Uterovaginal Prolapse in a Newborn with Meningomyelocele: Case Report

BackgroundNeural tube defects are a group of congenital malformations in which the spinal column is bifid as a result of failed closure of the embryonic neural tube. Although not common, they might be complicated with pelvic organ prolapse mostly due to abnormal innervation and the resulting atrophy of the pelvic floor musculature.CaseIn this case report we present a newborn with uterovaginal prolapse in the setting of meningomyelocele, in whom the prolapse of pelvic organs spontaneously ameliorated after surgical correction of meningomyelocele.     

Vaginal vault prolapse after nonsurgical and surgical treatment of MÄAdullerian agenesis

BACKGROUND:Women with Mayer-Rokitansky-Küster-Hauser syndrome fail to develop müllerian ducts, present with primary amenorrhea, and an absent or rudimentary uterus and vagina. After creation of a neovagina, vaginal vault prolapse may occur because of lack of support to the artificially created vagina.CASES:The first patient presented with vaginal vault prolapse 10 years after her vagina was mechanically dilated. The second patient presented with vaginal vault prolapse 27 years after a McIndoe procedure.CONCLUSION:Women with Mayer-Rokitansky-Küster-Hauser syndrome with an artificially created neovagina by dilatation or surgical procedure with a graft are at risk for vaginal vault prolapse. They can be successfully treated with abdominal sacrocolpopexy and paravaginal repair.     

Prolapse of the neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. A case report.

BACKGROUND: Mayer-Rokitansky-Kuster-Hauser syndrome is a rare entity. The creation of a sigmoid vagina was performed in some patients with this syndrome in the past, though it is not widely used now. We report on a patient who developed prolapse of a sigmoid vagina 33 years after the operation. CASE: A 57-year-old woman presented with a "falling-out" sensation in the vagina, pain, leukorrhea and dyspareunia. She had undergone an operation for creation of a sigmoid vagina 33 years earlier in our hospital. She and her husband desired conservation of the ability for sexual intercourse. The transabdominal method of retroperitoneal sacropexy of the sigmoid vagina was performed. The patient has maintained a satisfactory sexual life with her husband since the operation. CONCLUSION: There are a few cases of prolapse of a sigmoid vagina in the literature, while the repair methods are not described in detail. To our knowledge, this is the first report of reconstruction of a sigmoid vaginal prolapse. Although the reasons for the neovaginal prolapse were not understood, the retroperitoneal sacropexy was successful in this case.     

Study of uterine prolapse by magnetic resonance imaging: topographical changes involving the levator ani muscle and the vagina.

Alternations of the pelvic structure with an emphasis on those of the levator ani muscle, associated with uterine prolapse, were studied using sagittal magnetic resonance images obtained from 19 subjects without and 14 with uterine or vaginal prolapse of varied degree and 3 patients with Rokitansky syndrome who had undergone a McIndoe operation. Two additional patients with a grade III uterine prolapse were also studied before and 2-3 months after corrective surgery consisting of vaginal hysterectomy combined with anterior colporrhaphy and posterior colpoperineorrhaphy. Absence or presence of prolapse, irrespective of its grade, was found to be related to whether or not a reference line extrapolated from the levator plate crossed the pubis on sagittal images. This was the case as well in patients with Rokitansky syndrome with a neovagina and loss of such crossings was restored in patients with prolapse after surgery. Backward bending of the upper vagina noted in nonprolapse conditions was usually absent in patients with uterine prolapse. These results document that topographical changes involving the levator ani muscle and the vagina occur in association with uterine prolapse.     

Repair of vaginal prolapse after hysterectomy

Forty-one women with primary or recurrent prolapse of the vagina following either vaginal or abdominal hysterectomy were treated with a vaginal operation. The retroperitoneal approach of utilization of the perirectal fascia to support the vault of the vagina is described and illustrated. This technique may also be used in selected patients to prevent this complication after vaginal hysterectomy and repair.     

