Genital prolapse (Part two)

Complications

1. Ulcers: In severe forms of a genital prolapse, ulceration occurs and sometimes they can become infected.
2. Carcinogenesis: The uterus may get stuck in the vagina or in the lower pelvis (especially in younger ages and during pregnancy), edema causes carcinogenesis and loss of blood supply to the uterus.
3. Prolapse of other organs: A prolapse of the urinary bladder (cystocele) may occur leading to difficulty in urination and high risk for urinary tract infections. A prolapse of the rectum (rectocele) may occur leading to constipation or there can simultaneously occur a prolapse of both the urinary bladder and the rectum (cystorectocele) leading to problems with both urination and defecation.

Prevention is achieved through a series of general actions.

• a balanced and healthy diet with proteins, fats, carbohydrates.
• regular physical exercises.
• performing Kegel exercises (for strengthening the pelvic floor).
• avoiding chronic straining such as constipation, chronic cough, heavy lifting...
• smoking cessation (reduces the risk for chronic cough).

Purpose of treatment

• Educating the patient about the pathology, its characteristics, risk factors, and ways to prevent them.
• Early detection of the pathology and treatment of complications.
• Consultation regarding the definitive treatment of the pathology.

Treatment

Treatment is carried out in two main ways: non-surgical (conservative) and surgical. Initially, non-surgical (conservative) management is carried out, before surgery.

The advantages of this treatment are: it is safe, inexpensive, not associated with mortality and morbidity, is minimally invasive, leads to higher satisfaction in patients, used in patients where surgery is contraindicated or in patients who refuse surgery.

Conservative treatment includes:

• pelvic muscle exercises (Kegel)
• pessary

1 - Kegel Exercises are exercises that increase the tone of the pelvic floor muscles and treat stress urinary incontinence, but there is no data showing regression of the pelvic organ prolapse. They are repeated 4 (four) times a day with a frequency of 10 (ten) times.

2 - Pessary are safe, cost-effective, and minimally invasive, have fewer contraindications (vaginal fistula, uterovaginal erosion, unknown uterovaginal bleeding).

Before placing the pessary, local estrogen is applied, topical estrogen cream 1-2 times a week or a vaginal estrogen ring every 3 months. Vaginal erosions indicate the temporary removal of the pessary and treatment with local estrogen. Several types of pessaries are used, their selection depends on the severity of the prolapse.

Proper placement is not distinguished at the introitus, does not cause pressure and discomfort. It is placed between the posterior fornix and the pubic symphysis. It should not obstruct the urinary tract.

If the pessary falls with the Valsalva maneuver or abdominal pressure (constipation), a larger one or another type is chosen.

Vaginal discharges and bad odor are common and are treated based on antibiotic therapy or mycotherapy with antibiotic or antifungal ovules.

In cases of vaginal bleeding, the cervix and vagina are inspected for erosions, a pap smear is done for cervical pathologies, or an endometrial biopsy for endometrial pathologies.

Preparation before surgery

• Informed about the possibility of incomplete resolution, recurrence of the prolapse, complications of surgery (bladder damage, urinary dysfunction and retention, possibility of prolonged catheterization).
• Before surgery, local estrogen is applied for 1-2 months.
• Before surgery, ultrasound, pap smear, endometrial biopsy for any possible pathology are performed.
• Surgery aims to anatomically correct the structures and preserve normal function.
• Surgery is carried out when symptoms of prolapse are severe, when the use of pessary fails, or when the patient refuses pessary and requests surgery.
• The type of surgery depends on the defect such as: anterior or posterior colporaphy or both simultaneously.

Complications of surgery

• Damage to the urinary bladder, ureters, urethra, difficulty urinating
• Dyspareunia, vaginitis
• Erosive risk, ulcers
• Fecal incontinence
• Fistula
• Bleeding

After the operation

• Avoid heavy exercises.
• Avoid sexual contact for 6 weeks after the intervention.
• Avoid anything that increases intraabdominal pressure (constipation, smoking) for 3 months.
• In postmenopausal patients, vaginal estrogen therapy continues.
• After the insertion of the pessary, the next visit is after 2-4 weeks, then every 3 months in the first year and then every 6 months.