Uterovaginal Prolapse

Tahira Butt
 Uterovaginal prolapse is defined as
protrusion of uterus or vagina beyond their
normal anatomical confines
 12 – 30% in multiparous women.
 2% in nulliparous women.
 Home deliveries by untrained staff
 Large family size
 1st degree:
uterus has descended from its normal but still lies
in vagina and nothing appear outside vagina
 2nd degree:
Uterus descent up to the introitus while body of
uterus lies within vagina
 3rd degree:
uterus descent out side the introitus & usually
accompanied by cystourethrocele & Rectocele,
cyctocele.
 Anterior vaginal wall prolapse;

◦ Urethrocele;
• Descent of lower one third of anterior vaginal wall
which contains urethra
◦ Cystocele;
 Descent of upper two third of anterior vaginal wall
which contain urinary bladder.
◦ Cystourethrocele;
 Descent of whole anterior vaginal wall which contain
bladder & urethra.
o Rectocele;
o Descent of two third of posterior vaginal wall contain
rectum.
o Enterocele;
o Descent of one third of posterior vaginal wall contain
Small bowel .
oVault prolapse;
Post hysterectomy inversion of vaginal apex.
 Congenital;
◦ 2% symptomatic prolapse occur in nulliparous.
◦ Congenital weakness of connective tissue.
 Multiparity mostly common;
◦ Multiple vaginal deliveries;
 Causes damage to major supports of vagina,
nerves, endopelvic fascia & levator ani
As a result of
 Prolonged and difficult labour
 Bearing down before full dilatation of cervix
 Laceration of lower genital tract in second
stage.
 Forceful delivery of placenta in third stage.
 Inadequate repair of palvic floor injuries.

 Raised Intra-abdominal Pressure

Added strain on pelvic floor, especially in susceptible- e.g.: chronic

cough, constipation, tumors- very rarely chronic ascites or
pregnancy may be implicated.

 Menopause
Estrogen maintain the tissue tone. After menopause
estrogen
level decreased resulting in weakness of the pelvic floor.

• Surgery-
Post hysterectomy (approx. 1% cases)- other surgical
procedures such as colposuspension. (a surgical procedure used in the
treatment of urinary incontinence caused by urethral sphincter mechanism
incompetence in female )


 Diagnosis is made by clinical examination;
 Clinical features;
 Symptoms;
◦ Non specific;
 Lump.
 Local discomfort.
 Backache.
 Bleeding / infection if ulceration.
 Dyspareunia or apareunia.
 In sever cystourethrocele, uterovaginal or vault
prolapse renal failure may occur.
 Specific;

◦ Cystourethrocele;
 Urinary frequency.
 Urgency.
 Voiding difficulty.
 Urinary tract infection.
 Stress incontinence.

◦ Rectocele;
 Incomplete bowel emptying.
 Abdominal examination;
◦ Should perform to exclude organomegaly or
abdomino-pelvic mass.

 Vaginal examination;
◦ Prolapse may be obvious.
◦ Ulceration.
Pelvic examination
◦ to exclude pelvic mass.
Combine rectal & vaginal examination
◦ to differentiate Rectocele from Enterocele.
 Anterior wall prolapse;
◦ Congenital or inclusion dermoid vaginal cyst
◦ Urethral diverticulm.(an abnormal pouch or sac
opening from a hollow organ (as the intestine or
bladder)
 Uterovaginal prolapse;
◦ Large uterine polyp.
 No essential investigation.
 If urinary symptoms present;
◦ Urine microscopy.
◦ Cystometry.
◦ Cystoscopy.
 If renal failure suspected;
◦ B.Urea.
◦ S.Creatinine.
◦ U/s of renal areas.
 Depends upon patient`s wishes.
 Correct obesity.
 To treat chronic cough.
 To treat Constipation.
 If ulceration then seven days course of local
estrogen.
 Prevention;

◦ Shortening the 2nd stage of labor.

◦ Reducing traumatic delivery.
◦ Use of episiotomy.
◦ HRT in menopausal women.
 Conservative therapy;
◦ Silicon rubber based ring pessaries.
 Indications;
◦ Patient`s wish.
◦ As a therapeutic test.
◦ Child bearing not complete.
◦ Medically unfit for surgery.
◦ During & after pregnancy.
◦ While awaiting surgery.
 Complications;
◦ Vaginal ulceration & infection.
 Aim of surgical repair is to restore anatomy &
function.
 Cystourethrocele;
◦ Anterior repair or colporrhaphy(A/P vaginal wall
repair)
 Rectocele;
◦ Posterior repair or colporrhaphy.
 Enterocele;
◦ Anterior & posterior repair & peritoneal sac
containing the small bowel should be excised.
 Utero vaginal prolapse;
◦ Vaginal hysterectomy;
 If patient completed her family.
◦ Manchester repair;
 Involves partial amputation of cervix & approximation
of cardinal ligaments.
 Usually combined with anterior & posterior repair.
 Sacrohysteropexy;
◦ Abdominal procedure,
◦ Attachment of synthetic mesh from the uterocevical
junction to the anterior longitudinal ligament of the
sacrum.
 Vault prolapse;
◦ Sacrocolopopexy(repairing of pelvic organ prolapse)
 Similar to Sacrohysteropexy but the inverted vaginal
vault is attached to the sacrum.
 Sacrospinous ligament fixation.
 Fascial defect repairs;
◦ Fascial or muscle plication( the process of suturing
together the wall of hollow organ) or attachment to
ligaments to support the vagina in its presumed
original position.
 A pessary is a device which is inserted into the upper
part of the vagina to provide support to the pelvic
structures. The majority of pessaries are made of
silicone and come in a number of shapes and sizes. A
pessary needs to be inserted by a medical
professional and can be kept in place for 3-4
months, after which it will require changing. When
inserted properly, a woman should not be able to feel
a pessary. Pessaries provide a temporary solution to
prolapse symptoms for pregnant women, women who
have recently given birth or for women who are
awaiting surgery. Pessaries can also be used
permanently by women who do not wish to have
surgery or who are unsuitable candidates
 Thorough explanation of the procedure ,expectation and
effect on future life.
 Written, informed consent.
 Arrange and X-match blood.
 Investigations for anesthesia fitness (baseline, cervical
smear, ECG.
 CXR in patient over forty and/or with relevant symptoms).
 NPO at least 24 hr before surgery.
 Clean and shave the surgical part.
 Pre-medication.
 IV fluids started on morning of surgery.
 Prophylactic IV antibiotics.
 Catheterize patient and shift to operation theatre.

Pt is to void the few hour after surgery.
catheterize the patient if unable(after 6 hours)
 Pain
 Constipation
 Urinary incontinence
 Sexual dysfunction
 Risk for infection