MAR 2004
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Correct assessment of prolapse essential

Source: Medical Tribune
Publisher: MediMedia Asia
15 April 2003

Correct assessment of prolapse essential p4

MALAYSIA�Proper assessment of genital prolapse is essential prior to surgical treatment, says an Australian consultant urogynecologist.


According to Professor Ajay Rane of James Cook University in Townsville, Queensland the pelvic organ prolapse quantification (POPQ) system is the best method of grading the level of prolapse. Although POPQ is more complex than the Baden-Walker classification, recent trials have proven the former is more standardized and reproducible.


Ajay said that assessment was needed to ensure appropriate treatment, which should primarily aim at restoring function instead of appearances.


�We want to look at the effectiveness of treatment and this does not only mean a good looking vagina, it means restoration of function ... so longer, tighter and higher is no longer the dictum for the vagina. You also want it to be better from a functional point of view. The bladder, bowel and coitus have to work better.�


Ajay said that the mobility of the anterior part of the vagina was less compared with its posterior component. This is because the anterior only has to allow the passage of urine from the bladder while the posterior has to accommodate the passage of solids through the rectum. If the vagina were a rigid organ, nothing would come out.


Ajay said that a prolapse could be classified as a Level I, II or III defect through symptom observation.


Level I defects are observed when the cervix prolapses into the vagina. The prolapse is visible and the patients normally have backache but may not have other functional disabilities.


Besides suffering from backache, patients with Level II defect are also unable to empty their bladder properly and experience postmicturition dribble. Straining to open the bowels and resorting to manual digitation to defecate are other symptoms.


Level II defects are associated with functional disorder as both the anterior and posterior vaginal walls have prolapsed.


Patients presenting with Level III anterior defects that result from damage to the pubourethral ligaments, have stress incontinence.


The diagnosis of a Level III defect in the posterior vaginal wall is usually missed, said Ajay.


He added that this defect, however, could be corrected in about five minutes of surgery, by attaching the perineal body to the lower one third of the vagina.


Patients with a Level III posterior defect have an enlarged hiatus, a loose vagina and suffer from vaginal flatus, an embarrassing symptom. Bubbling noises during intercourse may lead them to refuse intercourse.


Regardless of parity, when women are standing up, their vagina should be turned backwards at an angle of 135˚ posteriorly.


According to Ajay, in treating genital prolapse, gyneurologists must counter the effects of gravity on the vagina when women are standing or walking around.


The pelvic floor is a collagenous fibromuscular type of tissue intersected with nerves and blood vessels that supports the uterus, vagina, bladder and rectum.


�It is the best dynamic, antigravity trampoline because it has slow-twitch and fast-twitch fibers, which constantly adjust muscle tone to the woman�s movements.�


Although the pelvic floor is akin to a dynamic hammock, women should take good care of it by doing Kegel exercises regularly, he stressed.


The dynamic hammock does get denervated with childbirth, lack of exercise and depleting estrogen, Ajay added.

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