Vaginal prolapse

　　1. Western etiology and pathogenesis

　　The causes of vaginal prolapse are multifaceted. The main cause is delivery injury, such as prolonged labor, difficult labor, and cesarean section, which can lead to excessive stretching and laceration of the para-cervical tissue, pelvic fascia, pelvic floor muscles and their fascia. In some cases of early menopause (ovarian failure) or menopausal period, when the ovarian function gradually declines, the level of estrogen decreases, and the function of the supporting structures of the reproductive tract weakens, prolapse or aggravation of the existing prolapse may occur. In addition, congenital maldevelopment of supporting structures, chronic cough, and other factors can also lead to prolapse. The prolapse of the anterior vaginal wall is mainly due to the excessive stretching or tearing of the pubocervical fascia and the vesicocervical ligament, while the prolapse of the posterior vaginal wall is caused by the rupture of the pubotail muscle fibers. These causes can lead to secondary or primary infertility due to the impact on sexual life or the decline of ovarian function.

　　Secondly, the etiology and pathogenesis of traditional Chinese medicine

　　1. Principal symptoms:Anterior vaginal wall prolapse, long-standing without recovery, with a sensation of descending in the lower abdomen, lumbago and weak legs, frequent urination, especially at night, or dizziness and tinnitus, pale red tongue, deep, weak pulse.

　　2. Pathogenesis:The meridian of the uterus is connected to the kidney. Deficiency of the kidney leads to the inability to control the uterus, causing anterior vaginal wall prolapse and a sensation of descending in the lower abdomen; the kidney governs bones, and the waist is the residence of the kidney. Deficiency of the kidney leads to lumbago and weak legs; deficiency of the kidney leads to loss of control of bladder qi, causing frequent urination, especially at night; deficiency of kidney essence leads to malnutrition of the brain, causing dizziness and tinnitus; pale red tongue and deep, weak pulse are signs of kidney deficiency. 2. Deficiency of the spleen and qi

　　3. Principal symptoms:Anterior vaginal wall prolapse, more severe after labor, with a sensation of descending in the lower abdomen, weakness in the limbs, fatigue, and lack of vitality, pale complexion, or frequent urination, excessive leukorrhea, thin and white in quality, pale tongue, thin white fur, thready, fine pulse.

　　4. Pathogenesis:Deficiency of spleen and qi leads to insufficient lifting power, so the anterior vaginal wall prolapse causes a sensation of descending in the lower abdomen; the spleen governs the four limbs, and deficiency of the spleen and yang leads to weakness in the limbs, fatigue, and lack of vitality, with pale complexion; deficiency of qi leads to incontinence of urine, frequent urination; deficiency of the spleen and excess dampness leads to excessive leukorrhea, thin and watery; pale tongue with thin white fur and thready, fine pulse are signs of qi deficiency.

　　1. The dangers of anterior vaginal wall prolapse

　　Severe cases may have a sensation of falling, and the prolapsed mass may enlarge during fatigue or exertion. Gradually, difficulty in urination and incomplete urination may occur; if urinary retention occurs, it often leads to cystitis. When the urethra prolapses, stress urinary incontinence may occur due to the disappearance of the posterior angle of the urethra and bladder. Coughing or increasing abdominal pressure may cause the bladder pressure to exceed the urethral pressure, resulting in involuntary urine leakage.

　　2. The dangers of posterior vaginal wall prolapse

　　A mass or bulge may appear in or outside the vagina, causing a feeling of weight and discomfort, and may lead to back pain. Especially after lifting heavy objects or overexerting muscles, back pain may occur. In some cases, symptoms of stress urinary incontinence may appear, but in other cases, prolapse may have the opposite effect, making urination difficult. If the posterior vaginal wall falls, you may find it difficult to defecate. Straining during defecation can cause further prolapse of the vaginal wall, making the problem worse.

