In the list of gynecological diseases, prolapse of pelvic organs is about 28%, and 15% are so-called major surgery in gynecology held in this occasion. Although it is believed that this pathology is the “prerogative” of the fairer sex of the elderly or old age, it is known that the disease quite often starts to develop in the child bearing age and has a tendency to progression.
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Prolapse of the pelvic organs is quite common. For example, in India, this pathology is found in almost every woman, and in the U. S. the disease is diagnosed in 15 million of the fairer sex.
Statistical data on pelvic organ prolapse are striking:
- the age of 30 – disease occurs every tenth woman;
- age 30 – 45 years – pathology diagnosed in 40 women out of a hundred;
- age over 50 years – prolapse of the pelvic organs suffers every second woman.
According to epidemiological investigation, every eleventh woman in the world to be operated about this disease, because of the high risk of prolapse of the genital organs. Makes you wonder and the fact of the recurrence of the disease, which re-operated for more than 30% of patients.
The location of the pelvic organs
The location of the pelvic organs in women, the Uterus is a hollow organ composed of smooth muscle and is pear-shaped. The main task of the uterus is a gestation and birth of a child. It normally is wired to the axis of the pelvis (in the center and along a line passing down from the head to the feet). The body of the uterus is slightly inclined anteriorly, forming an angle open towards the anterior abdominal wall (the position of antiflexion). Uterine bottom is at the level of or beyond the plane of the entrance to the pelvis.
The second angle formed between the cervix and the vagina, which is also open anteriorly. The front of the uterus in contact with the bladder and behind the rectum. And the uterus and appendages possess a certain physiological mobility that is necessary for their normal functioning (pregnancy/childbirth, work related organs: bladder/rectum). At the same time the uterus is in the pelvis firmly fixed, which prevents it from falling out. Fixation of the uterus performed in the following structures:
- suspensory ligaments (broad, round ligament, ovarian ligament) – at the expense of their uterus and appendages are fixed to the walls of the pelvis;
- muscles and fasciae of the pelvic floor and abdominal wall (their normal tone ensures correct positioning of the internal genital organs, while the loss of muscle elasticity develops drooping of pelvic organs);
- dense ligaments that secure the uterus to adjacent organs (mocevic/rectum), the fascia and the pelvic bones.
What is prolapse of the pelvic organs?
Ptosis (prolapse) of pelvic organs is called disease in which there is a violation of position of the uterus and/or vaginal walls, characterized by the displacement of the genital organs is either to the vagina, either by stepping (loss) them beyond it. Often prolapse of the genital organs leading to prolapse and protrusion of the bladder with the formation of cystocele and/or rectum – rectocele. The disease is progressive and develops in the insolvency of the muscular layer of the pelvic floor, stretching of the ligaments that support the uterus and increasing intra-abdominal pressure. Pelvic organ prolapse for ease of understanding can be called a hernia.
The location of the uterus in normal position and when patologiilor prolapse
Prolapse of the genitals is due to several reasons, which can be divided into several groups:
- injury to the pelvic floor;
- violation of the synthesis of steroids (in particular estrogens);
- the failure of the connective tissue;
- chronic somatic diseases, which are accompanied by circulatory disturbance, metabolic or cause an increase in intra-abdominal pressure.
Injury to the pelvic floor
The first group of reasons is mainly due to complicated childbirth. It can be perineal tears 3 to 4 degrees, the use of the obstetric forceps in the period of expulsion of the fetus, childbirth large fruit, fast-paced labour, labour with malposition of fetus (breech and foot presentation), multiple pregnancy. Often, a muscle injury of the pelvic floor in childbirth it happens in the “old” nulliparous women when the crotch has lost its elasticity and ability to stretch and re-birth (short breaks between births or multiple births). An important role in the development of prolapse of the pelvic organs has heavy physical work, and constant heavy lifting that leads to increased intra-abdominal pressure.
Production of steroids
The lack of production of estrogen typically observed in pre – and postmenopausal periods, but may be due to hormonal disorders in women of reproductive age. Estrogens are responsible for tone and elasticity to muscles, connective tissue and skin structures, their deficiency contributes to sprain and muscular layer of the pelvic floor.
The failure of connective tissue
Insolvency connective tissue say, when there is a “systemic” failure of the connective tissue, due to genetic predisposition (congenital heart disease, astigmatism, hernia).
Chronic diseases, leading to disorder of microcirculation is and metabolic processes (diabetes, obesity), as well as supporting intra-abdominal pressure at a high level (pathology of respiratory system – cough) or gastrointestinal diseases (problems with defecation, constipation) also provoke the development of genital prolapse.
For the practical activities of the most convenient is classification of prolapse of the genital organs:
- 1 degree is determined by the prolapse of the cervix no more than ½ the length of the vagina;
- the 2nd stage the cervix and/or vaginal wall down to the entrance to the vagina;
- about 3 degrees say in the case of location of the cervix and vaginal wall outside of the vagina, whereas the uterine body is located above;
- if the uterus and the vaginal walls are defined outside of the vagina – this is 4 degree.
The clinical picture, symptoms
The disease is slow but steadily progressive, although in some cases the process can evolve relatively quickly, especially when you consider that in recent years, among the contingent of patients, more and more young women of reproductive age. Genital prolapse leads to functional disturbances of almost all of the pelvic organs:
Part of the reproductive system there is a feeling of a foreign body in the vagina, joined by the severity and discomfort in the lower abdomen and lower back. Characteristically, after the adoption of the horizontal position or after sleep these complaints disappear, and their amplification occurs by the end of the day or after lifting/heavy physical work. In prolapse of the uterus and/or vagina patients feel a “hernial SAC” in the crotch, which not only hampers the sexual life (intercourse is possible only after the reposition of the organ), but also walking. The Uterus and the vaginal walls when viewed look either matte or shiny, dry mucous membrane, on which are numerous abrasions and cracks. At 3 to 4 degrees diseases that often there are trophic ulcers and bedsores, due to the constant friction of the uterus and vaginal walls about the clothes and the interruption of the blood supply in them (venous stasis).
