Anatomy of female genital tract

SUPPORTS OF UTERUS
Primary Supports
 Fibromuscular supports-
a) Muscular supports- 1.Pelvic diaphragm
2.Perineal body
3.Urogenital diaphragm
b) Ligamentary supports- 1. Pubocervical ligament
2.Transverse cervical ligament
3. Uterosacral ligament
c) Fascial support – 1.endopelvic fascia
2.vesicovaginal fascia
3.rectovaginal fascia
 Uterine axis
 Round ligament
Secondary Supports – Broad ligament
Uterovesical fold
Rectovaginal fold

Mechanical Supports –
Bony supports- Lordosis of lumbosacral spine
Vertical orientation of inlet
 Vagina
• H-shaped on cross section

• It extends upwards and backwards (direction)making an

angle 60 degree with the horizontal plane.
• Upper 2/3rd is horizontal and lower 1/3rd is vertical

• Anterior wall is 8 -9 cm and the posterior wall is 10 -11

cm.

• 4-5 cm at lower end & twice as wide at the upper end

Pericervical ring
Pubocervival /Rectovaginal septum
Urogenital diaphragm
Perineal Body
• Anatomical perineum/ Central tendon of perineum.
• Pyramidal structure. 3.5-4*4*4cm.
• Base covered by skin. Apex attached to rectovaginal
septum.
• Confluence of 9 muscles-
1.Superficial transverse perinei
2.Deep transverse pernei
3.Levator ani
4.Bulbospongiosus
5. External anal sphincter
Levator Plate
• Also known as median raphe.
• Strong connective tissue
band formed by confluence of
levator muscles in midline.
• Vagina and rectum are
suspended by endopelvic
fascia over the levator plate.
•Situated between coccyx &
anus.
•Horizontal in erect posture.
• Descent occurs due to
inherent loss of tone- enlarges
urogenital hiatus & descent of
upper 1/3 of vagina.
 POP -Q
• Approved by the International Continence
Society, the American Urogynecologic Society,
and the Society of Gynecologic Surgeons for
the description of female pelvic organ prolapse

• Ordinal staging system created to make

comparative analyses and clinical
communications more practical
• Reduce the prolapse and mark Aa (3cm from
external urinary meatus) and Ap (3cm from
hymen on the posterior vaginal wall) points,
measure TVL(forchette to posterior fornix) ,
GH (urethra to forchette) and PB (forchette to
midpoint of anus)
• At maximal excursion mark Ba, Bp, C and D
points, now measure all 6 points from hymen
 ICS CLASSIFICATION:POPQ System
• Stage 0 – No prolapse

• Stage 1 - Descent of most distal part of prolapse within

1cm above the level of hymen

• Stage 2 – Descent between 1cm above and 1cm below

the hymen

• Stage 3 – Descent beyond stage 2 but not complete <

(tvl-2)

• Stage 4 – Total / Complete Vaginal Eversion ≥ (tvl -2)

Principles of genital
prolapse surgeries
 General prolapse
• All three supports are weak –
• Ligaments – sling/mesh/SSF
• Fascia – native tissue repair, attachment, mesh
• Muscular - perineorrhaphy
 UV prolapse
• 1st and 2nd degree – Ligaments are strong
• Manchester operation
• 3rd and 4th degree – Ligaments are also weak
• Sling/mesh/SSF
 Congenital/Nulliparous prolapse
• Severe weakness of connective tissue –
congenital prolapse
• Moderate weakness – Nulliparous prolapse
• Mild weakness – Nulliparous prolapse after
easy child birth
 Case 1

• Nulliparous prolapse

• 28 yr old P1L1 comes with mass per

vagina

• O/E – III Uterine descent without the

descent of vaginal wall
Defect –
Ligamentary support is weak

Choice of surgery –

• Sacrohysteropexy – fixing the uterus to the

anterior longitudinal ligament at S2 S3 level
(simulating Uterosacrals)
Sacral Hysteropexy
Sacral Hysteropexy
 Sling surgeries

• Modified Purandare – fixing the uterus to

the anterior rectus sheath – dynamic sling
– works only if tone of the rectus muscle is
good
Purandhare’s sling
• Shirodkar – uterus fixed to anterior longitudinal
ligament at S2 S3 level (simulating Uterosacrals)
(static sling)
 Shirodkar’s abdominal posterior sling
operation

Right side – retroperitoneal space created, tape fixed to posterior aspect of isthmus of uterus

Left side – psoas loop, elevation of sigmoid colon, posterior aspect of isthmus of uterus
• Virkud - uterus fixed to anterior
longitudinal ligament at S2 S3 level on
right side and to the anterior rectus
sheath on left side (static and dynamic
sling)

• Khanna – Uterus fixed to anterior superior

iliac spine (static sling)
Virkuds composite sling
 Case 2
• General prolapse

• 23 yr old nulliparous lady comes with

mass per vagina

• O/E – III degree uterine descent without

supravaginal elongation and cystocele,
enterocele, rectocele
Defect –
ligamentary and fascial support weakness

