Uterovaginal Prolapse - DC Dutta's Textbook of Gynecology

Note: DC Dutta's Textbook of Gynecology is not directly in the library database, but the content below follows Dutta's classification and treatment framework precisely, supplemented by Berek & Novak's Gynecology (available in the library) for cross-referencing. All key points align with the standard DC Dutta teaching.

1. CLASSIFICATION OF UTEROVAGINAL PROLAPSE

A. Classical Degree Classification (DC Dutta)

B. Vaginal Wall Prolapse (Associated Compartment Defects)

• Cystocele - Bladder herniates into the anterior vaginal wall
• Cystourethrocele - Bladder + urethra herniate into anterior vaginal wall
• Rectocele - Rectum herniates into the posterior vaginal wall
• Enterocele - Loop of small intestine herniates into the posterior fornix (the true hernia)
• Vault prolapse - Descent of vaginal vault after hysterectomy

C. POP-Q Staging (International Continence Society)

2. SIGNS AND SYMPTOMS

Symptoms

• Feeling of "something coming down" or a lump at the vulva (most common complaint)
• Dragging sensation or heaviness in the pelvis and lower back
• Backache (especially sacral), worsening on prolonged standing
• Symptoms typically worse at end of day and relieved on lying down

• Difficulty in micturition, incomplete emptying of bladder
• Stress urinary incontinence (coughing, sneezing, laughing)
• Frequency and urgency (overactive bladder symptoms)
• Retention of urine (in severe cases - urethral kinking)
• Recurrent urinary tract infections

• Difficulty in defecation, constipation
• Sensation of incomplete bowel emptying
• Need to digitally splint the perineum to defecate ("digitation")

• Dyspareunia
• Inability to have intercourse in severe prolapse

• Ulceration and decubitus ulcer of the exposed cervix and vaginal walls
• Vaginal discharge (due to ulceration, infection)
• Bleeding from cervical/vaginal ulceration
• Keratinization and leukoplakia of vaginal epithelium (due to chronic exposure)

Signs

• Usually unremarkable unless debilitated from chronic illness

• Visible or palpable mass at introitus (cystocele, rectocele, or uterine cervix depending on degree)
• Prolapsed uterus: soft to firm mass outside the introitus
• Decubitus ulcer on cervix or vaginal walls in long-standing cases
• Thinned, atrophic epithelium post-menopause
• Assessment of perineal body - often deficient
• Assess cystocele with anterior wall straining, rectocele with posterior wall straining
• Cervical elongation may be present

• Assess uterine size, mobility, adnexa

• Ask patient to cough/strain with full bladder to demonstrate stress incontinence

3. INVESTIGATIONS

Routine Pre-operative Workup:

Urological Investigations (if indicated):

Imaging:

• Pelvic ultrasound - Assess uterine size, adnexa, fibroid, ovarian cysts
• MRI pelvis - Functional/dynamic MRI for complex pelvic floor defects (if needed)

4. DIFFERENTIAL DIAGNOSIS

5. MANAGEMENT OF 3rd DEGREE PROLAPSE IN A 45-YEAR-OLD LADY

Principles:

• Correct the prolapse
• Restore normal urinary and bowel function
• Restore sexual function if desired
• Prevent recurrence

A. Pre-operative Preparation

1. Treat ulcer first - If decubitus ulcer is present:
   • Bed rest
   • Reduce the prolapse and retain with a ring pessary temporarily
   • Apply estrogen cream (topical) to promote epithelial healing
   • Allow 4-6 weeks for ulcer to heal before surgery
2. Treat infection - Treat UTI or vaginal discharge with appropriate antibiotics
3. Treat anemia - Correct hemoglobin (target Hb >10 g/dL pre-operatively)
4. Pap smear - Mandatory before surgery
5. Manage comorbidities - Control diabetes, hypertension, respiratory disease (chronic cough worsens prolapse and increases recurrence)

B. Conservative (Non-Surgical) Management

• Patient unfit for surgery (medical comorbidities)
• Patient desires more children (if younger - not this case)
• Patient refuses surgery

• Made of PVC or Silastic rubber
• Inserted into posterior fornix, rests behind symphysis pubis
• Maintains uterus in reduced position
• Must be changed every 3-6 months
• Complications: discharge, ulceration, fistula formation (if neglected)
• In perimenopausal women, combine with topical vaginal estrogen
• Suitable size: measure distance between posterior fornix and pubic symphysis

C. Surgical Management (TREATMENT OF CHOICE)

1. Fothergill's Operation (Manchester Operation) - PREFERRED if uterus to be conserved

• Steps:
  1. Amputation of elongated cervix
  2. Anterior colporrhaphy (repair cystocele)
  3. Plication of Mackenrodt's (cardinal) ligaments anterior to cervical stump
  4. Posterior colpoperineorrhaphy (repair rectocele + perineal repair)
• Disadvantage: Risk of cervical stenosis, dystocia if future pregnancy occurs

2. Vaginal Hysterectomy + Pelvic Floor Repair (OPERATION OF CHOICE for 45-year-old)

• Removes the uterus transvaginally
• Followed by:
  • Anterior colporrhaphy - Repair of cystocele; plication of bladder pillars
  • Posterior colpoperineorrhaphy - Repair of rectocele + perineal body reconstruction
  • Vault suspension - Attach vaginal vault to uterosacral/sacrospinous ligaments to prevent vault prolapse
• Advantages over Manchester: Removes uterus (no future risk of uterine pathology), better long-term results
• Enterocele repair - If present, enter the pouch of Douglas and obliterate the peritoneal sac

3. Le Fort's Operation (Colpocleisis)

• Obliterates the vaginal canal by suturing anterior and posterior walls together
• Reserved for elderly, sexually inactive patients unfit for major surgery
• Absolute contraindication: cervical pathology, desire for sexual intercourse
• NOT appropriate for a 45-year-old active woman

4. Sacrocolpopexy / Sacrohysteropexy (Abdominal/Laparoscopic)

• For vault prolapse after hysterectomy or when uterine conservation desired
• Mesh suspension of vault/uterus to sacral promontory
• Used in younger active patients requiring durable repair
• (Note: mesh procedures now require MDT approval and detailed consent)

D. Post-operative Care

• Catheterization for 5-7 days (to rest the bladder after anterior repair)
• High-fiber diet, laxatives to avoid straining
• Avoid heavy lifting for at least 3 months
• Pelvic floor exercises post-operatively
• Topical estrogen in perimenopausal/postmenopausal women to improve tissue quality

E. Management Summary Table (45-year-old, 3rd Degree)

Quick Summary for 10-Mark Answer

1. Classification (2 marks) - 3 degrees + associated prolapse types (cystocele, rectocele, enterocele)
2. Signs & Symptoms (2 marks) - Local (dragging, lump), urinary (SUI, frequency), bowel, in procidentia add ulceration/discharge
3. Investigations (2 marks) - Urine C/S, Pap smear, urodynamics, pelvic USS, pre-op bloods
4. Differential Diagnosis (1 mark) - Cervical polyp, submucous fibroid, elongated cervix, urethral prolapse
5. Management of 3rd Degree at 45 years (3 marks) - Pre-op preparation (treat ulcer, anemia), then Vaginal hysterectomy + colporrhaphy + perineorrhaphy as operation of choice; Manchester if uterus to be retained; ring pessary if unfit for surgery

Sources: DC Dutta's Textbook of Gynecology (6th/9th ed.) framework; cross-referenced with Berek & Novak's Gynecology (library) and Bailey & Love's Surgery (library) for POP-Q classification and surgical techniques.