Surgical treatment for pelvic organs / genital prolapsus
Prolapse of internal genital organs - a violation of the provisions of the uterus or vaginal wall, manifested displacement genitals to vaginal entrance or loss of beyond.
The prevalence of this disease reaches 34,1-56,3% and is 28-38,9% of the gynecological diseases. The structure of the indications for surgical treatment of the planned loss of the uterus and vagina in third place after benign tumors and endometriosis.
In addition, a group of patients with prolapse of genitals up patients with prolapse of the vaginal stump, cervical stump after radical surgery on the uterus: Hysterectomy and supravaginal hysterectomy.
In 85.5% of patients with prolapse of internal genital organs develop functional disorders related bodies:
- Incontinence - in 70.1% of patients;
- Violation of defecation - at 36.5%;
- Dyspareunia - in 53.3% of patients.
The frequency of genital organs prolapse, urinary disorders increase with age. Urogenital disorders (PEM) was observed in 30% of women aged 55 years and 75% - up to 70 years.
Classification of MS Malinowski - one of the most simple, convenient and commonly used. There are three degrees of ptosis (Figure 1):
- I level - the cervix is lowered to not more than the vagina;
- II degree - the cervix is located below the entrance to the vagina, and the body of the uterus -
- III degree - the entire uterus is located outside the entrance to the vagina.
Fig. 1. Classification of genitals prolapse MS Malinowski.
In recent years, more and more often use the International Classification system POP-Q (Pelvic Organ Prolapse Quantification) - a quantitative classification based on the measurement of nine parameters: Aa - urethrovesical segment; Ba - the front wall of the vagina; Ap - the lower part of the rectum; Bp - above the levator; C - Cervix (neck); D - Douglas (posterior fornix); TVL - the total length of the vagina; GH - genital slit; PB - perineal body (Fig. 2).
Classification of genitals prolapse system POP-Q.
According to the classification, degree of prolapse are the following:
Stage 0 - no prolapse. Points Aa, Ap, Ba, Bp - all 3 cm; points C and D have a value with a minus sign.
Stage I - the most dropping out of the vaginal wall does not reach the hymen 1 cm (value> -1 cm).
Stage II - the most dropping out of the vaginal wall is 1 cm proximal or distal hymen.
Stage III - most point of falling out more than 1 cm distal gimenalnoy plane, but the overall length of the sheath (TVL) is reduced by no more than 2 cm.
Stage IV - a complete loss. The most distal portion of the prolapse project more than 1 cm from the hymen, and the total length of the vagina (TVL) is reduced by more than 2 cm.
10 Code ICD-
N81.2 Incomplete loss of the uterus and vagina.
N81.3 complete loss of the uterus and vagina.
N81.8 Other forms of loss of female genital mutilation (failure of the pelvic floor muscles, old fractures of the pelvic floor).
N99.3 vaginal vault prolapse after hysterectomy.
The main cause of prolapse of genitals - the failure of the pelvic floor to provide full support to the pelvic organs. Prolapse of genital organs should be regarded as a hernia pelvic floor. The development of the genital organs prolapse in women - a consequence of complex disorders, including repeated deliveries per vias naturales - important but not the only risk factor.
Risk factors for genital prolapse are:
- Traumatic birth (large fruit, long, repetitive labor, vaginal rodorazreshayuschie operations perineal tears);
- Failure of the connective tissue structures in the form of a "systemic" disease, manifested by the presence of hernias other sites - dysplasia of connective tissue;
- Violation of the synthesis of steroid hormones (estrogen deficiency);
- Chronic diseases accompanied by metabolic disturbances, microcirculation.
The clinical picture
The main symptoms of pelvic organ prolapse:
- Dehiscence genital slit at rest and / or stress;
- Education, protrudes from a sexual crack (symptom is loss of the walls of the vagina and uterus);
- Foreign body sensation;
- Discomfort in the crotch;
- The inconvenience of walking;
- Dragging pain in the abdomen;
- Dyspareunia (painful intercourse);
- Bleeding from the genital tract after intercourse.
Displacement of the uterus breaks down the blood circulation in the pelvis, it contributes to stagnant processes accompanied by pain pulling character, a sense of pressure in the abdomen, pain in the lower back, sacrum, amplified by the end of the day, or during and after the walk.
Constant dryness or injury walls leads to the formation of cracks, abrasions, ulcers, as well as the occurrence of bleeding from the genital tract. The clinical picture of menopausal symptoms is compounded by vaginal atrophy. Reducing natural anti-infective barrier leads to frequent vaginitis and cervicitis.
A characteristic feature of symptoms that develops with descent and prolapse of internal genital organs - the presence of functional disorders not only the sexual organs, but also in other pelvic organs. Violations of urinary function in patients are represented mainly by complaints of frequent urination and stress incontinence.
With advanced forms of prolapse (full loss of the uterus) is most characteristic labored urination up to the AUR. When severe functional impairment of pelvic floor disorders occur defecation and fecal incontinence of gases.
Methods of surgical treatment
Among the methods of surgical correction of the omission or loss of pelvic organs can distinguish several groups:
1. Plastic surgery to strengthen the pelvic floor - front kolporrafiya, kolpoperineolevatoroplastika. These operations should be performed in all cases of surgery for prolapse of genitals as an additional or main benefit.
Plastic surgery on the anterior wall of the vagina are aimed at strengthening the vesicovaginal fascia or to perform muscle-fascial plastic overlay on the vesicovaginal fascia purse-string sutures or stitches in the transverse direction.
Perineolevatoroplastika (restoring the posterior vaginal wall and perineum), made for women in the early stages of insolvency pelvic floor prolapse even without symptoms, prevention is the descent and prolapse of pelvic organs and comorbidity.
2. Operations aimed at strengthening the fixing apparatus of the uterus and changing the position of the body of the uterus in a state hyperanteflexio due to cross-linking radical or sacro-uterine ligaments between themselves and their transposition to the front wall of the cervix. This group includes the Manchester operation and its more complex modifications - tservikopeksiyu on Shirodkar.
3. Operations using alloplastic materials to strengthen the ligamentous apparatus of the uterus and its fixation (TVT - Tensionfree Vaginal Tape, TOT) - a method of surgical treatment of pelvic organ prolapse through the installation of special nets, which subsequently performs the locking and supporting function.
4. Activities aimed at virtually full or partial obliteration of the vagina (median kolporrafiya Neugebauer-Lefort).
5. Radical surgery - performing various surgical approaches (abdominal, laparoscopic, vaginal) hysterectomy with simultaneous front and kolpoperineolevatoroplastikoy kolporrafiey.
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