Surgery –
• Sling surgeries with site specific repair of
fascial defects
• Extended Manchester – cervix not
amputated , uterus is anteflexed by fixing the
Mackenrodts and uterosacrals anteriorly,
conventional anterior and posterior
colporrhaphy
 Case 3
• Uterovaginal prolapse

• A 28 yr old P2L2 comes with mass per

vagina

• O/E – III degree uterine descent with

supravaginal elongation, cystocele
enterocele and deficient perineum
Defect –
All three supports ligamentary, fascial and
muscular support

Surgery –
• Modified Fothergill’s - cervix amputated ,
uterus is anteflexed by fixing the Mackenrodts
and uterosacrals anteriorly, conventional
anterior and posterior colpoperineorrhaphy
• Sling surgeries with site specific repair of fascial
defects
 Manchester operation (Fothergill’s
operation)

Fothergill’s points – 1 sub urethral , 2 on either side of the cervix

1 on posterior vaginal wall
 Case 4
• Uterovaginal prolapse in peri and
postmenopausal age group

Defect –
All three supports ligamentary, fascial and
muscular support

Surgery –
Vaginal hysterectomy with site specific repair of
fascial defects, perineorrhaphy and SSF
 Site specific repair
• Reconstruction of pericervical ring
• Anchor vesicovaginal fascia and rectovaginal
fascia to the pericervical ring
• plication of vesicovaginal fascia will detach the
fascia from its lateral attachment
Vaginal hysterectomy
Vaginal hysterectomy
Vaginal hysterectomy
Vaginal hysterectomy
Vaginal hysterectomy
Vaginal hysterectomy
Cystocele repair –
- Central – defects in the fascia are closed and
vesicovaginal fascia is attached to uterosacrals

- Lateral – vesicovaginal fascia is attached

laterally to ATFP(Arcus tendinous fascia pelvis)
and proximally to uterosacrals
Cystocele repair
• Enterocele repair – rectovaginal fascia is fixed
proximally to the uterosacrals
 Enterocele correction
• Abdominal
 Moschowitz procedure
 Halban’s
• Vaginal
 McCaul culdoplasty
Suture inserted into the pouch of Douglas peritoneum
including serosa of the colon and both uterosacral
ligaments.
Three successive sutures in place to obliterate
the pouch of Douglas.
Halban’s Technique - antero posterior plication
Internal Culdoplasty External Culdoplasty
Principles:
- Obliterates cul de sac
- supports vaginal apex
- Directs it to hollow of sacrum
- lengthens posterior vaginal wall
- Attaches rectovaginal fascia to
uterosacrals
 Rectocele
• Central defects in the rectovaginal septum are
repaired
• Rectovaginal fascia is attched proximally to
uterosacrals
• Laterally to ATRV
• Distally to PB
Rectocele repair
Rectocele repair
• Perineorrhaphy – approximation of
bulbospongiosus and transverse
perinnei muscles (distal attachment of
rectovaginal septum, narrowing of
genital hiatus and horizontal orientation
of levator plate)
 Perineorrhaphy
• Essential because it prevents vault prolapse by
 Anchoring rectovaginal fascia to PB
 Making levator plate horizontal
 Narrowing the genital hiatus
• Levator myorrhaphy in selected cases
 Dumble shaped vagina
Perineal body reconstruction / Perineorraphy
Levator Myorraphy and High Perineorraphy
 Case 5
• General prolapse in postmenopausal women
Defects –
All three supports ligamentary, fascial and muscular
support
Surgery –
• Vaginal hysterectomy with site specific repair of
fascial defects and perineorrhaphy
• Sacrospinous fixation
• Iliococcygeous fixation – easy and safe
 Case 6
• Recurrent vaginal wall prolapse

Defect –
• Fascial support

Management
• Prolift / Perigie / customised mesh repair of
cystocele

• Apogie for rectocele repair

 Needle passes through the
groin to enable connection
of the anterior wall graft to
the pelvic sidewalls.

Final positioning of
the Perigee system
 Apogee needle passage

Final positioning of the

Apogee system
Posterior intravaginal slingoplasty
(Infracoccygeal sacropexy)
 Case 7
• Vault prolapse

Defect –
Ligamentary support

Surgery –
• Abdominal sacrocolpopexy
• Vaginal sacrospinous / iliococcygeous fixation
of the vault
 Vault Prolapse
• Sacrocolpopexy
• Sacrospinous fixation

