Descent and abasement of inner genitals are pathologies that often occur, but not always timely and correctly solved, because doctors find treatment and rehabilitation challenging in this case. About 15% of gynecological operations are aimed at treating this very pathology.
Incidence of genital prolapse is frightening: in India, this disease is close to epidemic, and about 15 mln women in the USA suffer from this condition.
There’s a common opinion that genital prolapse is a disease typical of the elderly. However, it’s not really so: about 10 women out of 100 aged up to 30 have this pathology. At the age from 30 to 45, this pathology is met in 40 cases out of 100, and after the age of 50 it’s diagnosed in every second woman. This disease may start during reproductive age, and is always progressing. Besides, while the process is developing, different functional disorders appear: they cause physical inconvenience and may even make women fully or partially incapable for work.
In fact, Descent and abasement of inner genitals should be regarded as a hernia that forms when the closing apparatus – pelvic floor – has lost its ability to contract so much that separate organs or their parts don’t get into the projection of the supporting apparatus.
Prolapse of genitals is a polygenic disease development of which is conditioned by physical, genetic and psychological factors.
The reasons influencing the state of pelvic floor and womb ligamentous apparatus include the following ones: age, heredity, childbirth, birth traumas, heavy physical work and increase of intra-abdominal pressure, scars after inflammatory diseases and surgical invasions, changes in production of sex steroids influencing the reaction of smooth muscles, inability of somatic musculature to ensure normal funcitoning of the pelvic floor, etc. As a rule, this pathology always features two factors: increase of intra-abdominal pressure and dysfunction of the pelvic floor, which can be conditioned by four main reasons or their combination.
- Post-traumatic damage of pelvic floor (often occurs during childbirth).
- Failure of connective tissues manifesting into systematic failures (hernias in other locations occur, other inner organs may prolapse).
- Disorder of sex steroid synthesis.
- Chronic diseases accompanied by disorder of metabolism and microcirculation.
Under one or general above mentioned factors, a person experiences failure of connective tissues of inner sex organs and muscles of the pelvic floor. When intra-abdominal pressure rises, organs start being pushed outside the edges of the pelvic floor. If one organ is located inside the widened pelvic floor, being devoid of any support, it’s pushed through the pelvic floor. If one part of organ lies inside and another – outside hernial orifice, it’s first part is pushed out, while another is being pressed to the supporting basement. Therefore, the part of organ still lying outside hernial orifice keeps another from being displaced – the more it does, the more is intra-abdominal pressure.
Close anatomic connections between the bladder and vaginal wall contribute to the fact that pathological changes of pelvic diaphragm including bladder system cause prolapse of the front vaginal wall, which leads to prolapse of bladder wall, as well. The last becomes the content of hernia pouch forming colpocystocele.
This colpocystocele grows and is being affected by its own inner pressure in the bubble, which makes up for a vicious circle. The same way proctocele is being formed. However, if prolapse of the front vaginal wall is almost always accompanied by colpocystocele pronounced to this or that extent, proctocele can be absent even in case of abasement of vaginal walls, which is conditioned by more loosened connecting tissue between the vaginal wall and the intestine.
In some cases, hernial sac in wide intestinal-uteral and bubble-uteral space can include intestinal loops.
Movement of vagina down:
- lowering of the front wall of vagina, back wall, or two walls together; in all cases, the walls don’t go beyond the entrance to the vagina;
- partial descent of the front vaginal wall and part of the bladder, back and partially front part of intestinal wall, or combination of both types of descent; walls go beyond the edges of vaginal entrance;
- full descent of vagina accompanied by descent of womb.
Movement of uterus down:
- lowering of uterus or cervix – cervix is lowered to the level of vagina entrance;
- partial (starting) descend of uterus or its cervix; during straining, cervix goes beyond interlabial space, which is usually observed during physical loading, or when intra-abdominal pressure grows (straining, cough, sneezing, heavy lifting, etc.);
- partial descend of uterus: outside the interlabial space, the entire uterus with the cervix and uterus body can be distinguished;
- full prolapse of the uterus: outside the interlabial space (between fallen vaginal walls), the whole uterus can be defined, and index and muddle fingers of both hands can come together under uterus bottom.
The process of descent and abasement of vagina and inner sexual organs is characterized by its slow development. Recently, patients have become generally younger.
lmost in all cases, functional disorders of all organs of pelvis are observed, which is why they should be defined and cured. In case of sexual organ descend, people have the whole set of symptoms developing – urological and proctologic complications that make patients address doctors of collateral specializations (urologists, proctologists). The main symptom of uterus, cervix, vaginal wall and organ abasement is a part of organ extruding from the interlabial space.
The surface of the descended part of sexual organ looks like a matte shining dry skin with cracks and wounds, then some patients develop deep ulcers (pressure injuries). That happens because of permanent trauma of vaginal wall happening during walking.
If there are ischemic ulcers, the fibers can be infected, which causes new complications. When the uterus descends and goes down, normal blood circulation in the pelvic is affected, which leads to congestive phenomenon, then pains, feeling of pressure in the lower abdomen, discomfort, pain in the loins and sacral bone that can intensify during and after walking. Congestive phenomenon is characterized by change of coloring of mucous membrane that can lead to cyanosis and swelling of tissues.
Change of menstrual cycle is also typical (algodismenorrhea, hyperpolymenorrhea), as well as hormonal disorders. Sometimes these patients suffer from infertility, although it’s possible to get pregnant.
In case of sexual organ descend, a woman can restore sexual life only when organs are normally fixed.
