Uterine/pelvic organ prolapse + lump at vulva case

Link upto the lump at vulva case

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Lump at vulva => uetrine prolapse case

Common cae 1/3rd will get this for gyn case

To check whether its uterus, must see the cervix. Ask to see cervix.

Ask patient before reduction...if pain then fail!

How to check whether

2nr or 3rd degree prolspe, with enterocele, due to these factors and these are the complications Corrective measures? Fitness of surgery? Other comorbidities? Optimise what complication?

Lump at vulva case => uterine prolapse is one DD => then DD of prolapse

How to examine and present?

Neuro muscular damag can happen during birth and manifests after menapause

colposuspension surgery for incontinence and therefore posterio wall weakens

LUTS must ask in detail

voiding symptoms because urethra is kinked

types of incontinense

Urge incontinence because bladder wall damaged or stress incontinence because its comed out

put finger to emoty it

Vaginal symptoms wehther sexualy active because relevant for extent of surgery

————————————————————————— Definition and epid

Aetilogy

Pudendal nerve is dedamaged during child birth and labor So repeated deliveries predisposes to prolapse These ligaments aren't true ligaments but just connective tissue Thickening

History

Examanition

broad ligament and the uetro sacral ligament and the pubo cervical ligament .

So which type of prolapse that occurs depends on which support is weakened. can match the support weakened with the likely prolapse that will occur.

the top of the vagina is called the vaginal vault. After hysterectomy, we cut the uterus supports so the vault can prolapse then out as a result.

enetrocoeale can occur if the uterosacral is torn? top of rectovaginal septum is dsiturbed.

the same woman can have multiple defects...rectoceale, cystocele and everything in one. Must be ablet o manipulate the lump etc to elicit whether there are other prolapse.

Lump in vulva examaintion ⇒ must be learnt and done throughly because its a common short case. Must be perfect in this!!!!!!

get them to cough to see whether its an abdominal lump or not.

women get used to lviing with the prolapse eg when urinating they may manually retract the lump/prolapse in order to urinate properly.

for the first the refrence point is the introitus and for the second and third its the hymen

the refrence of cervix to the introitus. and the last degree is fundus outside the intoritus.

the small a stands for the anterior wall and the small p stands for the posterior wall.

A is a point 3 cm above the hymen (which is the refrence point in this classification

point B is the most dependant part of the prolapse when measured out.

C is the vervix or cuff

The refrence point is the hymen. So anything above it is given minus points, and anything below it is given a plus score.

TVL is the total vaginal lenght.

GH is the lenght of the genital introitus.

perineal body is the lenght between the vagina and the anus

First the prolapse is put back in ad tvl is measured.

and then the patient is asked to cough and it all protudes

and then the measurements are taken relative to the hymen

A ruler isnt used but special intruments with marked lenghts are.

D is the posetrioir fornix lenght

these lenghts are put into this box diagram which can then be communicated effectively

Management

Mc cull culdoplasty involves both enterocele repair and repairing the ueterosacral suspensiosn as well...that is stiching the ligaments back to the vault and repairing the spetum as well.

ITs repaired by stictching back the stuff to its attachments once again!

eg rectovaginal spetum back into the perineal body

anterior and posterioir repair refers to the above!!!!

uterosacral suspension is no longer done.

sacrospinous fixation is where the vagina is stitched onto the sacrospinous ligament. second best.

sacrocolpopexy is where the vagina is fixed onto the vagina using a mesh to keep the vagina up and this is the best surgery.

both macnhester surgery ad fothergill repair means the same thing. manchester because the surgery first took place there..and forthergill because he made that special stitch.

cut cervix and then stitch the cardinal ligaments together.

preliminary d and c to eliminate uetrine path and keep the os open

any pelvic floor repair can be done as well.

hysterectomy is not idicated for a benign cause...dont take it lightly.

but even this srugery is going out of favour and is not found in any textbooks. its being replaced with the mesh surgery that is being done for uniparous women.

initially also for uniparous women sling surgeries was done but its evolved and now they use the mesh surgeries

sling surgerous done to replace the supports

2 types of anterior slings attaching to two different places. but then it caused posterioir weakening and enterocele as a result.

so then post slings was tried but then it caused damaged to the sacral vessels and genitofemoral n in the region of the anterioir longitidunal ligaments for which is was attached to.

so then they tried composite.

but now these surgeries as well as the ones for multiparoud women have been replaced by sacrocervicopexy.

which gives the best result. and theres a mesh all around.

But how pregnancy?

that is why whenever we o hystercetomy we have to suspend the vault - so tha future vault prlapse doesnt occur ...suspend by repairing the ligaments

forthergills repair is usually paired up with tubal ligation. obviously the women dont want to have anymore pregnacies so thats why she choses this repair to have the cervix cut out ...so why give her contracetion as well.