Sacrospinous ligament fixation of vaginal apex for repair operation of uterine prolapse--operative procedure and postoperative outcome evaluated with score system and X-ray subtraction colpography

To preserve a snug vagina with complete repair, sacrospinous ligament fixation (SLF) to the vaginal apex was applied in operations for uterine prolapse from the April of 1983 to the April of 1984. SLF was added to 11 vaginal hysterectomies with anterior and posterior (A-P) colporrhaphy, 1 Manchester operation and 1 A-P colporrhaphy. SLF was performed at the stage of posterior colporrhaphy in each operation. The postoperative outcome was evaluated with a score system and an X-ray subtraction colpography. The score system describes the grade of vaginal relaxation in each part of the vagina before and after the operation. It showed that the vagina was repaired quite well by the SLF especially in the area of the vaginal apex and posterior wall. The subtraction colpography revealed the side view of the vagina and its movement on straining. It suggested that the SLF was a reasonable procedure for the prevention of recurrence. SLF also proved to have wide application to the repair of uterine prolapse including patients desiring the preservation of childbearing capability and elderly or poor-risk patients.     

Classification and evaluation of prolapse

Pelvic organ prolapse is prevalent among older women. Milder stages of prolapse, cranial to the hymen, are common and usually symptomless. A specific symptom is a bulge outside the vagina. Functional symptoms from the bladder, bowel and sexual life frequently coexist without a known cause/effect relationship to prolapse. Prolapse should be measured by the validated internationally approved pelvic organ prolapse quantification (POPQ) system that can measure prolapse in the three compartments and three levels of the vagina. We should work on a common classification system and agreement in which symptoms should be recorded as related to prolapse and expected to improve by prolapse surgery.     

Fallopian tube prolapse after laparoscopic resection of pelvic endometriosis

BACKGROUND: Fallopian tube prolapse is an unusual but often reported complication after hysterectomy. This problem has not yet been reported in a patient undergoing laparoscopy but not hysterectomy. CASE: Fallopian tube prolapse was diagnosed in a patient after laparoscopic excision of pelvic endometriosis, without hysterectomy. The prolapsed fallopian tube was preserved by laparoscopic retrieval from the vagina and closure of the vaginoperitoneal fistula. CONCLUSION: Laparoscopic surgery, when associated with the creation of a vaginoperitoneal fistula, is a risk factor for fallopian tube prolapse. This problem can be diagnosed and safely managed with a laparoscopic approach.     

Carcinoma verrugoso de vagina. Presentación de un caso

Verrucous carcinoma of the vagina is a rare neoplasm. This entity is a slow-growing, locally invasive but generally nonmetastasizing neoplasm, with a characteristic gross and microscopic appearance.We report a case of verrucous carcinoma of the vagina in a postmenopausal woman diagnosed 4 years after transvaginal hysterectomy for grade 4 uterine prolapse. We also discuss the differential diagnosis and treatment.Verrucous carcinoma of the vagina is a rare neoplasm. The differential diagnosis includes typical squamous cell carcinoma, warty carcinoma, and condyloma acuminatum. Surgery remains the most effective treatment.     

Uterine Prolapse and Acute Renal Failure in a Chinese Patient

EDITORIAL COMMENT: A large prolapse of the uterus and vagina (often called a procidentia, although strictly speaking this term refers to any prolapse) may be associated with urgency, frequency, difficulty in passing urine, no urinary symptoms at all, or as in this patient with anuria and acute obstructive renal failure. Women with longstanding prolapses that have not been reduced and which rarely are irreducible, often have hydronephrosis and chronic renal failure. However it is exceedingly uncommon for a prolapse to be associated with anuria as occurred in this patient. The Editor has experience of an elderly patient admitted to the Austin Hospital, Melbourne, 32 years ago who was thought to be demented and who died shortly after admission. At autopsy she was found to have a large uterovaginal prolapse and hydronephrosis, the cause of death apparently being renal failure. A similar case was also reported in a letter in the BMJ approximately 30 years ago. These cases are rare but make the point that a patient who has a uterovaginal prolapse should have the mass replaced and her renal function assessed prior to the anticipated surgery. Usually it is possible to operate on such a patient within 4 or 5 days even when there has been gross ulceration of the cervix and posterior vagina which normally heals rapidly when the uterus and prolapsed vaginal walls (cystocele, enterocele ± rectocele) are reduced and the vagina packed with gauze soaked in oestrogen cream. When a prolapse is large, the bladder can be outside the body with kinking of the ureters, and passage of ureteric catheters may be impossible because of this. Reduction of the prolapse will relieve this obstruction of the ureters, and so lead to improvement in renal function. (See Illustrated Textbook of Gynaecology. Eric VMackay et al. Figures 23.10 and 23.11, pages 344 and 345).     

