UTEROVAGINAL PROLAPSE

CASE :

A 62 years old woman complains of low back

pain and perineal pressure for 1 and half years. She

has been prescribed a pessary which she is reluctant

to wear. On pelvic examination a 2nd degree uterine

prolapse with cystocele and rectocele is observed.

UTERINE PROLAPSE:

“Is the condition of the uterus collapsing, falling

down, or downward displacement of the uterus with

relation to the vagina. It is also defined as the bulging of

the uterus into the vagina.’’

VAGINAL PROLAPSE:

“ Is characterized by a portion of the

vaginal canal protruding from the opening of the vagina.”

ANATOMY:

In the pelvic floor, pelvic diaphragm is divided into

anterior triangle and posterior triangle.

Anterior triangle consist of urethra and vagina.

Posterior triangle consist of rectum.

SUPPORTS OF THE UTERUS:

1. Cardinal ligament(mackenrodt’s, transcervical,lateral

Cx ligament)

2. Uterosacral ligament

3. Pubocervical fascia

SUPPORTS OF VAGINA:

1. Cardinal ligament

2. Pubo cervical ligament

3. Pelvic floor muscles

4. Perineal body

HISTORY:

First recorded in about 2000 BC.

First ever successful vaginal hysterectomy for prolapse

was done by a peasent woman on her own. She cut

down her uterus,but end up with urinary incontinence.

TYPES OF VAGINAL PROLAPSE

• a.Urethrocele b.cystocele

• c.Cystourethrocele

Anterior vaginal

wall prolapse

• a.Rectocele

• b.Enterocele

Posterior vaginal

wall prolapse

• a.Uterovaginal

• b.vault prolapse

Apical vaginal

prolapse

Degrees of prolapse of uterus:There is usual a Right angle Relationship between

uterus and vagina.

How the uterus changes into the same plane as the vagina?

As the uterus gets start descending, the uterus starts moving down and down and down until

Outside of the body.

When it almost outside the body is called procidentia: marked prolapse

Grade I: cervix is not in vagina.

Grade II: cervix is now in vaginal opening.

Grade III: (procidentia)

The uterus is hanging outside and here it is wrapped by anterior and posterior wall of vagina.

ETIOLOGY of Pelvic Relaxation

It is most commonly related to

CHILD BIRTH.

When you push a nine pounds baby through a pelvic floor,

injury is not uncommon.

1-EVALUATION

1-HISTORY

a-non specific symptoms

b-specific symptoms

c-also ask about

PARITY

MODE OF DELIVERIES

2-PHYSICAL EXAMINATION

1-GENERAL EXAMINATION

2-SPECULUM/VAGINAL EXAMINATION

Sim’s position

3-RECTAL EXAMINATION

3-INVESTIGATIONS

A-BASE LINE

FBC,UCE,FBS,Blood group

X match,Urine microscopy,CXR,ECG

B-ADDITIONAL

RFTs,U/S,CT, MRI

DIFFERENTIAL DIAGNOSIS

Cervical polyp

Large endometrial polyp

Cervical cancer

Metastasis of ut.cancer

Pedunculated myoma

Urethral diverticulum

Vaginal wall cyst

COMPLICATIONS

Decubitus ulcers

Keratinization of vagina

Hypertrophy of cervix

Recurrent UTI

Acute urinary retention

Hydroureter/hydronephrosis

Renal failure

Incarceration

MANAGEMENT

According to age of the patient,level of fitness,her wish

for future fertility.

a-counselling

b-prevention

c-treatment

TREATMENT

DIVIDED INTO TWO CATEGORIES

A-MEDICAL

Pessary

B-SURGICAL

SURGICAL

*CYSTOCELE/URETHROCELE

1-Anterior colporrhaphy

2-Burch colposuspension

*RECTOCELE

1-Conservative

2-Posterior

colporrhaphy

*ENTEROCELE

1-ABDOMINAL APPROACH

2-VAGINAL APPROACH

Sacrospinous fixation

*Uterovaginal prolapse

1-CONSERVATIVE

a-Manchester repair

b-Sling operation

2-RADICAL

a-Vaginal hysterectomy

*Vault prolapse

1-Le fort’s operation

2-Utero sacral ligament suspension

3-Sacro spinous ligament fixation

THANK

YOU

Rizwan Ullah Khan

Roll No: 08-157

Batch: ‘I’