Omission and prolapse of the internal genital organs is a change in the position of the uterus and the walls of the vagina relative to the entrance to the vagina. With the omission, the walls of the vagina and uterus reach the level of the genital slit, with prolapse – beyond its limits.
- Cystocele – isolated omission of only the anterior wall of the vagina.
- Rectocele – isolated prolapse of the posterior vaginal wall.
- Elongation of the cervix – isolated lengthening and lowering of the cervix to the level of the genital slit or beyond.
Most often, a gynecologist with the problem of omission of the uterus and the walls of the vagina comes to patients of older and older age. Here, the development of genital prolapse is immediately affected by many factors – accumulated pelvic floor injuries during childbirth, weakening the elasticity of connective tissue and ligaments during menopause and estrogen deficiency, and many still have overweight and long-term work associated with lifting weights.
According to the data of 2016, in Russia the number of patients with perineal ptosis syndrome is 15-30% of all who applied to the gynecologist. Of these, about a third have cystocele, 20% rectocele, and 15% uterine prolapse.
The degree of prolapse (omission) of the genitals
I – the genital gap gapes, the walls are lowered slightly;
II – omission of the walls of the vagina and cervix to the level of the entrance to the vagina, without going beyond its borders;
III – the cervix and vaginal walls are located during straining or at rest outside the vaginal opening, but the uterus does not fall below the genital slit;
IV – the uterus and the walls of the vagina outside the genital slit in the form of a hernia sac.
The stump (dome) of the vagina with its walls after a previous removal of the uterus can also fall out.
The picture of genital prolapse is complemented by the pelvic muscle insufficiency syndrome, cicatricial changes of the pelvic floor muscles with old fractures.
Damage to the pelvic floor muscles during traumatic labor with a large fetus, with prompt labor during labor – application of obstetric forceps, episiotomy, deep perineal tears, fast and rapid labor.
Exogenous causes leading to a chronic increase in intra-abdominal pressure. This group of patients can be attributed to female workers of heavy physical labor (for example, kitchen workers raising heavy pans, or milkmaids moving jars with milk), as well as athletes whose sport is associated with weightlifting.
Endogenous causes leading to a chronic increase in intra-abdominal pressure. This may be a chronic tendency to constipation , excessive force when trying to empty the bowel, as well as chronic pulmonary pathology, accompanied by a strong, irrepressible cough.
Obesity with a body mass index (BMI) of more than 30 increases the risk of developing pelvic ptosis syndrome by 40-75% (according to research conducted by the American Organization for the Women’s Health Initiative in 2002 and confirmed later ).
Congenital weakness of the ligament apparatus due to the nature of the connective tissue. This is indicated by cases of omission of the genitals in young, skinny girls who have not given birth, and who have not had any reason for the appearance of genital prolapse.
Violation of the innervation of the muscles of the urogenital diaphragm (spina bifida with paralysis of the III and IV sacral nerves – prolapse of the uterus in childhood, multiple sclerosis);
Condition after removal of the uterus (loosened vaginal fixation ligaments are weakened).
Changes in the connective tissue in conditions of menopause and a decrease in the level of sex hormones, in particular, estrogen. Estrogens influence the amount of collagen content in the connective tissue, its elasticity and elasticity.
Patients with a degree of omission may not experience any discomfort in ordinary life. Patients after childbirth with a slight decrease in muscle tone and first-degree omission may complain of constipation.
As the prolapse of the genitals progresses, a feeling of a foreign body in the vagina appears, especially when straining, in the advanced form, the patient can feel the hernial protrusion in the vagina with a hand.
Since the ligaments fixing the genitals are extended, pain syndrome appears – dragging, aching pain in the lower abdomen and lower back.
The disease is characterized by pain and discomfort during intercourse.
As the proliferation progresses, urinary system symptoms join: urinary incontinence during straining, coughing, physical effort, frequent urge to urinate, and there is a feeling of not emptying the bladder. This is due to the fact that when the walls of the vagina are lowered, the course of the urethra is deformed. Sometimes with a complete prolapse of the uterus and the walls of the vagina, the hernial sac creates a mechanical obstruction to the emptying of the bladder.