　　Mild cases show no obvious symptoms. Severe cases may experience a sensation of falling, lumbago, and a mass protruding from the vagina, which is actually the prolapsed anterior vaginal wall. After prolonged standing, intense activity, or increased abdominal pressure, the mass may enlarge, and the sensation of falling becomes more pronounced. If only the anterior vaginal wall and bladder prolapse are present, the posterior angle of the urethra and bladder becomes acute, often leading to difficulty in urination and urinary retention, even secondary urinary tract infections. If the anterior vaginal wall is completely prolapsed, the posterior angle of the urethra and bladder disappears, and urine may leak out during activities that increase abdominal pressure, such as coughing or straining, which is known as stress urinary incontinence.

　　I. Menopause

　　It is a period of transition from maturity to aging in female physiological function, and also a transition period from the reproductive mature period to the elderly period. During this period, the ovarian function gradually declines until it finally disappears. Therefore, women during and after menopause and old age are prone to vaginal prolapse. Proper health care during the menopausal and elderly periods is of great importance for preventing vaginal prolapse.

　　1. Women during and after menopause and old age should pay special attention to balancing work and rest, avoid overfatigue, and at the same time, pay more attention to maintaining a pleasant mood and reducing mental burden, eliminating feelings of tension, anxiety, and fear.

　　2. Appropriately reduce work and avoid participating in heavy physical labor.

　　3. Pay attention to nutrition, appropriately engage in physical exercise, persist in doing pelvic floor muscle exercises to prevent excessive relaxation or premature aging of tissues.

　　4. Actively prevent and treat senile chronic bronchitis and habitual constipation, and regularly conduct general and gynecological examinations to discover and treat common diseases in postmenopausal and elderly women in a timely manner.

　　5. Accept estrogen replacement therapy as soon as possible. When excluding systemic diseases such as gynecological tumors, cardiovascular diseases, breast cancer, hyperlipidemia, and liver and gallbladder diseases, estrogen replacement therapy should be accepted in a timely manner. It not only prevents osteoporosis from worsening and relieves menopausal symptoms but also improves the physiological basis of vaginal prolapse and vaginal wall prolapse in postmenopausal and elderly women due to the decline or even disappearance of ovarian function.

　　II. Women experience many special physiological periods throughout their lives

　　It is also a period when they are prone to diseases. Proper health care during these periods can prevent or alleviate the pathological basis of vaginal prolapse, and is the key to preventing vaginal prolapse in women during menopause and old age.

　　1. Strengthening labor protection for women: Excessive burden and posture-related efforts are one of the important causes of vaginal prolapse. Strengthening labor protection for women is a reliable guarantee for preventing and reducing vaginal prolapse.

　　2. Health care during adolescence: Girls between the ages of 12 to 18 are considered to be in adolescence. Due to the incomplete development of the ovaries and female reproductive organs during adolescence, they are prone to various diseases influenced by both external and internal environments, which can affect the normal development and reproductive function of women. Women with poor muscle strength and ligament tension, often accompanied by relaxed and weak abdominal walls, are referred to as asthenic physique. Such individuals usually have descended internal organs (such as kidney and stomach prolapse). If the intra-abdominal pressure increases due to certain reasons, it is easy to develop vaginal prolapse. Therefore, health care during adolescence is of great significance for ensuring women's health and normal development, and preventing the occurrence of vaginal prolapse.

　　3. Pay attention to menstrual period health care: Although the menstrual period is a physiological phenomenon in women of childbearing age, women's cerebral cortex excitability decreases during the menstrual period, and the pelvic congestion is caused by the influence of endocrine. Therefore, the resistance of the whole body and the local area is reduced. If not paying attention to menstrual period health care, it is easy to cause various acute and chronic diseases in women, affecting women's health. Especially when women are stimulated by cold during the menstrual period (mainly cold water), it is easy to cause ovarian dysfunction and lead to menstrual disorders or amenorrhea. It is believed that there is a significant relationship between ovarian function and the tension of pelvic supporting tissue. During amenorrhea, due to the decline in ovarian function and the reduction in estrogen secretion, the tension of pelvic supporting tissue decreases, which is prone to vaginal prolapse. Therefore, strengthening menstrual period health care is also of great significance in preventing the occurrence of vaginal prolapse.

　　4. Ensure effective prenatal health care: Ensuring effective prenatal health care for women, timely detecting and correcting abnormal fetal positions to prevent dystocia caused by fetal position, is also one of the important measures to prevent vaginal prolapse.