Abdominal repair of vaginal prolapse and the postoperative outcome as judged by a scoring system and X-ray colpography

Three abdominal procedures were combined to suspend the prolapsed vagina in patients with post-hysterectomy vault prolapse and a narrow vagina and uterine prolapse with pelvic diseases (such as fibroids) necessitating laparotomy. We used Moschcowitz's method (obliteration of the cul-de-sac by purse-string sutures) Burch's method (fixation of the anterior vaginal wall to Cooper's ligament) and Williams and Richardson's method (suspension of the vaginal stump using fascial strips from the external oblique aponeurosis. The postoperative outcome of 8 operations was judged by a scoring system and by X-ray colpography with superimposition of films obtained at rest and during straining (subtraction technic). The scoring system indicated that the anterior vaginal wall and the vaginal vault were well supported by this combination procedures. However, the prolapse of the lower posterior vaginal wall needed an additional vaginal repair. The X-ray colpogram showed that the axis of the repaired vagina was slightly more vertical than normal. But displacement of the vagina on straining was within the normal range. Neither dyspareunia nor stress urinary incontinence were seen as complications of our procedures.     

The role of apical vaginal support in the appearance of anterior and posterior vaginal prolapse

OBJECTIVE: To describe how simulated apical support affects the appearance of prolapse in the anterior and posterior vagina using a modification of the Pelvic Organ Prolapse Quantification (POP-Q) examination. METHODS: Women with prolapse stage II or greater were examined using the POP-Q. To simulate apical support, the posterior blade of a standard Graves speculum was positioned over the posterior vagina to support the vaginal apex while remeasuring points Aa and Ba and over the anterior vagina to support the apex while remeasuring points Ap and Bp. Change in anterior and posterior POP-Q points and prolapse stage with apical support were calculated. RESULTS: One hundred ninety-seven women were enrolled with mean age of 62+/-14 years, median parity of 2 (range 0-8), and mean body mass index of 28+/-5 kg/m(2). By standard POP-Q, 36% had stage II prolapse, 54% had stage III, and 10% had stage IV prolapse. With simulated apical support, point Ba changed to stage 0 or I in 55% of cases and point Bp changed to stage 0 or I in 30% (P<.001 for each point). Mean change for point Ba with apical support was 3.5+/-2.6 cm and point Bp was 1.9+/-2.9 cm (P<.001). CONCLUSION: When the POP-Q examination is performed with simulated apical support, the critical role of level I vaginal support on the position of the anterior and posterior vagina, particularly the anterior vagina, becomes apparent. LEVEL OF EVIDENCE: II.     

Dehiscencia de cúpula vaginal tras histerectomía laparoscópica: a propósito de un caso

Vaginal vault dehiscence after total hysterectomy with small bowel prolapse through the vagina is a rare complication, especially in premenopausal women. Appropriate management includes early diagnosis and surgical treatment. The combination of an abdominal and vaginal approach may facilitate repair.     

Colpopexy: a modification of Shaw's technique.

The efficacy of colpopexy using an autograft is assessed. The method was used in patients with post-hysterectomy vaginal vault prolapse and/or suffering from uterine prolapse complicated by ovarian pathology. Thirty-five patients were subjected to a modified operative procedure based on Shaw's original method and completed with a posterior colporrhaphy. All patients are now free of urinary and/or pelvic symptoms with a functional vagina, after a 48 to 60 months post-operative follow-up. Pelvic cellulitis was observed in two patients and low abdominal pain in three others for a period of 1 month.     