Also for the syndrome of prolapse and insufficiency of the muscles of the pelvic floor is characterized by a weakening of the muscle ring around the anus and insufficiency of the anal sphincter. Clinically, it may manifest as an incontinence gas or feces. A decrease in the tone of the pelvic floor muscles and lowering of the posterior vaginal wall are also manifested by chronic constipation.
Patients with cicatricial changes of the perineum and vaginal walls due to their insufficiency cause discomfort and difficulties in sexual life, which often requires plastic surgery on the perineum.
By itself, pregnancy is not the cause of prolapse, only unsuccessful childbirth. Before pregnancy, prolapse can occur (as already described above) due to the congenital characteristics of the connective tissue, when lifting weights and obesity.
Omission after childbirth may be present in the initial 1-2 degrees and manifest itself by a decrease in the tone of the vaginal walls and a gap in the vaginal opening, but it can also be pronounced up to the 3 degree (for example, in the form of elongation (elongation) of the cervix to the genital slit. A woman can even grope her hand when hygienic procedures, when washing away.
Contribute to this large size of the fetus in childbirth, a long potentnoy period, or, conversely, rapid delivery, when the head of the child injures the pelvic floor.
The failure of the pelvic floor muscles after childbirth can also contribute to deep perineal tears. Any rupture of the perineum and vaginal wall or an episiotomy performed during labor should be sutured in layers of quality after birth (episiotomy is a perineal incision made when there is a threat of rupture, for example, with a large fetus, or to shorten the laboring period, according to the testimony from the mother and fetus).
It’s possible to get pregnant if there is a 1-2 degree omission without problems, but if you have a 3-4 degree prolapse, the woman will most likely want to improve her quality of life first of all than to give life to another being again.
Recommendations for childbirth and after
At birth, it is very important to listen to the commands of the midwife and the doctor.
For example, at the end of the first stage of labor, when the cervix is opened close to full, any woman will have a desire to poduzhit. But from the moment of complete disclosure of the cervix until the moment when it is already possible to begin to actively push, it takes about an hour on average – during this time the head of the fetus sinks to the pelvic floor. This is one of the most crucial periods of childbirth, when a midwife commands a woman in labor to restrain attempts, makes you breathe properly.
If you do not listen to the command and start to push out ahead of time, while the head of the baby is still high, then you can get an omission of the vaginal walls after birth.
After childbirth, the restoration of muscle tone of the perineum and the walls of the vagina takes up to 6 months. During this time, the omission of 1-2 degrees can regress. If, as a result of traumatic labor, a grade 3 prolapse has formed or there are gross cicatricial changes in the vagina and perineum, then after 6 months, it will be possible to decide on the method and the possibility of surgical correction of prolapse. Omission 4 degrees (complete loss of the uterus and vagina) immediately after childbirth almost does not happen, for this there must also be congenital pathology of connective tissue. But over time, in a few years (or decades), even a small omission after unsuccessful births can progress and reach 4 degrees.
To restore the muscle tone of the vagina and perineum after childbirth, Kegel exercises are recommended (read more about them below in the section on the treatment of prolapse). You can do these exercises already in the maternity hospital 1-2 days after birth and continue them after discharge (the more often the better). If there are stitches on the perineum, you can start exercising 5-7 days after delivery, even if at this time the doctor has not yet allowed to sit down completely (with stitches on the perineum, it is sometimes not allowed to sit for up to 2 weeks).
2 months after giving birth, if you omit, you can start having sex with a partner. The initial stages of omission may not affect sex, especially if the muscle tone returned after a couple of months. If the quality of sexual life suffers due to the omission of grade 3 or cicatricial deformity of the perineum, then this should be noted at the reception at the gynecologist (possibly, plastic surgery is indicated).