　　5. Properly handle the stages of labor: Labor injury is an important cause of vaginal prolapse. The longer the labor process, the higher the incidence of vaginal prolapse, which is related to the greater opportunity for injury to the suspensory apparatus and pelvic floor soft tissue that support the uterus. The injuries caused during the first delivery are even more critical. Among the patients with vaginal prolapse, those who developed the disease after the first child accounted for about 30%. Therefore, properly handling the stages of labor and preventing injury is the most important link in preventing vaginal prolapse.

　　6. Carefully attend to postpartum health care: From the delivery of the placenta to the recovery of the reproductive organs to a non-pregnant state, it usually takes 6 to 8 weeks. This recovery period is known as the puerperium. During this period, there are significant anatomical and physiological changes in women. If not paid attention to, vaginal prolapse is most likely to occur. According to reports, the incidence of vaginal prolapse during the puerperium is significantly higher than in other periods, with the highest incidence among workers participating within one month, accounting for more than 85% of all cases. This is due to the physiological and pathological changes caused by pregnancy and delivery, which have not been fully recovered before participating in labor (including heavy domestic labor) easily leads to vaginal prolapse. Therefore, carefully attending to postpartum health care is of great significance in preventing vaginal prolapse. ⑺ Ensure effective lactation period health care: During lactation, the ovarian function decreases. Especially for long-term breastfeeding after childbirth, the atrophy of the uterus can be caused due to the long-term low ovarian function, leading to relaxation and weakness of the supporting structures and suspensory apparatus of the uterus, as well as the reduction of the tension and elasticity of the pelvic floor muscles. In this situation, any external factors that increase abdominal pressure or exert force in body posture can trigger vaginal prolapse. The incidence of vaginal prolapse in lactating women within one year is only 9% or less, while those with lactation period of more than one year account for more than 90%. This indicates that the incidence of vaginal prolapse increases significantly in women with lactation period of more than one year. Another finding is that the descent of the uterus in lactating women under abdominal pressure is more obvious than in non-lactating women. Therefore, ensuring effective lactation period health care is an important measure to prevent vaginal prolapse.

　　First, Medical history

　　There is often a history of physical weakness, multiple deliveries, difficult labor, assisted labor, difficult labor, or injury during delivery.

　　Second, Clinical manifestations

　　Mild cases have no symptoms, severe cases have low back pain,坠感, and exacerbation after standing, feeling a mass prolapse in the vagina, increased secretion, sometimes bloodstained or purulent, abdominal distension, difficulty in defecation and urination. Physical examination: the vaginal orifice is relaxed, or there are old lacerations in the perineum. The anterior vaginal wall presents as a spherical prolapse, soft to the touch, can be reduced when lying flat, increased or moved downward when holding breath, the urethral prolapse when the urethral transverse groove disappears, and the bladder prolapse when the bladder prolapses, it is larger when urinating and smaller after urination, the urethral transverse groove is concave when palpated, and the space between the vaginal wall and bladder wall can be palpated; the posterior vaginal wall presents as a spherical prolapse, the mass increases when holding breath, and the tip of the index finger can be inserted into the anus, with the tip pointing forward, it can bend into the cavity of the prolapsed mass.

　　Third, Special examination

　　Anterior vaginal wall prolapse:

　　1. Metal catheter examination, during urination, the tumor in the anterior vaginal wall can be felt with the catheter.

　　2. Cysto-urethrography examination, the posterior angle and oblique angle of the urethra are all within the normal range.

　　3. Posterior vaginal wall prolapse: During rectal examination, the tip of the finger can be inserted into the blind bag of rectal prolapse.

　　First, Health care for vaginal prolapse

　　1. Take 250 grams of pig's large intestine, 100 grams of black sesame seeds, and 9 grams of cimicifuga, wash the pig's large intestine, wrap cimicifuga in gauze, put it with black sesame seeds into the intestine, place it in a pot, add water to cook until soft, remove cimicifuga, add seasonings, and eat twice a day, drinking the soup twice a week or every three days.

