UTEROVAGINAL PROLAPSE

BY DR H. DANIEL

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UTEROVAGINAL PROLAPSE INTRODUCTION CLASSIFICATIONS ANATOMY OF PELVIC SUPPORT AETIOLOGY / PREDISPOSING FACTORS CLINICAL PRESENTATION INVESTIGATIONS COMPLICATIONS

INTRODUCTION
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Definition Due to defect in the pelvic supporting structures hence Uterus and/or adjacent organs descend from their anatomic confines to positions within or outside the vaginal introitus ◘ Components / Varieties ANTERIOR VAGINAL WALL Urethra urethrocele Bladder - cystocele Uterine prolapse / vault prolapse POSTERIOR VAGINAL WALL Rectovaginal pouch Enterocele Rectum Rectocele

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Introduction cont.
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Note: May occur in combinations, e.g. ○ Cystourthrocele: most common ○ Eneterocele + Rectocede ○ Uterine prolapse + enterocele Vaginal prolapse may occur without uterine prolapse Uterus cannot prolapse without carrying the upper vagina ◘ Prevalence Incidence in UPTH- 3.75% ( Ugboma ,Okpani et al) Estimates ○ Multiparous 12 – 30% ○ Nullipara - 2% Less among black women compared with white Increase in the elderly / postmenopausal women

CLASSIFCATION
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2. CLASSIFICATION: staging systems ◘ Conventionally Cervix is reference point Degrees (grades) ○ 1st degree – cervix within vagina ○ 2nd degree – cervix at introitus ○ 3rd degree – outside introitus, at the vulva- procidentia ◘ Shaw’s classification- same as above
-Additional 4th degree – procidentia

◘ Baden’s Classification Hymen is reference point Grades 0 to 4 for each component

POP – Q (Pelvic Organ Prolapse Quantification) Staging System  Devised by International Continence Society (ICS) in 1996  Standardization of terminology / reports lacked in other grading systems.  Hymen is the fixed reference point from which measurements are made  Staging  ○ Measurements (in cm) – defined sites (9) on the vag. walls and perineum  ○ Stages 0: No prolapse (-3cm)  I : > 1cm above Hymen (< -1cm)  II: ≤ 1cm above or below Hymen (≥ -1cm but ≤ +1cm)  III: > 1cm below Hymen but 2cm less than TVL  (> + 1cm but < + [TVL -2]cm) IV: ≥ + (TVL -2)cm ○ Specify condition of exam & position of patient  (eg straining down, traction, standing)

ANATOMY OF PELVIC SUPPORT
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Peritoneum: not contributory Pelvic fascia Pelvic floor muscles ◘ Pelvic floor fascia Fascia over pelvic floor muscles Endopelvic fascia: main support ○ Lateral cervical (transverse cervical, cardinal or Mackenrodt) ligament lat. aspect of cervix / upper vagina to pelvic side walls ○ Uterosacral ligament back of uterus to front of sacrum

ANATOMY CONT.
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○ Pubocervical ligament (fascia) ant. 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 Transverse perineal muscles * Deep Transverse perineal muscles

AETIOLOGY/PREDISPOSING FACTORS
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◘ Aetiology ▪ Weakness in one or more supports of the uterus and vagina
-Transverse cervical / uterosacral complex uterine prolapse

-Pubocervical cystocele
- Pubocervical + post. Pubourethral urethrocele

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-Recto vag. fascia / defects in ® and (L) levator ani Inherent defect in supports - strong familial incidence Acquired factors ○ Child birth * Single most important factor * 7 times high in para 7+ * Bad obst. Practice

AETIOLOGY CONT.
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Ageing Menopause Increase intra-abdominal pressure -COAD -Ascites -Tumors * -Pregnancy: rare Surgery – post-hysterectomy Congenital factors -Weakness of pelvic fascia and conn. Tissues e.g. Ehlers – Danlos syndrome -Congenital shortness of the vagina -Deep uterovesical / uterorectal pouches

Clinical presentation
◘ History : Symptoms  Lump in vagina or protruding out of it  Lower backache  Frequency of micturition  Urgency  Feeling of incomplete voiding / retention of urine  Stress incontinence  Difficulty evacuating the bowel  Digitations rectally or vaginally to empty the bowel  Discharge / bleeding p/v – decubitus ulcers  Inquiry of predisposing factors, eg.  COAD, Parity / mode of deliveries etc.

Physical examination

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General – state of health, anaemia, chest/cvs, abd etc. Vaginal examination / speculum examination ○ State of vulva / vagina ○ Stress incontinence ○ Ulcerations – decubitus ulcers Identify components – speculum exam Rectal exam

Differential diagnosis
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Cervical polyp Endometrial polyp Pedunculated myoma Cervical cancer Metastasis of uterine cancer Urethral diverticulum Vaginal wall cyst

Investigations
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FBC E/U/C FBS Genotype Blood group, X-match
URINALYSIS /MCS

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CXR ECG

Others
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IVP Imaging
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Ultrasonography Computed tomography (CT) MRI Videocystourethrography

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

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