The main diagnostic method – a visual examination on the gynecological chair and vaginal examination, helps to determine the degree and type of omission of the genitals, as well as select the method of treatment.
Ultrasound of the pelvic organs is assigned to all patients to exclude another gynecological pathology, the results of the survey can also affect the choice of treatment.
Cough test with a full bladder and questioning
When conducting a cough test, the patient with a filled bladder when viewed from a gynecological chair demonstrates urinary incontinence during straining (when coughing).
Answers to the questionnaire questions help to find out exactly what type of urinary incontinence is present in the patient. This is important because only a type of stress urinary incontinence (“stress urinary incontinence”) arises as a result of the prolapse of the genitals, and only this type of incontinence is effectively treated with surgery. If the type of urinary incontinence is associated with impaired neural regulation of the bladder or only with a lack of estrogen in menopause, then surgical treatment of incontinence and omission will not help to overcome it.
Consultation of the urologist is prescribed for concomitant urinary incontinence. The urologist performs cystoscopy (endoscopic examination of the bladder), evaluates urine tests, prescribes ultrasound of the kidneys and bladder, eliminates other causes of incontinence.
Consultation proctologist and rectoscopy in the presence of insolvency of the anal sphincter.
Treatment of the pubescence of the uterus and vaginal walls can be conservative and surgical.
Conservative treatment can be recommended at stage 1-2 of omission, in the absence of symptoms of urinary incontinence and insufficiency of the anal sphincter. Also, conservative treatment can be used in case of a temporary weakening of the pelvic muscle tone in newly born women (in the absence of perineal injury, postpartum muscle weakening is reversible).
Gymnastics for pelvic floor muscles (Kegel method)
- This set of exercises includes combinations of compression and relaxation of the muscles of the perineum and pelvis in different tempos and different poses. First, the patient needs to practice feeling the muscle ring of the vaginal opening. You can even try to insert a finger into the vagina and produce a slight squeezing and lifting the muscles in the lower part of the pelvis inside the body. The patient should feel the compression of the muscles of the vaginal ring, while other muscles (such as the gluteus) should not be reduced. Then you should learn how to perform slow muscle contractions (for 5–20 seconds), followed by smooth relaxation.
- Another exercise is muscle contraction and relaxation at the fastest pace possible. Another option: after 30 contractions of muscles, hold them in a voltage of 30-100-120 seconds, then a break of 30 seconds, repeat again. Exercises should be performed as often as possible, standing, sitting, lying down. They can be done while watching TV, sitting at your desk or taking a shower.
With menopause and insufficiency of sex hormones, hormone replacement therapy or phytoestrogens are possible (they are prescribed by the doctor, since these drugs have many contraindications for use).
- Hormone therapy improves metabolism, collagen synthesis and blood circulation in the connective tissue of the perineum and strengthens the ligamentous apparatus. In addition, if urinary incontinence is associated more with the manifestations of menopause, its symptoms can pass on the background of treatment.
Elimination of physical activity associated with weight lifting.
Prevention of constipation ( diet, use of large amounts of fiber and water, cereal).
Sometimes a patient with complete and incomplete prolapse of the uterus is shown to have surgery, but due to the elderly and concomitant diseases (for example, heart failure) there is a great risk when performing anesthesia and surgical treatment. In such cases, refraining from surgery and used to maintain the normal anatomy of the genital organs pessary – vaginal plastic ring. Such pessaries support the uterus and relieve the patient from permanent loss of the genitals. Vaginal rings should be removed 1-2 times a month, treated for infection, and use emollient ointments (for example, sometimes apply an ointment with levomekol on the ring).
Surgical treatment of uterine prolapse and vaginal walls
Surgical treatment is indicated in cases of 3 and 4 degrees of genital prolapse (incomplete and complete prolapse of the uterus), cervical elongation, in the presence of stress urinary incontinence, in case of insufficiency of the anal sphincter, in case of severe cicatricial changes of the vagina and perineum, which worsen the sexual life of a woman.
