Uterovaginal Prolapse

: Aetiology : Clinical Presentation :

: Diagnosis : Mangement :
 The physician should look
upon the patient as a besieged
city and try to rescue him with
every means that art and
science place at his
command. 
Alexander of Tralles
 In this presentation…

• Review of applied anatomy

• Definitions – What is a Prolapse?
• Types of Prolapse
• Classification of Prolapse
• Signs and Symptoms, Examination, Differential diagnosis,
Investigation of UV Prolapse
• Management of an UV Prolapse
Review of Applied
Anatomy
 Uterine
fundus

Sacrum

Cervix

Vagina

A schematic, simplified sagittal view of the female pelvic structures

 The Vagina

• A fibromuscular canal, 7-9 cm long, extending from the uterus to the vulva.
• Four-walled structure with a vault superiorly into which projects the cervix.
• The vaginal vault is divided into four fornices by the cervix.

• Relations:
Anteriorly: base of the bladder and urethra
Laterally: the levator ani, visceral pelvic fascia and ureters
Posteriorly (inferior to superior): the anal canal, rectum and rectouterine
pouch.
• Highly elastic structure, capable of distension during delivery of the fetus.
• Support to the upper part of the vagina is provided by the cardinal
(transverse cervical) and uterosacral ligaments.
 Supports of Pelvic Floor
• Peritoneum: not contributory

• Pelvic fascia

• Pelvic floor fascia (fascia over pelvic floor muscles)

- Endopelvic fascia: main support
- Lateral cervical (transverse cervical, cardinal or Mackenrodt) ligament:
lateral aspect of cervix and upper vagina to pelvic side walls
- Uterosacral ligament: back of uterus to front of sacrum
- Pubocervical ligament (fascia): anterior aspect of cervix to back of body
of pubis
- Posterior Pubourethral Ligament: post. inf. of symphysis pubis to ant. of
middle ⅓ of urethra & bladder
• Pelvic Floor muscles

- Levator ani muscle (pelvic diaphragm): Pubococcygeus,

Iliococcygeus, Puborectalis

- Coccygeal muscle

- Urogenital diaphragm: superficial and deep transverse perineal

muscles
Definition
Pelvic organ prolapse:

A hernia of one or more pelvic organs (uterus,

vaginal apex, bladder, rectum) and its associated
vaginal segment from its normal location.

(ref: Neeraj Kohli, MD, Donald Peter Goldstein, MD.An overview of the clinical manifestations,

diagnosis, and classification of pelvic organ prolapse.)  

 Types and
Classification
A vaginal prolapse can be of the following types:

Anterior Vaginal wall prolapse

• Urethrocele: urethral descent
• Cystocele: bladder descent
• Cystourethrocele: descent of bladder and urethra

Posterior Vaginal wall prolapse

• Rectocele: rectal descent
• Enterocele: small bowel descent

Apical vaginal prolapse

• Uterovaginal: uterine descent with inversion of vaginal apex
• Vault: post hysterectomy inversion of vaginal apex

These may occur singly or even in combinations in a patient.

Uterine prolapse
Vaginal Vault Prolapse
Rectal prolapse
(Rectocele)
Bladder prolapse
(Cystocele)
Enterocele
 Classification Systems

There are two systems of classification for pelvic prolapse:

• Baden Walker (1968) and Beecham (1980)
• Pelvic Organ Prolapse Quantification (1996)

Baden Walker and Beecham system:

• Conventional
• Three degrees of prolapse are described and the lowest or most
dependent portion of the prolapse is assessed whilst the patient lying in
the left lateral position and is straining.
1st degree: cervix within vagina
2nd degree: cervix at introitus
3rd degree: descent outside the introitus, at the vulva (procidentia)
 Pelvic Organ Prolapse Quantification (1996)

• Devised by International Continence Society in 1996

• Hymen is the fixed reference point
• provides standardized means for documenting, comparing, and
communicating clinical findings with proven interobserver and
intraobserver reliability
• Necessary to specify condition of examination and position of patient
• Approved by the International Continence Society, the American
Urogynecologic Society, and the Society of Gynecologic Surgeons for
the description of female pelvic organ prolapse

Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol
1996; 175:10.

Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed International Continence Society, Society of
Gynecologic Surgeons, and American Urogynecologic Society pelvic organ prolapse classification system. Am J Obstet Gynecol 1996; 175:1467
 POP-Q
Stage Description

No descent of pelvic structures during straining

• 0
The leading surface of the prolapse does not
• I descend bellow 1 cm above the hymenal ring

• II The leading edge of the prolapse extends from 1

cm above the hymen to 1 cm through the
hymenal ring

• III The prolapse extends more than 1 cm beyond the

hymenal ring, but there is not complete vaginal
eversion
• IV The vagina is completely everted
Prevalence
Estimated prevalence of UV Prolapse:

• 12-30% of multiparous women

• 2% of nulliparous women
• Less among Blacks compared with Caucasians
• More common among elderly/postmenopausal
women
Aetiology
Congential:

- seen in nulliparous women (accounting for 2% of prevalence)

- inherent defect in supports, strong familial incidence
- Eg: Ehlers-Danlos syndrome, congenital shortness of vagina, deep
uterovesical/uterorectal pouches

Acquired:
1. Childbirth

- mechanical and nerve damage during vaginal delivery

- parity associated with increasing prolapse, rare in nulliparous
- seven times mores common in women with seven or more children
- rare during pregnancy itself

2. Raised Intra-abdominal Pressure:

- added strain on pelvic floor, especially in susceptibles

- eg: chronic cough, constipation, tumors
- very rarely chronic ascites1 or pregancy may be implicated

 
Massive uterovaginal prolapse in a young nulligravida with ascites: a case report. J Reprod Med. 2007 Aug;52(8):727-9
1
3. Ageing

4. Menopause

5. Surgery
- post hysterectomy (approx. 1% cases)
- other surgical procedures such as colposuspension
Clinical Presentation
 History
(nonspecific symptoms)

Lump in vagina
or
protruding out of it

Renal failure Local

(rare) discomfort

Nonspecific
symptoms

Dyspareunia
backache
Or Apareunia

Bleeding
Or infection
 History
(specific symtoms)

Urinary
frequency

Urinary
UTI urgency
Cystourethrocele

Stress Voiding
Incontinence difficulty
 History
(specific symtoms)

Incomplete
bowel
emptying
Also ask about…
• COAD
• Parity
Rectocele • Mode of deliveries

Digitation
(to
empty bowel)
Physical Examination
General examination:
• State of health, anemia, chest and cardiovascular examination, abdominal
examination

Vaginal/Speculum examination:
Examine the patient in the left lateral position while she is straining, using a Sims’
speculum.
• Prolapse may be obvious
• Ulceration and atrophy may be apparent
A vaginal pelvic examination should be performed to rule out a pelvic mass.

Rectal examination:
To differentiate rectocele from enterocele, if present.
Differential Diagnosis
• Cervical polyp
• Large Endometrial polyp
• Pedunculated myoma
• Cervical cancer
• Metastasis of uterine cancer
• Urethral diverticulum
• Vaginal wall cyst
Investigations
Baseline:

• FBC
• UCE
• FBS
• Blood group, X-match
• Urine microscopy (MCS)
• CXR
• ECG

Additional:

• Ultrasonography
• Computed tomography (CT)
• MRI
• Cystoscopy
Complications
•Keratinization of vagina
•Hypertrophy of the cervix
•Decubitus ulcers – ischaemic changes
•Recurrent UTI
•Acute urinary retention
•Hydorureters / Hydronephrosis
•Renal failure
•Incarceration of the prolapse
•Malignant change: rare
Mangement
Management options

• Prevention
• Medical
• Surgical
 Prevention

• Correct obesity, chronic cough, constipation

• Avoid Crede’s maneuver during delivery of baby and placenta
• Shorten second stage of delivery
• Avoid forceful instrumental delivery technique
• Prevention of post hysterectomy vault prolapse by apposition of the
cardinal and uterosacral ligament to the vaginal vault
• Family planning
 Medical
Physiotherapy:
Minor prolapse or prolapse developing within six months of
delivery.
Use of pessaries:
- Therapeutic test
- Prolapse discovered during pregnancy, puerperium and
throughout the period of lactation
- Patients not fit for surgery
- Those who refuse surgery
- Promote healing of decubitus ulcers before surgery
- When family size is not complete

