You can use them yourself at home without going to a medical facility.
Simultaneously with strengthening muscle functions, it is necessary to treat primary and accompanying ailments, for example, neurological ones. During therapy, it is necessary to exclude excessive physical activity and heavy lifting. At strong stretching Doctors advise wearing a special bandage on the front wall of the abdomen.
The prognosis for recovery depends on the degree of the disease and whether prolapse of nearby organs has occurred. If you seek medical help early, the outcome is favorable.
If non-surgical methods fail to relieve unpleasant symptoms, surgery will come to the rescue. Several types of operations have been developed that help get rid of such dysfunctions. The doctor will suggest a suitable manipulation depending on the degree of damage and characteristic symptoms.
The main goal of all interventions for urinary incontinence is to provide bladder support. Excreta incontinence requires operational recovery muscles of the anus.
If omitted internal organs, the muscular-ligamentous apparatus of the pelvic floor needs to be corrected. Women are recommended to have uterine rings installed to support sagging organs. IN difficult cases When the uterus prolapses, surgery is performed to return it to its place.
In folk medicine, decoctions of nettle roots, flaxseed, and St. John's wort are used to stimulate muscle activity. Before trying the recipe on yourself, consult your doctor so as not to worsen the situation.
Failure of the pelvic floor muscles often occurs due to their overload. Muscular fatigue gradually accumulates, and at some point, muscle masses and ligaments sag. In some cases, it is impossible to prevent dysfunction, but some prevention of muscle failure exists. To prevent muscles from weakening, you must:
Preventing constipation is extremely important. Eat foods high in fiber and try to avoid stress.
A person suffering from urinary and fecal incontinence has to make efforts to maintain normal hygiene. There are certain medications that help relieve discomfort: absorbent pads, disposable panties, or special underwear with the ability to change pads. There are options that help even with severe incontinence, for example, special diapers for adults.
It is important to take care of your skin to avoid overhydration, rashes and diaper rash.
Specialized powders, lotions and antibacterial soaps should be used. Special creams have been developed that keep the skin dry even with severe incontinence and protect against irritation.
Medicine is constantly looking for ways to get rid of NMTD and its unpleasant companions - genital prolapse and involuntary discharge of urine and excrement. However, any disease is easier to prevent, which is why preventive measures are so important.
Incompetence of the pelvic floor muscles - let's put everything back in place!
Or it’s easier to prevent than to treat.
Pelvic floor muscle failure is a condition when the muscles designed to hold the pelvic organs in a certain position are unable to fully perform their functions.
Not so long ago, such a problem was delicately hushed up by the fair sex, but the situation is radically changing and now more and more publications are appearing aimed at increasing women's awareness of ways to combat this unpleasant illness.
The pelvic floor muscles are a group of muscles located deep in the pelvis. Everyone knows that in order to perform their functions well, they must undergo regular training to maintain good tone. The muscles that form the pelvic floor practically do not take part in usual workouts, even if a woman regularly visits the gym. This is the problem of maintaining the tone of this muscle group.
In the absence of regular exercise, the muscles weaken, which leads first to sagging and then to prolapse of the pelvic organs.
What accelerates the manifestation of the problem?
How to determine if there is a problem?
Most often, incompetence of the pelvic floor muscles begins to appear after childbirth and during menopause With intimate problems. Dysuric disorders are typical: frequent urination, a feeling of incomplete emptying of the bladder, urinary incontinence during stress (coughing, sneezing, laughing). As the problem progresses, a sensation of a foreign body in the vagina occurs. in advanced cases, failure of the pelvic floor muscles leads to varying degrees of prolapse of the pelvic organs through the vagina
.
Methods to combat the problem
In advanced cases (in the presence of prolapse or prolapse of the genital organs), the only treatment method is surgery. Despite the development plastic surgery Today, surgical treatment is often carried out repeatedly, because the disease is prone to relapse.
Surgical treatment – promontofixation.
If surgical treatment is contraindicated ( old age, severe diseases), then individual selection and installation of gynecological pessaries is carried out. Currently, the German pessaries of Dr. Arabin are considered the most convenient - special devices that can have various sizes and shape: ring, cube, mushroom, etc. Pessaries serve as support for sagging organs and prevent genital loss.
With timely treatment, each patient individually (taking into account age, condition of connective tissue, pelvic floor muscles, degree of incompetence and its causes) can choose a conservative approach, including a special set of exercises for the pelvic floor muscles (Kegel exercises or others) using a variety of exercise machines or without them, pneumopelviometry, electrical stimulation, plasma lifting, etc.
The rehabilitation complex in each specific case had to be individual, since the causes and anatomical damage in this disease can be different, and approaches that are useful for some patients can contribute to the progression of prolapse in other women.
Complete solution problems of pelvic floor muscle incompetence in women:
Incompetence of the pelvic floor muscles is not a death sentence, but just a problem.
Let's solve it together. And the specialists of our clinic will help you.
Consult a specialist
Clinics for women's and men's health "Fenareta"