Corresponding urological complications are different, and these can be all kinds of urinary excretions disorders. When descend is well pronounced, and sexual organs fall out forming colpocystocele, people experience difficult urination, retained urine, engorgement in the urinary system, and, as the result – infection of the lower and, as process progresses – of the upper departments. Long-term full abasement of inner sex organs can cause obstruction of ureter, hydronephrosis, and uroureter.
Urinary incontinence during straining also develops. Most often, secondary complications include pyelonephritis, cystitis, kidney stone disease, etc. Urological complications happen in every second patient.
Pretty often, the disease has proctologic complications that develop in every third patient. Constipation is the most widespread complication, which sometimes can be the reason of disease and sometimes – its outcome or symptom.
This group of patients usually has varicose veins, especially in the lower limbs which is explained by disorders of venous drainage caused by changes of pelvic architectonics, and by failure of connective tissues that are regarded as systematic failure.
Pathologies of breath organs and endocrinal disorders happen more often than with other gynecologic diseases – these can be regarded as predisposing factors.
Colposcopic examination is obligator, because it allows revealing procto- and colpocystocele. Doctors also evaluate functional state of bladder sphincter and intestine (whether there’s urinary or gas incontinence during straining, for instance, when a person coughs).
The examinations should include:
- general urine analysis;
- bacteriologic urine analysis;
- intravenous pyelography;
- urodynamic examination.
Besides, patients with descent and abasement of inner genitals should go through rectal examinations that help to reveal presence of proctocystocele, evaluate the health of intestine sphincter. When organ-preserving plastic surgery is considered, and there’s a corresponding pathology of uterus, the complex of examinations should also include the following special methods:
- hysteroscopy with diagnostic curettage;
- ultrasound examination;
- hormonal analyses;
- examination of smears to define flora and the degree of cleanliness, as well as atypical cells;
- analyses of seeding of vaginal discharge, and so on.
The choice of treatment tactics is challenging, because doctors need to define the most rational way. It depends on the following factors:
- degree of abasement of the inner sexual organs;
- anatomical and functional changes of genitals (the presence and peculiarities of corresponding gynecologic pathology);
- possibility and necessity in saving fertility and menstrual function;
- peculiarities of bowel dysfunction and intestine sphincter;
- of patient;
- corresponding extragenital pathologies and the degree of risk in case of surgical invasion and anesthesia administration.
When the inner sexual organs descend but don’t reach the entrance of vagina, and when there are no dysfunctions of adjacent organs, a patient can be prescribed conservative treatment that includes:
- Kegel exercises,
- special exercise therapy (controlled pelvic muscle constriction during urinating that stops when urinating is totally finished);
- balms with estrogens and metabolites used to anoint mucous membrane of the vagina;
- use of pessary and medical band.
In case of more serious stages of descent and abasement of inner genitals, doctors resolve to surgical methods of treatment. It should be noted that this pathology can be treated with a large number of different surgical operations. No other pathology counts so many ways of surgical treatment – there are hundreds of approaches and methods. Each of them has its own advantages and disadvantages, mostly – risk of recurrence. Most often, it happens during the first three years after surgical invasion, and risk of recurrence is about 30-35%.
All treatment methods can be combined in several groups distinguished by one key factor – which anatomic area is operated and fixed to normalize the location of inner sexual organs. The most widespread types of surgical invasion include the following:
- I group. These are operations aimed at strengthening the pelvic floor – colpoperineoplasty. Considering the fact that the muscles of pelvis are always involved in the process due to pathogenesis, colpoperineoplasty should always be performed as a basic or additional treatment measure with surgery. The same applies to plastic surgery on the front wall of vagina that’s aimed at strengthening the vaginovesical fascia.
- II group. Operations during which doctors apply different modifications: shorten and strengthen round ligament of uterus and fix uterus with the help of the above-mentioned formations. Most common and most often used method presupposes shortening of round ligament of uterus with their fixation to the front vaginal wall. However, this group of operations is considered to be not very efficient, because women often experience disease recurrence after such surgical invasion. It’s conditioned by the fact that doctors use round ligament of uterus as a fixing material – it’s not very reliable.
- III group. Operations aimed at strengthening of fixing uterus apparatus (cardinal and sacro-uterine ligaments) by stitching them with each other, transposing them, and so on. Although these operations presuppose fixing uterus with more solid ligaments, they don’t really help to solve the problem entirely, because they eliminate only one problem in the whole pathophysiologic mechanism. “Manchester operation” can be included within this group – it’s considered to be one of the most efficient methods of surgical treatment. However, this is a traumatic operation – it causes infertility on women depressing reproductive function.
- IV group. Operations with so-called rigid fixation of descended organs to pelvic walls (to the pubic bone, sacral bone, sacrospinal ligament, etc.).
- V group. Operations with use of alloplastic materials to strengthen connective apparatus of the uterus and fix it. These operations are not justified, because alloplastic material is often rejected, and they often lead to formation of fistulae.
- VI group. Operations aimed at partial obliteration of uterus.
- VII group. Radical measures of surgical treatment of abasement include vaginal hysterectomy.
All above-mentioned operations are performed via vagina or the front vaginal wall.
Recently, doctors started using combined surgical treatment – most gynecologists prefer this method. These surgeries presuppose strengthening of pelvic floor, plastics of vaginal walls and fixation of cervical stump, uterus, or vaginal vault, with one of the above mentioned methods. Unfortunately, that not always makes women recover fully, because sometimes functional disorders of adjacent organs (especially urinary system) cannot be avoided. However, the methods of treatment are always being improved so that to eliminate possible risks and preserve organs.