UTERINE PROLAPSE
BY DR. VANDANA DHAMA
(MS, FICOG,MRCOG)
PROFESSOR
DEPTT. OF OBSTETRICS AND GYNAECOLOGY
L.L.R.M MEDICAL COLLEGE , MEERUT
CONTENTS
Introduction
Causes
Types of prolapse
Degree of prolase
Signs and Symptoms
Diagnosis and investigation
Management
Introduction-
In prolapse , straining causes protrusion of
the vaginal walls at the vaginal orifice , while
in severe cases the cervix of the uterus may
be pushed down to the level of the vulva.
In extreme cases the whole uterus and most
of the vaginal walls may be extruded from
the vagina .
SUPPORTS OF THE GENITAL TRACT
Delancey introduced three level system of support
Level I- Uterosacral and cardinal ligaments support
the uterus and vaginal vault
Level II-Pelvic fascias and and paracolpos which
connects the vagina to the white line on the lateral
pelvic wall through arcus tendinous
Leve III- Levator ani muscle supports the lower one
third of vagina .
Etiology
MENOPAUSE – decrease estrogen deficiency and collagen
deficiency
BIRTH INJURY – stretching of pelvic floor muscles
PERIPHERAL NERVE INJURY –Pudendal nerve injury
Delivery at home – due to bear down before full dilatation
of the cervix
Rapid succession of pregnancy
Raised intra abdominal pressure
Classification of prolapse
Anterior vaginal wall
Upper two third –cystocele
Lower one third –urethrocele
Posterior vaginal wall
Upper one third – enterocele
Lower two third –rectocele
Uterine descent
-descent of cervix into the vagina
-Descent of the cervix upto the introitus
-Descent of the cervix outside the introitus
Procidentia – all of the uterus outside the introitus
Symptoms of prolapse
Something descending in the vagina or of
something protruding either at vulva or externally
Backache
Vaginal discharge
Micturition disturbances
Rectal symptoms less remarkable
Investigation
Patient made to cough and strain Lab investigation
– nature and degree of prolapse
CBC
Vulva examined for perineal
laceration Lft , kft PT-INR
Perineal body and levator muscle Urine examination
palpated to determine muscle
Blood urea
tone
Blood sugar
Look for stress incontinence
Per speculum – determines degree Chest xray
of uterine descent and condition ECG
of vagina , cervical cytology
Urine culture
POP Q for staging
High vaginal swab
Differential diagnosis
Vulval cyst or tumor
Congenital elongation of cervix
Urethral diverticula
Cyst of anterior vaginal wall
Cervical fibroid polyp
Prophylaxis of prolapse
Antenatal physiotherapy, relaxation exercise and due to weight gain and anaemia
are important
The proper supervision and management of the second stage of labor
Low forcep delivery shoulbe be readily resorted to if there is delay I second stage
A perineal tear must be immediately and accurately sutured after delivery
Postnatal exercises and physiotherapy are beneficial
Early postnatal ambulation
Provision of adequate rest for the first 6 moths
A reasonable interval between pregnancies –to allow recovery of muscle tone
Avoid multiparity
Prophylactic hormone replacement therapy .
Non operative management
Kiegel’s exercise – prevent to come in level 3 but not resolve the
level
Method-Tighten pelvic floor muscle like trying to pass gas
For3 seconds then relax for 3 seconds, do 10 contractions three
times a day .Increase your hold by 1 seconds for atleast 4 months
For urinary incontinene for 3 months
Pessary – Gellhorn, doughnut
advise to – unfit for surgery
Pregnancy with prolapse
Refuse for surgery
Surgical Treatment
CASE 1 – 60 yr P3L3 3rd degree +cystocele + rectocele =
Vaginal hysterectomy +
Surgery for cystocele – Anterior colporaphy-- midline incision – remove extra
wall
Surgery for rectocele-Posterior colpoperineorapphy –lax vagina over
rectocele excised and rectovaginal fascia repaired after reducing rectocele .
VH WITH PFR =WARD MAYO SURGERY
Surgery for enterocele – Mc calls culdoplasty
Obliterate pouch of douglas
Case-2 Reproductive Age women
1. Sling surgery
Material used – tensor fascia lata , merselene tape
=SHIRODKAR SURGERY –posterior sling surgery
=Sacrocervico pexy –mesh used
2. Sling Manchester repair –(fothergill surgery)- cervical amputation
Disadvantage – cervical stenosis
Cervical incompetence , done only when family is complete , and has
congenital cervical elongation
3rd case - third degree uterocervical descent
+comorbities-fit for surgery
=Leforte colpocleisis – remove mucosa from anterior
abdominal wall and remove mucosa from posterior
wall – they adhere – fibrosis
Vault prolaose
Abdominal surgery
Sacrocolpopexy
Uterosacral suspension
Vaginal surgeries
Sacrospinous fixation
Uterosacral suspension
Thank you
