Review on Prasramsini Yonivyapad (Pelvic Organ Prolapse)

Laxity of vaginal canal and uterine descent is one of the conditions commonly seen in perimenopausal age with predominance of vata dosha, also seen as a complication of prolonged labour. syandana-prolapse, kshobhana-irritation, dushprasuta-difficult labour and other features of vitiation of pitta dosha are seen in prasramsini yonivyapad. Local therapy play an important role in these conditions. The descent of an organ is called Sramsana and condition called Prasramsini. Prasramsini yonivyapad is enumerated in pittaja yonivyapad by Sushruta which may be co-related with 1st and 2nd degree uterine prolapse. This condition is seen in perimenopausal or postmenopausal period although young age group with distress during labour is no exemption. Prasramsini is a vatanubandhi, pittaja yonivyapad, the drugs with the properties of vata and pitta doshahara, kashaya rasa, balya and agnideepana can be selected. Vaginal tamppon is helpful to strengthen the vagina and cervix. In Ayurveda, local treatment of Prasramsini yonivyapad is sthanapavartana, pichu dharana and veshavara pinda with gophana bandha.


INTRODUCTION
Uterine prolapse is a very common condition with which the patient usually reports to the gynecologist.
Causes of prolapse are multifactorial and result from weakening of the pelvic supporting connective tissue and muscles as well as ligament injury. [1] Phalini yonivyapad, Andini yonivyapad, Prasramsini yoni vyapad, and Mahayoni-all these incorporate the pelvic organ or Uterine prolapse according to the stage and part prolapsed out.Initial degrees of uterine prolapse can be correlated to Prasramsini yoni. [2] Conservative line of management is with pessary, which has many side effects and is only a temporary measure. Surgery is contraindicated in many conditions like puerpera, elderly females etc. and there is a chance of 30% recurrence. [3] 50% improvement in PFDI score was associated with continued pessary use. [4] The line of treatment mentioned aims to pacify Vata and strengthen the pelvic floor musculature. The treatment advised is Sthitisthapana, snehana, swedana and yoni pichudharana with Gophana Bandhana. [5]

AYURVEDIC REVIEW
Prasramsini yonivyapad arises due to vitiated Pitta. The word yoni refers to vaginal canal and uterus and Prasramsana means displacement of vaginal canal from its original place may be caused by some external stimulus or itself without any external stimulus. [6] (Su. U. 38/13-14) [7] 2.1 Samprapti of Prasramsini Yonivyapad [8] Mithyachara leads to PittaPrakopa it results in Rasa-Mamsa Dushti then sthan sanshray in Yoni/Garbhashaya it results in Discharge, Descent, Difficulty in labour it leads to PrasramsiniYonivyapad Madhukosha has interpreted as being displaced from its place or prolapse and as being compressed which means when compressed yoni is displaced/ prolapses. [9] Madhava nidana , Bhavaprakash, Vangsen and Yoga Ratnakar described similar to Sushruta Samhita.[10, 11,12] Dalhana explains the reason for difficult labour is abnormality in the passage.
Mithyachara according lifestyle also lead to Uterine prolapse.

Rupa (Clinical features)
Any irritation causes excessive vaginal discharges or its displacement and difficult labour due to abnormality of passage due to displacement of vaginal canal from its original place. Other features of Pitta vitiation i.e. burning sensation, suppuration, fever. It can be correlated with first and second degree uterine prolapse. [5]

Modern Aspect of Prasramsini Yonivyapad
Pelvic organ prolapse /(POP) includes descent of the vaginal wall and/ or the uterus. The descent of these structures occurs due to weakness of the supporting structures of these organs which maintains them in its normal position. [13] 1. The congenital weakness of the supporting structure is responsible for prolapse in nulliparous women, Early reproductive age, Pelvic organ prolapse or Uterine prolapse may lead to primary infertility.
2. Mismanaged vaginal delivery is the single most common cause for the Pelvic organ prolapse. Premature bearing down efforts prior to full dilatation of the cervix, delivery with forceps or ventouse with forceful traction, prolonged second stage of labour, downward pressure on the uterine fundus for placental delivery.
3. Conditions which increases intraabdominal pressure like chronic asthma, constipation, repeated childbirths at frequent intervals, excessive sexual activity in abnormal postures are also contributory. [13]

Prolapse of Uterus [14]
 First degree -It is the descent of the uterus from its normal anatomical position but external os still remains above the introitus.
 Second degree-The external os protrudes outside the vaginal introitus but the uterine body still remains inside the vagina. • Difficulty in passing urine • Incomplete evacuation may lead to frequent desire to pass urine. • Urgency and frequency of micturition may also be due to cystitis • Painful micturition is due to infection.

