PROLAPSUL PELVI-PERINEAL-SCURT ISTORIC
english version
E.Crauciuc
Clinica a-III-a Obstetrica-ginecologie
Spitalul Clinic de Obstetrica-ginecologie "Elena-Doamna" UMF "Gr.T.Popa" Iasi

Prolapsul pelvi-perineal a fost cunoscut din timpuri stravechi, inca de la inceputurile fiintei umane, cand nasterea se producea numai pe cale joasa, in conditii de promiscuitate absoluta, avand drept consecinte sechele multiple.
Referiri vechi la PPP s-au descoperit relativ recent, in Peru, unde "pietrele pictate de la Ica" ilustreaza, pe langa alte interventii chirurgicale, o serie de manevre pentru reducerea prolapsului genital.
Hipocrate, Soranus si Gallenus sunt probabil printre primii care au descris "caderea mitrei", propunand pentru corectare hamuri din piele de vitel.
Egiptenii gasisera ca remediu un tip de pesarii rudimentare, pe care le introdueau in vagin, alcatuite din materiale vegetale si apoi din ceara de albine, sustinute cu fasii de panza.
In China antica, prolapsul genital era tratat prin acupunctura, exercitii fizice si dieta.
Corectarea chirurgicala a prolapsului incepe teoretic in secolul al XV-lea cu Scoala din Padova, dar parintele adevaratelor operatii plastice si reparatoare, destinate corectarii viciilor de pozitie ale uterului este socotit Ambroise Par. Realizarea ideei lui nu a fost insa posibila decat abia la sfarsitul secolului trecut, odata cu introducerea antisepsiei si asepsiei chirurgicale, precum si a procedeelor de anestezie.
Interpretarile etiopatogenice ale prolapsului au urmatoarea evolutie istorica:
Meissner si Fritsch au considerat prolapsul ca rezultat al slabirii tesutului perineal;
Bell-Duncan il punea pe seama lezarii integritatii si tonusului peretilor vaginali;
Kirsch si Veit au incriminat factorul atrofic, datorat varstei si lezarea tesuturilor conjunctive musculo-aponevrotice perineale;
Kstner a considerat ca toti acesti factori amintiti contribuie la producerea prolapsului;
Schroeder considera ca mai intai se produce o alunecare a peretelui vaginal anterior, urmata de coborarea vezicii si a colului; Hffel considera ca prolapsul vaginal urmeaza prolapsului uterin.
Contributia romaneasca cu privire la etiopatogenia PPP a debutat in 1946, cand dr. Condiescu a comunicat primul caz de prolaps dupa histerectomie.
In 1955, la USSM Ploiesti si apoi in revista "Obstetrica - Ginecologie" 1958, T. Pana si colaboratorii publica o tehnica de histeropexie istmica la ligamentele Cooper, care poate fi socotita precursoarea celei publicate de P. Orsoni in "Journal de Chirurgie", nr.5 din 1965. De altfel, T. Pana a utilizat pentru prima oara suspensia vaginului la ligamentele Cooper pentru preventia tulburarilor de statica pelvina posthisterectomie totala.
C. Popescu si Al. Trestioreanu semnaleaza in 1955, in revista "Chirurgie" nr.1, tulburari de statica vezicala dupa histerectomie.
V. Peteanu, O. Ungureanu si C. Radulescu (Tg. Mures) au studiat frecventa incidentei prolapsului pe baza datelor personale si din literatura.
O. Rusu si colaboratorii (Cluj) au subliniat valoarea metodelor profilactice in PPP dupa histerectomie si enumera procedeele curative de reconstituire a suspensiei bontului cervical sau vaginal.
M. Teodorescu (Timisoara) s-a ocupat de profilaxia intraoperatorie a PPP prin modificari de tehnica ale histerectomiilor totale si subtotale.
N. Coja a apreciat ca "in opera]iile abdominale sunt obligatorii masurile de prevenire a prolapsului dupa histerectomie, iar in cele vaginale, restabilirea unei chingi puternice pelvine".
V. Dobrovici (Iasi) este de parere ca prolapsul genital apare atunci cand exista un teren distrofic la nivelul tesutului subperitoneal, la nivelul vaginului etc.
Gh. Teleman (Iasi) a emis ipoteza ca "in cazul prolapsurilor consecutive histerectomiei, terapia chirurgicala va fi neaparat profilactica".
Amintim, de asemenea, preocuparea prof. dr. Gh. Lupascu, pentru introducerea unor variante de tehnica, domnia sa putand fi citat ca exemplu de acceptare a diverselor metode chirurgicale, in functie de conditiile locale.
In prezent, in cazurile de prolaps, ginecologii din Clinica a III-a de Obstetrica Ginecologie "Elena Doamna" Iasi combina tratamentul hormonal, fizioterapic si kinetoterapia cu tratamentul chirurgical, obtinandu-se rezultate notabile in peste 1000 cazuri luate in evidenta si tratate in intervalul 1990-2001.