Types of operations for prolapse of the genitals:
The operation with the use of mesh implants involves the strengthening of the pelvic floor with a special mesh (made of polypropylene). During such an operation, the uterus is preserved; if necessary, another plastic of the vaginal walls and the vaginal ring is performed. Prior to the establishment of a net implant, preoperative preparation of the vagina is carried out, sanitizing vaginal suppositories are used, and hormone suppositories with estrogen are used for menopausal women to improve blood supply in the mucous membrane. Anesthesia for such an operation is usually spinal anesthesia, a stab in the back, the patient is conscious. In the postoperative period, treatment of sutures is carried out, in the hospital the patient usually spends about 7-10 days. The outpatient sick-list can be extended up to 27-40 days, after the operation the patient applies a course of hormonal and wound-healing vaginal suppositories.
In urinary incontinence, there is a well-defined mesh implant, implants are also different for the operation when the anterior wall and the posterior wall of the vagina are omitted.
With the complete prolapse of the uterus, vaginal removal is possible. This operation is usually performed under general endotracheal anesthesia (the patient sleeps and breathes through the endotracheal tube), the uterus is removed through the vagina easily enough, since the ligamentous apparatus is stretched and does not hold the organ. In the case of old age and the absence of sexual activity, one can also resort to vaginal removal of the uterus and excision of the lowered walls (median colporrhaphy).
Organ-preserving treatment using the laparoscopic method (with the help of puncturing the abdominal wall in three places) hemming the uterus to the sacral ligaments (ligaments in the pelvic cavity).
With an isolated lengthening of the cervix, it can be amputated while preserving the uterus, and a mesh implant can also be installed.
When cicatricial deformity of the vagina and perineum, colporrhaphy (excision of the lowered wall and suturing) and levatoroplasty (strengthening the muscles of the perineum around the vaginal ring and the muscles that raise the anus) are performed. In the case of such a plastic surgery in the postoperative period, the patient is forbidden to sit up to 2 weeks (you can sit down gently on one side).
The ban on sex after surgical treatment of omission prescribed for 7-8 weeks. In any case, after surgery, physical activity is limited to 1-2 months, then it is recommended to lift no more than 8-10 kg. It is also necessary to carry out the prevention of constipation, apply toning exercises for the pelvic floor muscles (starting 2-3 weeks after surgery). If the operation on the omission of the genitals is done to a young woman, then in the case of her next pregnancy, childbirth is recommended by cesarean section.
Prognosis after treatment
In case of compliance with all recommendations, the prognosis at 3-4 degrees (after surgery) and at 1-2 degrees of omission is favorable. When you return to heavy loads, weight lifting, with chronic severe constipation, with an increase in weight and with the progression of symptoms of menopause, genital prolapse recurrences may occur.
What kind of sports can be practiced during omission and after treatment for genital prolapse
Some sports, such as bicycles, are prohibited in the gym with weight lifting more than 8-10 kg. You can crouch with your own weight and run, but not earlier than 2-3 months after surgical treatment. Download press is not recommended, the abdominal muscles can be strengthened by actively swimming in the pool. Not recommended horse riding. Visits to aerobics and aqua aerobics are allowed, exercises are recommended functional with its own weight. Yoga is useful for strengthening the ligamentous apparatus (also not earlier than 2-3 months after treatment).
Complications of omission and prolapse of the uterus in the absence of proper treatment and implementation of recommendations:
- the progression of the degree of omission,
- aggravation of symptoms of urinary and fecal incontinence, the addition of urinary tract infection (cystitis, pyelonephritis),
- disorder in family life due to reduced quality or lack of sex due to genital prolapse and cicatricial deformity of the pelvic floor,
- the hernia sac mucosa can fall out as a result of chronic microtraumatization, ulcerations appear on it, so-called “trophic ulcers”,
- pinching of the uterus in the hernial sac with impaired vascular circulation, pain syndrome can lead to emergency surgery to remove the uterus.