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Case Reports, Clinical Photographs and CommentariesDR. S. Kalaichandran, MBBS, MD, FRCSC,FSOGC (Canada), FRCOG
Lecturer University
of Ottawa
1. Utero Vaginal Prolapse – Vaginal Hysterectomy with repair.
Mrs. A. R is an active 76 year-old grandmother who lived on her own for several years. She had an uncomfortable vaginal lump for several years. Occasionally, this required reduction by her late family physician. The patient did not visit a physician after the death of her family doctor ten years earlier. She felt that prolapse is a woman’s lot and nothing could be done about it.
This patient was brought to the emergency room with a history of vaginal bleeding. Examination showed that the uterus was totally outside the vulva (prosidentia), atrophic and ulcerated vaginal mucosa and inflamed cervix. The bladder and rectum were also prolapsed with the uterus and the patient was unable to empty her bladder. X-rays of the kidneys, ureters and bladder with contrast (IVP) suggested chronic inflammation of the bladder.
The patient was admitted, the prolapse reduced, bladder drained with indwelling catheter and vagina packed with estrogen cream to improve the quality of the vaginal mucosa.
Two weeks later the patient underwent a vaginal hysterectomy, suspension of the vaginal vault (to prevent a vault prolapse) and repair of the cystocoel (bladder prolapse), rectocoel and enterocoel (rectal and small bowel prolapse). The procedure was performed under spinal anesthesia.
When the patient was seen 6 months later in the office, she was back to her normal active self with no urinary or bowel problems (“A one”)
Commentary
Definition: Vaginal prolapse is the herniation of the pelvic (uterus, bladder rectum) or lower abdominal (bowel) content through the pelvic floor.
Aetiology: Vaginal child birth with its inevitable neuro muscular damage of the pelvic floor is the major aetiological factor in the development of prolapse. Spinal cord injury with denervation of the pelvic floor muscles, increased intrabdominal pressure (chronic constipation, heavy lifting), poor nutrition, connective tissue disorders and post-menopausal status (with no HRT) are other aetiological factors.
Prevention: Active management of labour with good perinial repair and appropriate use of C-section, use of Kegal exercises, not only post partum, but for ever after and use of HRT will reduce the incidence of prolapse.
Symptoms: Early symptoms are vaginal pressure, back ache and urinary incontinence with stress. Large vaginal lump, difficulty in emptying the bladder and bowel, recurrent urinary tract and kidney infection are late symptoms. Ulcerations, bleeding and infection of the cervix and vagina also occur in prosidentia.
Treatment: In early stages Kegal exercises, electrical stimulation of the pelvic floor and bio feedback can alleviate these symptoms. Definitive management usually requires surgery. Various peseries may be used as a temporary measure or for women who are not candidates for surgery.
Copyright © 1999 [Dr. Kalaichandran]. All rights reserved.
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