Uterovaginal prolapse and

cystocele/rectocele

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 Definition
• Pelvic organ prolapse is Descent of one or
more of the genital organs below their normal
anatomical position.
• Prolapse is a condition in which organs, which
are normally supported by the pelvic floor,
namely the bladder, bowel and uterus,
herniate or protrude into the vagina due to
weakness in their supporting structures.

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 Epidemiology
• Common Problem in Women
• 50% of parous women have some prolapse,
10-20% have symptoms
• 11% Lifetime Risk for Surgery, Of these, 29%
require repeat surgery
• 5-7% Develop Post-Hysterectomy Vault
Prolapse

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 ANATOMY-SUPPORTS OF THE UTERUS
AND VAGINA
• The normal position of the uterus is
maintained mainly by 3 factors:
1. The cervical ligaments: consist of 3 pairs:
• The Mackenrodt’s/tranverse cervical/cardinal
ligament; the most important part
• The uterosacral ligaments
• The Pubocervical ligaments

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2. The pelvic floor muscles:
• The levator ani muscles is the most important &
consists of 3 parts:
o The ischio-coccygeus muscle
o The ilio-coccygeus muscle
o The pubo-coccygeus muscle; the most important part
• Others include obturator internus, coccygeus .
3. The anteverted position of the uterus/posterio
Angulation of the vagina
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 Levels of support of uterus
DeLancey's three levels of support
Level 1 (suspensory axis)
• Uterosacral and cardinal ligaments
• support the uterus and vaginal vault.
• Defects in level 1
o Uterovaginal prolapse UVP
o Enterocele
o Vault prolapse

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Level 2 (attachment axis)
• Pelvic fascias and paracolpos
• Fascial septae connects mid vagina to the pelvic
sidewalls
• Anteriorly - Pubocervical
• Posteriorly - Rectovaginal facia
• which connects the vagina to the white line on the
lateral pelvic wall through arcus tendinous
• Avulsion results in cystocele or rectocele
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Level 3 (fusion axis )
• Levator ani muscle
• supports the lower one-third of vagina.
• Anteriorly
o Urethra
o Urogenital diaphragm
o Pubis
• laterally
o Levator ani fascia
• Posteriorly
o Perineal body
• Damage results in deficient perineal body or urethrocele

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 RISK FACTORS
• Increased intra- • Obesity
abdominal pressure. • Smoking
• Chronic cough. • Multiparity
• Chronic constipation. • Congenital Weakness-
• Weight lifting. rare, due to deficiency in
• Presence of abdominal collagen metabolism
tumors e.g fibroid & • Injury to pelvic floor
ovarian cysts. muscles
• High impact exercises • Iatrogenic/Pelvic surgery-
• Age/Menopause Hysterectomy
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 PATHOGENESIS
• Congenital weakness of the pelvic supports is
associated with
o short vagina, spina bifida & deep utero-vaginal & utero-
sacral pouches
o It leads to the appearance of prolapse at an early age,
the so-called “nulliparous” or even “virginal” prolapse.
• Acquired weakness of pelvic supports;
o This is associated with direct injury to pelvic
musculature and fasciae as well as partial denervation
of pelvic floor muscles

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• Obstetric childbirth trauma:
o Straining during the first stage of labour.
o Wrong forceps application before full cervical dilatation.
o Prolongation of the 2nd stage of labour leads to pressure &
stretching of levator ani
o Rapid succession of pregnancies; before involution of the pelvic
structures.
o unsutured or badly repaired perineal tear
• Postmenopausal atrophy:
o Oestrogen deficiency & ageing may lead to loss of collagen and
weakness in CT & fascia, particularly in patients predisposed to by
obstetric trauma.

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 CLASSIFICATION OF PELVIC ORGAN
PROLAPSE
• Uterine prolapse: 1st, 2nd, or 3rd, degree
• Vaginal prolapse: which may be;
o Anterior vaginal wall prolapse
 Cystocele (bladder descent)
 Urethrocele (urethral descent)
 Cystourethrocele (both bladder and urethral descent)
o Posterior vaginal wall prolapse
 Rectocele (rectal descent)
 Enterocele (small bowel descent through the Pouch of Douglas)
• Combined Uterovaginal prolapse:
• Vault prolapse:
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 Uterine prolapse
• Weakness of endopelvic fascia and
detachment of cardinal and uterosacral
ligaments
• The uterus gradually descends in the axis of
the vagina taking the vaginal wall with it.
• It may present clinically at any level, but is
usually classified as one of three degrees.