　　2. Use 1000 grams of litchi and 1000 milliliters of yellow wine, soak for 7 days, and drink 30 milliliters each time in the morning and evening.

　　3. Take 5-10 heads of turtle (shui yu) heads, wash and chop them, fry them in a pot, grind them into powder, and take 3 grams at bedtime before going to bed, with rice wine or yellow wine.

　　4. Take one egg and 30 grams of polygonum multiflorum, decoct the polygonum multiflorum in water to get a concentrated juice, then add the egg and cook until熟. Eat the egg and drink the soup twice a day.

　　Second, Dietotherapy

　　1. Take 60 grams of wu qi mei (Chinese prune), decoct it in water, steam and wash while hot, and use it twice a day.

　　2. Use 9 grams of chu wu (Chinese aconite) and Chinese toadstool, decoct the water and add 60 grams of vinegar for steam and wash.

　　3. Take 30 grams each of lonicera japonica, scutellaria baicalensis, and dandelion, 15 grams each of cnicus, and 10 grams of atractylodes, decoct the water and steam the vulva for those with vaginal prolapse and infection, discharging yellow fluid.

　　4. Use 6 grams of chicken stomach, 9 grams of red stone lime, 6 grams of Chinese toadstool, 0.6 grams of bing pian (ice powder), grind into fine powder and store in a sealed bottle for later use. First, decoct Chinese toadstool in water and steam the vulva, then dry it and apply the powder. After inserting the prolapsed uterus into the vagina, support it with a menstrual belt, and use it twice a day in the morning and evening.

　　Firstly, surgical treatment

　　1. Uterine Pessary (Pessary):An ancient treatment method suitable for various degrees of vaginal prolapse. The diameter of the uterine pessary is larger than the transverse diameter of the urogenital cleft, which can support the uterus and vaginal wall and keep them inside the vagina without prolapse. The materials used for making it include silicon rubber, plastic, etc., and there are many shapes, commonly used ones include ring-shaped and trumpet-shaped, or spherical uterine pessary. Choose a pessary of appropriate size. The first use of the uterine pessary should be under the guidance of a physician. Use it during the day and remove it at night to clean and reserve. If it is not removed for a long time, it can cause the pessary to be embedded, or even lead to a vesicovaginal fistula or a rectovaginal fistula. It is not suitable for use in patients with cervicitis and vaginal wall inflammation, genital tract ulcers, and severe prolapse that cannot be returned. Stop using it during the menstrual period and pregnancy. Review every 3 months after use.

　　2. Pelvic Floor Muscle (Pubococcygeus Muscle) Exercise:Suitable for patients with mild vaginal prolapse. Instruct patients to perform anal contraction exercises, use force to contract and relax the pelvic floor muscles for 10-15 minutes each time, 2-3 times a day. This therapy can be combined with the administration of traditional Chinese medicine, such as the Decoction for tonifying the middle and reinforcing the vital energy, at the same time.

　　3. Improve Overall Condition:Treat and remove chronic diseases that increase abdominal pressure, such as cough and constipation. Postmenopausal women should supplement estrogen in moderation to avoid overfatigue, and rest can improve and alleviate the degree of vaginal prolapse.

　　Secondly, surgical treatment

　　1. Strengthening Pelvic Fascia Surgery:Suitable for patients with stage I prolapse or stage II prolapse with vaginal anterior and posterior wall prolapse, and patients with cervical elongation. Common surgeries include: (1) Vaginal anterior and posterior wall repair surgery; (2) Vaginal anterior and posterior wall repair + partial cervical resection and uterosacral ligament shortening surgery; (3) Ligament suspension surgery. Laparoscopic shortening of the round ligament and sacral ligament is suitable for patients with congenital simple mild vaginal prolapse.

　　2. Total Vaginal Hysterectomy and Vaginal Anterior and Posterior Wall Repair Surgery:Suitable for patients with stage II and III prolapse without the need for childbirth.

　　3. Vaginal Closure Surgery:Also known as Le-Fort surgery. Suitable for patients with no malignant change in the cervix, who are elderly and cannot tolerate large surgery, due to partial vaginal closure after surgery, resulting in loss of sexual function during intercourse.