Morbid
• Stress incontinence is usually due to associated urethrocele. • Retention of urine may rarely occur.

j. Bowel Symptoms
• Difficulty in passing stool Excessive white or blood stained discharge per vaginum is due to associated vaginitis or decubitus ulcer.

Assessment Parameters
Subjective parameters: [15,16] i. Bulge symptoms ii. Urinary symptoms iii. Backache iv. Bowel Symptoms v. Sexual symptoms Subjective parameters will be assessed as per the grading scale. Pelvic Floor Distress Inventory 22 items (PFDI) can be used to assess the impact of prolapse on the Quality of life of the patients before and after the treatment. [17]

OBJECTIVE PARAMETERS
i.
Pelvic floor musculature tone willbe assessed using Oxford grading scale before and after the treatment. [17] ii. Pelvic floor musculature tone will be assessed using Oxford grading scale before and after the treatment,was graded from 0-5 as follows. During evaluation, an index finger is placed 2-3 cm inside the hymenal ring, at 4 and then 8 o' clock position. Muscle tone is assessed using the following grades.

Level of the Cervix Before and After the Treatment Will be Measured [17]
Level of the cervix from hymenal ring will be measured before and after the treatment in centimetres.Wooden stick marked with centimetres,then sterilized and used for measuring the level of cervix.
Pelvic Organ Prolapse Quantitative Scoring [14]  Leading edge of the prolapse remains 1cm or more above the hymenal ring(≤1cm) 2 Leading edge of the prolapsed extends from 1cm above(-1) to1cm below(+1) the hymenal ring 3 From 1cm beyond the hymenal ring but without complete vaginal eversion 4 Essentially complete eversion of vagina

Principles of Treatment
Local douching, irrigation, anointment, massage and tampons prepared with the drugs either having cooling properties or capable of suppressing Pitta should be done. For oleation either only Ghrita (ghee) or else Ghrita medicated with the drugs capable of suppressing Pitta should be used. The cooling drugs or methods prescribed for Raktapitta should be used. [6] According to Ashtanga Samgraha, in Prasrasta Yoni Snehana with ghee, Swedana with Ksheera and Veshavara bandha till Aamutrakala.
[18]  Group -A Uttara Basti with Bala Taila Intrauterine, 3ml-5ml with increasing dose, started on 6thday of menstrual cycle and on the day of admission in menopausal women. Total 3 sittings were given each month. Each sitting comprises of 3 days Uttara Basti (uterine) followed by 3 days gap.9 sittings were conducted in each patient in which contain total 27 Basti were given.

Ghrita for Oral Administration
Group -B Matra Basti with Bala Taila ,Perrectum , 60 ml, started on 6th day of each menstrual cycle and on the day of admission in menopausal women, continuously for 18 days each month,This was followed for 3 months.Snehana, swedana followed by Basti (Uttara basti and Matra basti), Compare effect of Uttara basti (Uterine) and Matra basti.
Matra basti (group B ) found better than Uttara basti.

DISCUSSION
Cardinal ligament, uterosacral and the pubocervical ligament hold the uterus in position.In post-menopausal age with estrogen deficiency and atrophic changes, there is increased laxity of vaginal canal and laxity in the ligaments causing uterine descent. Complication of labour like prolong labour and multiple pregnancy is also a cause for uterine prolapse. As there is overstretching of the ligaments holding the uterus. Thus this uterine descent may also be seen in a young patient. Prasramsini yoni vyapad is pitta dosha predominant yoni vyapad mentioned by Acharya Sushrut; and having features of syandate, kshobhita and dusprasuscha. In Prolapse of Pelvic Organs On irritation/Difficult labor and jurky movements which is considered as Syandate and is considered as sravati by Dalhan i.e. having excessive amount of srava with kshoba or sanchalita.
Yonishopha or GarbhashayaMukhaShopha also leads to increased vaginal discharge.

CONCLUSION
Prasramsini yonivyapad can be correlated with first and second degree uterine prolapse.According to Ayurveda, snehana, swedana and pichudharana along with oral medications for balasamvardhana is the line of treatment. Conservative line of management is with pessary, which has many side effects and is only a temporary measure. Ayurveda treatment seems to be more beneficial, cost effective and more over it gives mental relief to the patient from the anxiousness of surgery.

CONSENT
It is not applicable.

ETHICAL APPROVAL
It is not applicable.