THE PELVI-PERINEAL PROLAPSUS - A SHORT HISTORY

Eduard Crauciuc 3rd Clinic of Obstetrics and Gynecology The "Elena Doamna" Obstetrics and Gynecology Hospital The "Grigore T. Popa" University of Medicine and Pharmacy of Iasi

The pelvi-perineal prolapsus has been known since the oldest times, even from the beginnings of the human being, when birth was only given by the lower way, in absolutely promiscuous conditions, having as a consequence a lot of after-effects.
Ancient references to pelvi-perineal prolapsus have been discovered quite recently in Peru, where the "paint stones of Ica" illustrate, besides other surgeries, a series of handlings which were performed in order to reduce the genital prolapsus.
Hippocrates, Soranus and Galen are probably among the first ones who have described the "womb downfall" and proposed the wear of calf leather harness in order to remedy it.
The ancient Egyptians had found, as a remedy, a sort of rudimentary pessaries, composed of vegetal materials, and then of bee's wax, sustained by cloth strips, which had to be introduced into the vagina. In the ancient China, the genital prolapsus was treated by acupuncture, physical exercises and diet. The surgical correction of the prolapsus has theoretically begun in the 15th century with the School of Padova, but Ambroise Par is considered to be the originator of the real plastic and reparatory surgeries, performed in order to correct the positional vices of the uterus. But the putting into practice of his idea was only possible at the end of the 19th century, when surgical antisepsis and asepsis and ansthetic proceedings have been introduced into practice.
The etio-pathogenic interpretations of the prolapsus has had the following historical evolution:
- Meissner and Fritsch considered the prolapsus as being a result of the weakening of the perineal tissue;
- Bell-Duncan deemed it as being a consequence of injuries of the integrity of the tone of the vaginal walls;
- Kirsch and Veit incriminated the atrophic factor as a consequence of the age and the injury of the perineal musculo-aponeurotic connective tissues;
- Kstner considered that all the factors above-mentioned have a contribution to the emergence of the prolapsus;
- Schroder considered that a sliding of the anterior vaginal wall occurs first, followed by the descent of the bladder and cervix;
- Hffel considered that the vaginal prolapsus follows the uterine prolapsus.
The Romanian contribution concerning the pelvi-perineal prolapsus has begun in 1946, when Dr. Condiescu notified the first case of prolapsus after hysterectomy.
In 1955 at USSM Ploiesti and then in 1958 in the "Obstetrics & Gyncology" journal, T. Pan and his assistants have published a technique of isthmic hysteropexy at the Cooper ligaments, which can be considered as a forerunning of the one that was published by P. Orsoni in "Journal de Chirurgie" No. 5 in 1965. Moreover, T. Pan used for the first time the suspension of the vagina at the Cooper ligaments in order to prevent the pelvine statics troubles after total hysterectomy.
C. Popescu and Al. Trestioreanu have reported bladder statics troubles after hysterectomy in 1955, in the "Chirurgie" journal No. 1.
V. Peteanu, O. Ungureanu and C. Rdulescu (Tg. Mures) have studied the prolapsus incidence frequency, based on their personal data and by the data collected from literature.
O. Rusu and his assistants (Cluj) have emphasized the value of the prophylactic methods in the pelvi-perineal prolapsus after hysterectomy and enumerated the curative techniques for the re-constitution of the cervical or vaginal stump.
M. Teodorescu (Timisoara) engaged himself into the intra-operating prophylaxis of the pelvi-perineal prolapsus by changements of techniques in total and sub-total hysterectomies.
N. Coja appreciated that "in abdominal surgeries, the steps for preventing the prolapsus after hysterectomy, and in vaginal ones, the re-constitution of a strong pelvine girth, are compulsory".
V. Dobrovici (Iasi) meant that the genital prolapsus appears when there is a distrophic breeding ground at the level of the sub-peritoneal tissue, at the vagina's level, etc.
Gh. Teleman (Iasi) voiced the hypothesis "in the cases of prolapsus consecutive to hysterectomy, the surgical therapy shall be by all means a prophylactic one". We also mention the concern of Prof. Gh. Lupascu, M.D., for introducing some technique variants, so that he may be quoted as an example of acceptance of several surgical methods, depending on the local situation.
At present, in the cases of prolapsus, the gyncologists of the "Elena Doamna" 3rd Clinic of Obstetrics and Gyncology of Iasi combine the hormonal and physio-therapic treatments and the kineto-therapy with the surgical treatment, so that they have obtained remarkable results in more than 1000 cases that had been recorded and treated during the period 1990-2001.