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 Degrees of uterine prolapse
• First-degree prolapse: the cervix rests in the
lower part of the vagina.
• Second-degree prolapse: the cervix is at the
vaginal opening.
• Third-degrees prolapse: the uterus protrudes
through the introitus.
• This is sometimes called complete procidentia

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 First degree prolapse

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 Second degree prolapse

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 Third degree prolapse

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 Etiology
• Stretching of muscle and fibrous tissue.
o eg. Pregnancy and childbirth.
• Increased intra-abdominal pressure as a result of
o chronic coughing, lifting of heavy objects and obesity, place
pressure on the pelvic floor.
• A constitutional predisposition to stretching of the
ligaments as a response presumably to years in the erect
position.
• Menopause and ageing increase the risk of prolapse.
o The female hormone estrogen plays an important role in
maintaining the strength of the pelvic floor

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 Clinical Manifestation
• Feeling like sitting on a small ball
• Difficult or painful sexual intercourse
• Frequent urination or a sudden urge to empty the bladder
• Low backache
• Uterus and cervix that stick out through the vaginal
opening
• Repeated bladder infections
• Feeling of heaviness or pulling in the pelvis
• Vaginal bleeding
• Increased vaginal discharge

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 Treatment
Vaginal pessary:
• This device fits inside the vagina and holds the
uterus in place.
• Used as temporary or permanent treatment,
vaginal pessaries come in many shapes and
sizes.

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Surgery:
• Several different types of surgery can be used
to treat a severe genital prolapse.
o to repair the tissue that supports the prolapsed
organ
o to repair the tissue around the vagina
o to close the opening of the vagina
o hysterectomy

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• Preoperative care:
o Thorough explanation of procedure, expectation
and effect on future sexual function
o Laxative and cleansing edema (rectocele) –
independently, at home a day prior procedure
• postop care:
o Pt. is to void few hours after surgery; catheter if
unable (after 6 hrs)

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• Preventive measures:
oEarly visits to HC provider = early
detection
oTeach Kegel’s exercises during PP
period

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 CYSTOCELE
• Also known as prolapsed bladder
• Occurs when the supportive tissue between a
woman's bladder and vaginal wall weakens
and stretches, allowing the bladder to bulge
into the vagina
• May associated with problems emptying the
bladder, urinary tract infections or
incontinence

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Causes
• Stress on the supportive during childbirth
• Frequent heavy lifting
• Chronic coughing (or other lung problems)
• Constipation (frequently straining to pass
stool)
• Obesity,
• menopause (estrogen levels start to drop)
• previous pelvic surgery.
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Symptoms
• Frequent urination or urge to urinate
• Stress incontinence
• Not feeling bladder relief immediately after urinating;
• Frequent UTI
• Discomfort or pain in the vagina, pelvis, lower abdomen,
groin or lower back
• Heaviness or pressure in the vaginal area;
• Painful intercourse
• Tissue protruding from the vagina that may be tender
and/or bleeding.
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Grade of cystocele
• grade 1 (mild) : The bladder protrudes only to
the upper (internal) vagina
• grade 2(moderated) : The bladder reaches the
vaginal opening
• grade 3 (most advanced) : The bladder bulges
directly through the vaginal opening

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Investigation
• Pelvic examination
• Voiding cystourethrogram
• Urodynamics
• Cystoscopy
• Fluoroscopy.

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Treatment
• Kegel exercises
• Estrogen replacement therapy
• Pessary (vaginal support device)
• Surgery

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Complication
• If case is left untreated, over time then
condition may get worse.
• Can cause to urinary retention (inability to
urinate) which may lead to kidney damage or
infection

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Kegel’s exercise
• Position : Supine lying with both knees flex
• Instruction : Tighten the pelvic floor muscles, hold the
contraction for five seconds, and then relax for five
seconds.
• Repetition : Do for 10 times
• Ask pt. to do the kegel’s exercise at home for 80 times
per day.
• Kegel’s can do in every static position like sitting and
standing.
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 Rectocele
• Chiefly a hernia in the posterior vaginal wall
secondary to weakness or defect in the
rectovaginal septum or fascia of Denonvilliers
• Symptoms include difficulty evacuating stool,
a vaginal mass, and fullness sensation
• Damage generally due to excessive pushing in
childbirth or chronic constipation
• Rectovaginal exam confirms diagnosis

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 Treatment
• Surgical treatment if symptomatic
• Posterior Colporrhaphy
• Laxatives and stool softeners
• Temporary relief
• Pessary not helpful

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 Enterocele
• A true hernia of the rectouterine or cul-de-sac
pouch (pouch of Douglas) into the rectovaginal
septum
• Descent of bowel in a peritoneum-lined sac
between posterior vaginal apex and anterior rectum
• Pulsion enterocele is filled with bowel and
distended by abdominal pressure
• Can occur anteriorly as well
• Generally after a surgical change in vaginal axis

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• Symptoms of fullness and vaginal pressure or palpable
mass
• Bowel peristalsis confirms diagnosis
• Commonly found in association with other defects
• Surgical approach
o Vaginal
o Abdominal
o Laparoscopic
• Ligation of hernia sac and obliteration of the pouch of
Douglas
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 Prevention
• Obstetric care to protect pelvic floor
• Decreased pushing times
• Avoid forceps, major lacerations
• Permit passive descent
• General lifestyle changes
• Smoking cessation and cough cessation

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• Routine use of Kegel pelvic floor exercises
• Regular physical activity
• Proper nutrition
• Weight loss
• void constipation and repetitive heavy lifting
• Hormone replacement therapy

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