Genital prolapse (Part one)

Definition:

Genital prolapse is the descent of genital organs from their normal position in the pelvis, down into the vagina.

Some of the types of genital prolapse are:

1. Uterine prolapse is the descent of the uterus from its normal position in the pelvis, down to different levels of the vagina or outside of it.
2. Cystourethrocele is the descent of the urinary bladder and the urethra from their normal position into the vagina or outside of it.
3. Cystocele is the descent of the urinary bladder from its normal position into the vagina or outside of it.
4. Cystorectocele is the descent of the urinary bladder and the rectum or the large intestine from their normal position into the vagina or outside of it.
5. Rectocele is the descent of the rectum or the large intestine from their normal position into the vagina or outside of it.
6. Enterocele is the descent of the small intestines from their normal position into the vagina or outside of it.

Epidemiology

The frequency of genital prolapse is the same in all countries of the world.
About half of the women suffering from genital prolapse are over the age of 50.
About 50% of women who have given birth suffer from various degrees of genital prolapse, and about 10-20% of them are symptomatic.

Etiology

1. Pregnancy and childbirth (baby's weight, physical trauma and childbirth, the stress of childbirth cause a pulling of the pelvic ligaments and muscles causing their weakening)
2. Large fibroids and tumors
3. Aging and menopause (decrease in estrogen levels causes weakening of the pelvic muscles)
4. Obesity
5. Chronic cough and constipation (chronic cough is encountered in smokers, in bronchial asthma, and in bronchitis)
6. Heavy weights, pulling, and various strains
7. Genetic conditions (Marfan syndrome, Ehlers-Danlos syndrome)
8. Previous pelvic surgery
9. Spinal cord injuries, muscular atrophy (multiple sclerosis, muscular dystrophy)
10. Race (Northern Europe more than Asia and Africa)

Pathophysiology

The uterus is held in place by muscles and ligaments that form the pelvic floor.

Prolapse occurs when the muscles and ligaments of the pelvic floor weaken or are damaged.

Based on the extent of the prolapse, it can be complete or incomplete.

It is classified into 4 main stages.

• Stage I: There is no prolapse.
• Stage II: The distal portion of the prolapse extends above 1 cm or less than the distal and proximal plane of the hymen.
• Stage III: The distal portion of the prolapse extends more than 1 cm from the hymenal plane and not more than 2 cm of the total vaginal length.
• Stage IV: When there is total eversion.

Symptoms

Asymptomatic
• Heaviness or pressure in the pelvis
• Protrusion of a mass of variable size in the vagina
• Pain in the pelvis, abdomen, or lower back
• Pain during intercourse
• Repeated urinary infections
• Increased unusual secretions from the vagina
• Difficulty in urination, urinary incontinence, or increased frequency of urination

Symptoms are mild in the morning and worsen during the day. They are exacerbated by walking or prolonged standing.

Physical Examination

• Abdominal examination to exclude a pelvic or abdominal tumor.
• Vaginal examination, with speculum and bimanual determines the degree of prolapse and any complications of it.

Imaging Examinations

• Do not present any particular importance in the case of simple genital prolapse.
• Ultrasound, differentiates prolapse from other pathologies.
• MRI, is used for staging of the prolapse.

Laboratory Examinations

In uncomplicated forms, they do not present any particular importance. The most common laboratory examinations include: complete blood count, metabolic balance, complete urine, pregnancy test, vaginal culture, Pap smear, biopsy if malignancy is suspected.

Differential Diagnosis

1. Cystitis
2. Early pregnancy loss
3. ECTOPIC pregnancy
4. Neoplasm
5. Ovarian cyst
6. Vaginitis