Complications of pessaries: impaction, ulceration of vaginal wall,

stress incontinence, infection, carcinoma of vaginal wall (rarely)
Various types of pessaries
 Surgery
• Definitive treatment
• Aim is to restore anatomy and function
• Who opts for surgery?1
• Many types of surgical procedures, depending on type and degree of prolapse
• Preoperative preparation:

- Correct anemia and nutritional deficiencies

- Treatment of UTIs, vaginitis, cervicitis
- treatment of decubitus ulcers
- Written, informed consent
- Arrange and X-match blood
- Investigations for anesthesia fitness (baseline, cervical smear, ECG and 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

1 Conservative versus surgical management of prolapse: what dictates patient choice? (Int Urogynecol J Pelvic Floor Dysfunct. 2009 Oct;20(10):1157-61.
Epub 2009 Jun 19)
• Anterior Colporraphy: most common procedure for
cystourethrocele
• Posterior Colporraphy: most common procedure for
rectocele
• Enterocele: Pouch of Douglas is closed surgically after
resecting peritoneal sac containing small bowel
• Uterovaginal prolapse:

- Manchester repair
- Sacrohysteropexy
- Vaginal hysterectomy: if patient does not wish to retain
the uterus
- Vaginal colpocleisis

In case of post-hysterectomy vaginal vault prolapse:

- Sacrocolpopexy
- Uterosacral ligament suspension
- Sacrospinous ligament fixation
 Post operative care
– Receiving notes
– NPO till gut sounds are audible
– I/O charting
– Remove vaginal pack after 24 hours
– Retain Foley’s for 2-5 days
– IV antibiotics
– Analgesics
Complications of Surgery
• Anesthesia complications
• Hemorrhage
• Urinary retention
• Urinary incontinence
• Vault infection
• Thromboembolic phenomenon
• Dyspareunia
• Apareunia
• Constipation
• Recurrent Prolapse
• Mesh erosion
• Vaginal stenosis
• Subfertility
• Premature/precipitate labour and cervical dystocia
 References
• POP-Q staging system: http://edu.ipuls.se/Utbildningskatalogen/CourseFiles/POPQ__.ppt
• Massive uterovaginal prolapse in a young nulligravida with ascites: a case report. J Reprod Med. 2007
Aug;52(8):727-9
• Bump, RC, Mattiasson, A, Bo, K, et al. The standardization of terminology of female pelvic organ prolapse
and pelvic floor dysfunction. Am J Obstet Gynecol 1996; 175:10.
• Hall, AF, Theofrastous, JP, Cundiff, GW, et al. Interobserver and intraobserver reliability of the proposed
International Continence Society, Society of Gynecologic Surgeons, and American Urogynecologic Society
pelvic organ prolapse classification system. Am J Obstet Gynecol 1996; 175:1467
• Conservative versus surgical management of prolapse: what dictates patient choice? (Int Urogynecol J Pelvic
Floor Dysfunct. 2009 Oct;20(10):1157-61. Epub 2009 Jun 19)
• http://www.scribd.com/doc/6587132/Uterovaginal-Prolapse
• Vaginal reconstructive surgery for severe pelvic organ prolapses: a 'uterine-sparing' technique using
polypropylene prostheses (Eur J Obstet Gynecol Reprod Biol. 2008 Aug;139(2):245-51. Epub 2008 Mar 5)
• http://www.scribd.com/doc/6586665/Management-of-Uterovaginal-Prolapse
• Sacrohysteropexy with prolene-1 for the management of uterovaginal prolapse
Pak Armed Forces Med J Dec 2005;55(4):314-7.
• Uterovaginal Prolapse: Epidemiological and Biochemical Parameters
Mother & Child Dec 1999;37(4):147-152.
• The relationship of vaginal prolapse severity to symptoms and quality of life.  BJOG. 2005 Jul;112(7):971-6
Thank You