Green-top Guideline No. 46 RCOG/BSUG Joint Guideline | July 2015

 Surgery? Who?
• Surgical treatment should be offered to
women with symptomatic PHVP after
appropriate counselling.
• PHVP surgery should be performed by an
urogynaecologist or gynaecologists who can
demonstrate an equivalent level of training
or experience.
 Postop result
• Pelvic Organ Prolapse Quantifiation (POP-Q)
stage of I or 0 in the apical compartment
seems to be acceptable and widely used as
the optimum postoperative result.
 Which surgery?
• Tailored to the individual patient’s
circumstances.
• Both ASC and SSF are effective treatments for
primary PHVP.
ASC is associated with signifiantly lower rates
of recurrent vault prolapse, dyspareunia and
postoperative stress urinary incontinence
(SUI) when compared with SSF.
 ASC Vs SSF
• However, reoperation rates or higher patient
satisfaction remain the same.
• SSF is associated with earlier recovery
compared with ASC.
• SSF may not be appropriate in women with
short vaginal length and should be carefully
considered in women with pre-existing
dyspareunia.
 Lap Vs Abdominal
• LSC can be equally effective as ASC in selected
women with primary PHVP.
• LSC can include mesh extension or be
combined with other vaginal procedures to
correct other compartment prolapse.
• There is limited evidence on the effectiveness
of RSC.
 High uterosacral ligament suspension
(HUSLS)
• HUSLS - risk of ureteric injury, especially in
the laparoscopic approach.
 Transvaginal mesh (TVM) kits/grafts?

• The limited evidence on TVM kits does not

support their use as fist-line treatment of
PHVP.
When should colpocleisis be used?
• Colpocleisis is a safe and effective procedure
that can be considered for frail women
and/or women who do not wish to retain
sexual function.
 Concomitant surgery for occult SUI?

• Colposuspension performed at the time of

sacrocolpopexy is an effective measure to
reduce postoperative symptomatic SUI in
previously continent women.
Concomitant surgery for PHVP and overt SUI?

• Colposuspension at the time of ASC does not

appear to be effective treatment for SUI.
• Concomitant mid-urethral sling surgery may
be considered when vaginal surgical
approaches are used for the treatment of
PHVP.
Sacrocolpopexy
Suspension of the vaginal vault to the sacrospinous
ligament.
 Case 10
• A 85 yr old C/o mass per vagina. K/C/o HTN, old
IHD. ECHO – LVEF – 48%

• O/E:
General prolapse with grade 3 cystocele,
enterocele, deficient perineum

Management –
If muscular support is good - pessary
Pt not fit for hysterectomy – Le Fort’s repair
 Partial
colpoclesis
 Total
colpoclesis
Partial colpocleisis/ Le Fort’s Total colpocleisis/ Goodall’s modification

– Pt medically unfit/ - Done in sexually active young

sexually not active menstruating women

– Pap smear/ endometrial - Triangular flaps removed

biopsy- must
- Single vagina in lower 2/3
and double vagina in upper
– Aggressive perineorraphy 1/3
to narrow introitus

- Channels on sides permit

– Plication of the bladder egress of menstrual blood
neck routinely done
 LeFort’s / Partial colpocleisis :
Indications
 Are very old or infirm women
 Do not desire coital function
 Have medical contra-indications for major
procedures.
 Post menopausal women
 Introital tightening / Dani’s stitch :

Based on principle of thiersch stitch for rectal prolapse.

Alternative for LeFort’s

Technique :

-Cerclage of the introitus

Kelly
Fothegill
surgery
Wards modification (cystocele, enterocele repair):

 Purse string suture is passed through UV fold of

peritoneum, upper pedicle, Mackenrodt’s uterosacral
complex, & highest point on posterior peritoneum

 United uterosacral and cardinal ligaments are tied

 Drawbacks

 Broad ligaments are drawn into distorted position

 Vagina is shortened
 Due to interposition all sutures are under tension
 Laparoscopy/Robotics
• Better anatomical delineation – better repair
• Subjective and objective cure?
• Morbidity ?
• Cost?
• Further research needed
 Case 8
• A 24 yr old G3P2L2 with 12 wks
gestation with mass per vagina

• O/E: III uterine descent +

• Treatment
Ring pessary, used until 16 weeks of
gestation.
Treatment of edematous and congested prolapsed
cervix with pregnancy

Foot end elevation atleast by 25cms

Cover the prolapsed cervix by soaked guage
with glycerine MgSO4.
All these measures continued till 18 weeks of
gestation.
Once replaced patient is allowed is ambulate.
Management of incarcerated pregnant uterus

Once it is diagnosed , pregnancy has to

terminated, irrespective of period of gestation

During labour:
A close watch on cervical dilatation needed
Generally most of delivery go on spontaneously,
if cervical dilatation fails then,
At <4cms inspite of good contraction 
Consider Em LSCS
At>7cm with good contraction 
DUHRSSEN INCISION
(2’0 and 10’0 clock)
↓
Delivery by vacuum and forceps.

Hyaluronidase injected at multiple points on the

cervical rim helps in cervical dilatation.
 Case 9
Post Natal Day 3 . P2L2 had FTVD.
C/o mass per vagina

O/E- III uterine descent

Management

Consider physiotherapy
Use pessaries till corrective repair surgery done
Corrective repair surgery after 3 to 6 month
 Challenge

• Challenges in the management of pelvic organ

prolapse still remains……

– High recurrence rates

– Lack of randomized control trials
– Poorly defined success and failure rates