Repair of prolapse with vaginal sacrocolporectopexy: technique and results

OBJECTIVE: Axis and support of the vagina can be restored by sacrocolporectopexy with preservation of coital function. We developed a new technique of transvaginal sacrocolporectopexy for patients with prolapse of uterus and vagina or prolapse of the vaginal vault. STUDY DESIGN: During a 4-year period, 20 patients with vaginal vault prolapse and 83 patients with uterine and vaginal prolapse underwent transvaginal sacrocolporectopexy. Intra- and postoperative complications were recorded. After a mean follow-up period of 24 months (6-48), the result of surgery with respect to prolapse, incontinence, and sexuality was evaluated by patient interviews. RESULTS: No serious perioperative complications occurred with the exception of one patient with bleeding from a presacral vein. Subjectively, 84 patients (82%) were cured of prolapse symptoms. One patient had recurrent grade II vault prolapse and four patients developed a grade II rectocele. Five patients developed urge incontinence grade I. One patient developed fecal incontinence. No patient had coital problems as a sequelae of sacrocolporectopexy. CONCLUSION: Transvaginal sacrocolporectopexy is a safe procedure with a success rate comparable to sacrospinous fixation.     

Endoscopic suspension of vaginal prolapse

A new alternative for the surgical treatment of vaginal prolapse is presented in which the prolapse vagina is brought towards the abdominal wall using an extraperitoneal abdomino perineal approach with endoscopic control. The technique consists of a small suprapubic transverse incision to expose the abdominis rectus muscle aponeurosis. A Stamey needle is passed retropubically to the vagina and the extremity of a helicoidal suture previously made in the vaginal wall is introduced in the eye of the needle. It is then withdrawn to bring the thread to the suprapubic region. The maneuver is repeated on the other side and the threads are tied up over the aponeurosis of the rectus abdominis muscles, bringing the vagina to its original position. Endoscopic control is important to avoid bladder perforation.     

Remodeling of vaginal connective tissue in patients with prolapse

PURPOSE OF REVIEW: Pelvic organ prolapse is a common disease that negatively affects the lives of women. To date, basic science research into the pathogenesis of prolapse has been limited. The vagina and its supportive connective tissues provide one of the primary mechanisms of support to the pelvic organs. This review summarizes our current understanding of the alterations in these tissues in women with prolapse. RECENT FINDINGS: Current research suggests that the vagina and its supportive tissues actively remodel in response to different environmental stimuli. The literature has many shortcomings due to restricted access to tissue, absence of longitudinal data, and limited animal models. Nevertheless, recent studies indicate that within prolapsed tissue metabolism of collagen and elastin is altered. Thus, not only the synthesis of those structural proteins but also the balance between the activity of the major proteolytic enzymes that degrade them and the inhibitors of proteolysis are important components to consider in studies on the pathogenesis of pelvic organ prolapse. SUMMARY: Biochemical studies of the vagina and its supportive connective tissues have improved understanding of the contribution of altered connective tissue to the pathogenesis of prolapse. It is important to continue research in this area, as the knowledge gained from these studies will allow for the development of innovative reconstructive procedures and the establishment of preventive measures.     

Kolpohysterektomie und Kolpokleisis – noch zeitgemäß?

Conservative treatment of the genital prolapse with pessars is mainly restricted to women with multiple co-diseases or contraindications for operative treatments. The first operative technique used (colpocleisis) intended a complete closure of the vagina. This technique has a low primary morbidity, but a high rate of prolapse recurrence. The colpohysterectomy is the technique of choice for women not planning to have intercourse in the future. Herewith the rates of recurrence of the prolapse and of incontinence are low. As a basic requirement of the operative treatment of the extended prolapse the vaginal skin should be spared. On a functional basis the vagina prevents incontinence and extension of the pelvic hernia, on a psychological basis the sexual integrity of the older woman is preserved. Perioperative morbidity and mortality of geriatric women differ not significantly from those of younger women. Therefore age should not be used as an argument for not applying organ preserving operative strategies.     

"Spontaneous perforation" of Douglas' pouch

"Spontaneous" perforations of Douglas's pouch are a rare complication following gynecological surgery. Three patients are reported, in which Wertheim-Meigs-operation, abdominal and vaginal hysterectomy had been performed. Laceration of the vaginal vault with opening of Douglas's pouch occurred "spontaneously" at sexual intercourse. In another patient rupture of the pelvic floor with prolapse of the intestinum was observed 7 months after colpocleisis. Small perforations may be closed through the vagina; prolapse of the intestinum requires laparotomy.