The emergence of trophic ulcers often provokes the infection of the surrounding tissue with the development of septic complications (parametritis, etc.). Displacement of the uterus down leads to disruption of normal blood flow in the pelvis, which causes stagnation of blood in it and is accompanied by pain and a sensation of pressure from below in the abdomen, discomfort, pain in the sacral and lumbar areas, which are amplified when walking. Due to stagnation of mucous membranes of the uterus and vagina become cyanotic and swollen.
In addition, the suffering and the menstrual function, manifested algomenorrhea and hyperprolinemia. Often develops infertility, although pregnancy is not excluded.
From the urinary system
Disrupts the function and the urinary system, manifested by difficult urination, presence of residual urine and stasis. Resulting in infection of the lower urinary tract (urethra, bladder), and then the upper (ureter, kidney). If a complete genital prolapse exists long enough, the possible obstruction of the ureter (shaped stones), development of hydronephrosis and hydroureter. Also, there is the stress incontinence (coughing, sneezing, laughing). Secondary complications are inflammation of the kidneys and bladder, urolithiasis, and so on. It should be noted that urological complications are present in every second patient.
On the part of the large intestine
Prolapse of the pelvic organs is accompanied by the development of kidney complications, which is typical for every third patient. To common include constipation, and it should be noted that on the one hand they act as a cause of disease, and on the other hand, the result and clinical signs of the disease. Also impaired function of the large intestine, resulting in colitis. Quite painful and unpleasant manifestation of the disorder is inability to retain feces and gases. Gas incontinence/stool caused by either trauma to the tissues of the perineum, the walls of the rectum and rectal sphincter (in childbirth) or the development of deep functional disorders of the pelvic floor muscles.
In women suffering from prolapse of the genital organs often develops varicose veins, particularly of the lower extremities. The development of varicose veins provoked by the violation of the outflow of blood from the veins, which occurred due to changes of location of pelvic organs and insufficient connective tissue structures.
Treatment of pelvic organ prolapse depends on several factors:
- degree of genital prolapse;
- concomitant gynecological diseases (endometrial polyps, endometriosis, uterine tumors, etc.);
- desire and ability to preserve reproductive and menstrual functions;
- clinical manifestations of functional disorders of the colon and rectal sphincter;
- the age of the patient;
- comorbid medical (General) diseases (risk of surgery and General anesthesia).
The treatment can be carried out conservatively and surgically.
When conservative treatment is recommended exercises to strengthen the abdominals Conservative therapy to women with 1 – 2 extent of the disease. Avoid heavy physical work and prohibit the lifting (no more than 3 kg). Also shown therapeutic exercises in Atarbekova, exercises that strengthen the abdominal muscles (“bike” tilts in the supine position, lifting the legs in a horizontal position), Kegel exercises (contraction and relaxation of the muscles of the perineum). You should also review the diet, giving preference to fermented milk products, vegetables and fruits (normalization of the bowel). With a lack of estrogen are appointed candles or intravaginal cream (Ovestin).
In case of contraindications (severe somatic disease) to surgery recommended wearing of vaginal pessaries (ring), plastic or rubber. But long-term wearing of pessaries worsens the disease, as there is an even greater stretching of the pelvic floor muscles.
Exercises with prolapse of pelvic organs
Surgical intervention is carried out under complete and incomplete prolapse of the uterus and vagina. There are several types of operations:
- promote and maintain pelvic floor (colpoperineoplasty);
- shortening of the round ligaments and fixation of the uterus by them;
- the strengthening of the cardinal and Sacro-uterine ligaments (their stitching, transposition, etc.);
- fixation of the uterus to the pelvic bones;
- strengthening ligaments of the uterus alloplastic materials;
- partial obliteration of the vagina;
- extirpation of the uterus through vaginal (women in premenopausal and postmenopausal women).
The prevention of prolapse of pelvic organs includes the following recommendations:
- The regime of physical labor and education
Should avoid excessive physical work, especially lifting heavy weights as a child, especially adolescent girls, formation of menstrual and reproductive function.
- Management of pregnancy/childbirth
Genital prolapse provokes not only a large number of genera, but their tactics and conduct. While providing operational benefits in childbirth (forceps and vacuum escolator, pelvic allowance, etc.) contributes to intrapelvical damage to the lumbosacral plexus (later develops paralysis of the obturator and sciatic nerves), the deep ruptures of the soft tissues of the perineum, involving the sphincter of the rectum and urethra, which later leads to the formation of incontinence. If possible, to prevent prolonged duration of bearing-down period, perform an episiotomy (when the threat of rupture of the perineum) and want to correctly map the soft tissue of the perineum when they are suturing in case of breakage or cut.
- Rehabilitation in the postpartum period
With special care after birth should be the prevention of development of purulent-septic complications (wound treatment with antiseptics, vaginal hygiene of the perineum, if necessary, antibiotic therapy). Are also rehabilitation measures designed to restore the function of the pelvic floor (special exercises, laser treatment, electrical stimulation of muscles of the perineum).
- Nutrition and drinking regime
Adhere to a diet that does not allow the occurrence of constipation (high in fiber). You should also drink 2.5 – 3 liters of fluid.