Prolapse of female genital organs

Falling out of the genitals is a polyethological disease, the basis of which is the degeneration and incompetence of the ligamentous apparatus of the uterus and the muscles of the pelvic floor, increased intra-abdominal pressure. Pelvic structures: uterus (prolapse of the uterus) or vagina (prolapse of the vagina), the front wall of the vagina (hernia of the bladder), or the back wall of the vagina (rectocele).

[1], [2], [3], [4]

Epidemiology

Prevalence of pelvic organ prolapse is estimated at about 11%.

[5], [6], [7], [8], [9], [10]

Risk factors

Factors contributing to the formation of failure of the muscles of the pelvic floor include pathological births, estrogen deficiency, age-related changes in the muscle and connective tissues, genetic predisposition, as well as a number of extragenital diseases and adverse social conditions.

[11], [12], [13]

Pathogenesis

In the pathogenesis of prostration and / or prolapse of genital organs, the systemic defect of connective tissue plays the leading role in young, nulliparous women (or who have uncomplicated births) with the unchanged hormonal background and normal social conditions. Under the influence of any of these factors or their combined effects, the functional inconsistency of the ligament apparatus of the internal genital organs and the pelvic floor occurs. Against the backdrop of functional failure of the ligamentous apparatus of the uterus and its appendages and increased intra-abdominal pressure, the organs begin to extend beyond the pelvic floor. At the same time, several variants of pathogenetic mechanisms of prolapse of the uterus and vagina are distinguished:

• The womb is found entirely within the widened single bottom; having lost all support, it is squeezed out through the pelvic floor;
• part of the uterus is located inside, and part - outside the hernia gates; The first part is squeezed out, the other is pressed against the supporting base.

In the second variant, the vaginal part of the cervix, due to constant pressure inside the hernial gates, can fall and stretch (elongatio coli); while the body of the uterus, lying outside the hernial gates and adjacent to the partially still functioning levator ani, counteracts the complete loss of the organ. This mechanism explains the formation of an elongated and thinned uterus, the elongation of which depends solely or predominantly on the neck's hypertrophy, while the uterus's bottom may at this time remain in an almost correct position. In this situation, complete loss of the uterus occurs with its retroflection - when the axis of the uterus coincides with the axis of the vagina. Therefore, retroflexia is considered a risk factor for complete loss of the uterus.

In clinical practice, to this day, the classification of female genital descent, proposed by KF Slavyanskii, is used.

[14], [15], [16], [17], [18],

Symptoms of the prolapse of female genital organs

The most frequent complaints of patients with prolapse of internal genital organs are: aching pain and / or a feeling of heaviness in the lower abdomen, leucorrhoea, violation of sexual function, foreign body sensation in the vagina, incontinence of urine and gases during physical exertion, coughing, sneezing.

Stages

Classification of vaginal displacements down (according to KF Slaviansky):

• 1 degree. Omission of the anterior wall of the vagina, posterior or both together (the walls do not extend beyond the entrance to the vagina).
• 2 degree. Loss of anterior or posterior vaginal walls. And also both together (the walls are outside of the vaginal entrance).
• 3 degree. Complete loss of the vagina, which is accompanied by loss of the uterus.

[19], [20], [21], [22], [23],

Diagnostics of the prolapse of female genital organs

Diagnosis of genital descent and prolapse usually does not cause difficulties and is carried out on the basis of objective survey data.

[24], [25]

Treatment of the prolapse of female genital organs

The anatomical and topographic features of the pelvic organs, the generality of the blood supply, innervation, and close functional connections make it possible to consider them as a whole unified system in which even local changes cause damage to the function and anatomy of neighboring organs. Therefore, the main goal of treating prolapses is to eliminate not only the underlying disease, but also to correct violations from the genitals, bladder, urethra, rectum and pelvic floor.

Among the factors determining the tactics of treatment of patients with genital prolapse, the following are distinguished:

• degree of prolapse of genital organs;
• anatomical and functional changes in the genital organs (presence and nature of concomitant gynecological diseases);
• possibility and expediency of preservation and restoration of genital and menstrual functions;
• features of the disorder of the large intestine and sphincter of the rectum;
• age of patients;
• concomitant extragenital pathology and the degree of risk of surgical intervention and anesthesia.

General restorative treatment. This type of therapy is aimed at increasing the tone of tissues and eliminating the causes contributing to the displacement of the genital organs. Recommended: high-grade food, water procedures, gymnastic exercises, changing working conditions, uterus massage.

Surgical treatment of prolapse of genital organs. Pathogenetically justified method of treatment of female genital prolapse should be considered surgical intervention.

To date, over 300 methods of surgical correction of this pathology are known.

Known methods of surgical correction of genital prolapse can be divided into 7 groups, based on anatomical formations, which are strengthened to correct the incorrect position of the genital organs.

1. The 1st operation group - strengthening of the pelvic floor - colpoperineolevatoroplasty. Considering that the pelvic floor muscles are pathogenetically always involved in the pathological process, colpoperineolevatoroplasty should be performed in all cases of surgical intervention as an additional or basic benefit.
2. The second group of operations - the use of various modifications of shortening and strengthening of the round ligament of the uterus. The most commonly used is the shortening of the round ligaments with their fixation to the anterior surface of the uterus. Shortening of the round ligament of the uterus with their fixation to the posterior surface of the uterus, ventrophilization of the uterus according to Kocher and other similar operations are ineffective, since round ligament of the uterus with a high elasticity is used as the fixing material.
3. The third group of operations is the strengthening of the fixation apparatus of the uterus (cardinal, sacro-maternal ligaments) due to their cross-linking, transposition, etc. This group is referred to as the "Manchester operation", the essence of which is the shortening of the cardinal ligaments.
4. 4-th group of operations - rigid fixation of the fallen organs to the pelvic wall - to the pubic bone, sacral bone, sacrospinal ligament, etc. Complications of these operations are osteomyelitis, persistent pain, and also the so-called operative-pathological positions of the pelvic organs with all the consequences .
5. The 5th group of operations is the use of alloplastic materials to strengthen the ligamentous apparatus of the uterus and fix it. The use of these operations often leads to the rejection of alloplast and the formation of fistula.
6. The 6th group of operations is a partial obliteration of the vagina (midline collegraphy according to Neugebauer-Lefort, vaginal-perineal adhesion - Labgardt's operation). Operations are non-physiological, exclude the possibility of sexual activity, there are relapses of the disease.
7. 7th group of operations - radical surgical intervention - vaginal hysterectomy. Undoubtedly, this operation completely eliminates the prolapse of the organ, nevertheless, it has a number of negative aspects: recurrence of the disease in the form of enterocele, persistent violation of menstrual and genital functions.

In recent years, the tactics of combined correction of genital prolapse with the use of laparoscopy and vaginal access is gaining popularity.

Orthopedic methods of treatment of genital prolapse. Methods of treatment of genital ptosis and prolapse in women using pessaries are used in old age with contraindications to surgical treatment.

Physiotherapy treatment. Great importance in the therapy of pubescence and incontinence in women have timely and correctly applied methods of physiotherapy, diadynamic sphincterotonization.