Uterine Prolapse

Prepared by: Ms. Mayuri Patel

Uterine Prolapse is the downward

displacement of the uterus into the vaginal canal or a gradually descends of the uterus in the axis of the vagina taking the vaginal wall with it.

Definition

Supports conveniently grouped

under three tier system

1. UPPER TIER Endopelvic fascia covering the

uterus Round ligaments Broad ligaments with intervening

pelvic cellular tissues

Support of the uterus

Cervico vaginal junction• Fibromuscular tissue surrounding the vessels

and nerves this is important direct support of the uterus.

Pelvic cellular tissues• In this connective tissue and smooth muscles .• The blood vessels and nerve supply to uterus,

bladder and vagina pass through it from the lateral pelvic wall.

• The pelvic cellular tissue condense surrounding them and give direct support

Middle tier

• This condensation of the tissues surrounding the supravaginal cervix and vagina down to the superior layer of the fascia covering the levator ani constitute a tough endopelvic facia covering the cervico vaginal junction.

• It condenced and reinforced by plain muscles to form ligaments – mackendrot’s, uterosacral and pubocervical.

3. INFERIOR TIERMusculofacial tone of the hollow vagina by the

facial condensation at the vault and by the pelvic floor.

Positional support to the anterior wall Pelvic floor tissue • Strong condensation of pelvic floor tissue• Below – posterior urethral ligament.• Laterally – pubocervical ligament Bladder Support of posterior vaginal wall • Endopelvic fascial sheath covering the vagina

and rectum• Uterosacral ligament to lateral wall of the

vault • Levator ani with its facial covering

Support of vagina

Predisposing factorsAcquired Vaginal delivery with consequent

injury to the supporting structure overstretching of the

mackenrodt’s and uterosacral ligament.

overstretching of the perineum subinvolution of the supporting

structure

Etiology

congenitalCongenital weakness of the supporting structures is responsible for the nulliparous prolase•short vagina•increased paravaginal tissue laxity•occult spina bifida associated with neurological abnormalities

postmenopausal atrophy increased increases intra abdominal

presser as in chronic cough& constipation

increased weight of the uterus as in fibroid or myohyperplasia

asthenia & undernutrition traction by anterior vaginal wall or

cervical polyp

Aggravating factors

Clinical types

Vaginal prolapse 1.Anteriorwall:

cystocele: formed by laxity & descent the 2/3 rd of anterior vaginal wall as the bladder is closely related to the area, there is herniation of the bladder through the lax anterior wall.

Urethrocele

formed by laxity & descent the 1/3 rd of lower anterior vaginal wall as the urethra is closely related to the area, there is herniation of the urethra thorough the lax anterior wall

Posterior wallRelaxed perineum

Torn perineal body protrudes gaping introitus with the buldge of the lower part of the posterior wall.

Rectocele

Primary Enterocele: formed by laxity of

the upper 1/3 rd of posterior wall., there is herniation of the pouch of Douglas through the lax wall, may contain omentum or gut hence called enterocele.

Secondary:May occur following either

vaginal or abdominal hysterectomy

Vault prolaps

Uterovaginal: This is the commonest type. cystocele

occurs first by traction effect on the cervix causing retroversion of the uterus. Intra abdominal presser has got piston like effect on the uterus thereby pushing it down into vagina.

Congenital: There is no cystocele. the uterus

descends down along with the inverted upper vagina often seen in nulliparous.

Uterine prolaps

First degree: The cervix droops

into the vagina. The uterus descends down from its normal position(external os at the level of the ischial spine)but external os still remains inside the vagina.

Degree of uterine prolaps

Second degreeThe external os protrudes out

the vaginal introitus but the uterine body still remains inside the vagina. The cervix sticks to the opening of the vagina.

Third degreeThe uterine body descends

to lie outside the inroitus. The cervix is outside the vagina.

Minor prolapse of the uterus may not cause any

problemsMore severe prolapse can cause:

• Increased vaginal discharge.• Feeling that something is coming out of the vagina• Dragging sensation in the lower abdomen and back.

If cystocele is present, symptoms include:• Difficulty in starting and stopping urination, Urinary

frequency.• A feeling that the bladder needs emptying again soon

after urination• Problems controlling the bladder.• Frequent urinary infections may result if the bladder

never empties properly.

SIGNS & SYMPTOMS

If Rectocele is present, symptoms include: Difficulty emptying the bowel, in spite of a constant

feeling that the rectum is full and needs to be emptied. Constipation can become a problem.

Some common Symptoms of Uterine Prolapse: Difficult or painful sexual intercourse Low backache. Feeling of rectal fullness. Constipation. Sensation of heaviness or pulling in the pelvis. Vaginal discharge Frequent urinary tract infections. Sensation of fullness in the vagina. Protrusion of pink tissue from the vagina that may be

irritated or itchy.

PREVENTIVE CONSERVATIVE SURGERY

TREATMENT

EFFECTIVE ANTENATAL CARE: -nutritional supplements, antenatal hygiene &

physiotherapy with relaxation exercisesINTRANATAL CARE: to prevent premature bearing down efforts to prevent premature application of forceps before

the cervix is fully dilated to avoid prolonged 2nd stage to avoid too much fundal pressure to expel out

the placenta to perform timely & adequate episiotomy to repair the perineal injuries immediate &

accurately.

Preventive

POSTNATAL CARE: -to prevent undue distension of bladder -to encourage early ambulance -to encourage the pelvic floor exercises

GENERAL MEASURES: -to avoid the strenuous activities 6 months

following delivery -to avoid future pregnancy too soon

1. assurance:2. improvement in nutritional status3.ExerciseSpecial exercises, called Kegel exercises, can

help strengthen the pelvic floor muscles.4. Vaginal pessary

Concervative

1.Anterior colporraphy Correct cystocele and urethrocele. To exercise a portion of the relaxed

anterior vaginal wall to mobilize the bladder push it upwards after cutting the vesico-vaginal ligaments.

Surgery

2. ColpoperineorraphyTo repair the prolaps of posterior vaginal

wall.It repair torn perineal bodyTightening of the pararectal facia.3. Pelvic floor repair4. fortergill’s operation Preliminary dilatation and curratgeAmputation of the cervixPalication of the mackenrodt’s ligament in

front of the cervix.Anterior colporrhaphy Colpoperineorrhaphy5. Vaginal hysterectomy

Thanks You!