Displacement of the Uterus; Utero-

vaginal prolapse, Incontinence of

the
urine, and fistulae. Management
and prevention

MUNKAILA ADAM
 Displacement of pelvic organ
• Utero-vaginal prolapse(U-V prolapse
 lecture outline of uv prolapse
• Introduction
• Definition
• Support Structures of uterus
• Classification of pelvic organ prolapse
• Grading of genital tract prolapse
• Aetiology and predisposing factors
• Clinical features
• Investigatigation
• Management and complication
• prevention
 Introduction
• pelvic organ prolapse (POP) is the descent of the
genital ograns into the vagina or outside
• caused by herniation through deficient pelvic
fascia or
• due to weaknesses or deficiency of the
ligaments or muscles or blood or nerve supply
to the pelvic organs.
• Conservative management involves the use of
pessaries, but surgery is the most appropriate
option for the physically fit woman.
 UTERO-VAGINAL PROLAPSE
Organ prolapse; defn
• DESCENT OF THE UTERUS AND/OR VAGINAL
WALL DUE TO WEAKNESS OF SUPPORT
STRUCTURES
Or
• PROTRUSION OF A PELVIC ORGAN BEYOND ITS
NORMAL ANATOMICAL CONFINES
3rd degree UV-prolapse
Uv prolapse
Rectocele
Support structures of uterus
 SURGICAL ANATOMY: MAIN SUPPORTS OF
UTERUS AND VAGINA
UTERINE SUPPORT
1.CARDINAL/MACKENRODT/TRANSVERSE CERVICAL
2.UTEROSACRAL LIGAMENT
3.ENDOPELVIC FASCIA
VAGINAL SUPPORT
1.CARDINAL LIGAMENTS
2.LEVATOR ANI
3.TRIANGULAR LIG /PERINEAL/ MUSCLES PERINEAL
BODY
 Classification of pelvic organ prolapse

• Anterior wall prolapse

• Posterior wall prolapse
• Apical vaginal prolapse
 CLASSIFICATION
Anterior vaginal wall prolapse;
• Urethrocele; urethral descent
• Cystocele; bladder descent
• Cystourethrocel; descent of both bladder and
urethra
Anterior vagina wall prolapse
 Classication cont.
Posterior vaginal wall descent;
• Rectocele; rectal descent
• Enterocele; small bowel descent
Posterior vag wall prolapse; Rectocele
 Apical prolapse,
Apical vaginal prolapse;
• Descent of uterus with inversion of vaginal
apexutero-vaginal prolapse(U-V prolapse)
• Vault prolapse; post hysterectomy
A procidentia (whole uterus outside
the body)
 Grading of prolapse
• Assessment of degree of prolapse is done by
examining the most dependent or the lowest
portion of the prolapse whilst the patient is
straining,
• in U-V prolapse,the cervix is the most
dependant part.
• 3 degrees of prolapse are described; ranges
from 1st to 3rd degree
 grading
• 1st degree prolapse; descent is within vagina
• 2nd degree; descent to the introitus
• 3rd degree/ procidentia; descent outside
vagina or complete prolapse of uterus and
vagina

• NB; 3rd degree UV-prolapse usually comes with

cystourethrocel and rectocel
AETIOLOGY or PREDISPOSING FACTORS

CAUSES ARE;
CONGENITAL OR ACQUIRED
Congenital ;
• Association with spina bifida,
• deep uterovaginal pouch,
• Short vagina
• Skeletal deformities,
• Connective tissue disorders
• Neuromuscular factors
• Race; Common in white

NB; the reason why UV prolapse can occur in

nulliparous women, is congenital
Aetiology of genital organ prolapse
Acquired
• Obsteric factorscommonest
• Ageing process
• Increase intraabdominal pressure
• Occupation
• posthysterectomy
 Obstetric factors
• Vaginal delivery is the major factor leading to
UV-prolapse. Levator ani muscle and fascia
and nerve supply are believed to sustain a
mechanical damage at difficult vaginal delivery
leading to weakining of these structures
 Obstetric factors
• High parity
• Prolong labor
• Shoulder dystocia
• fetal macrosomia
• Difficult forceps/vacuum delivery
• Bearing down prior to full dilatation of cervix
• Applying fundal pressure wrongfully at vag del
 Ageing/menopause
• Loss of estrogen support to the pelvic fascia
and connective tissues
 Increase intrabdominal pressure
• Chronic cough
• Chronic constipation
• Obesity
• Ascites
• Pelvic tumors
 Hard Physical exertion
• Lifting heavy loads
• Farming
 Posthysterectomy
• Poor attention to vaginal vault at
hysterectomy leads vault prolapse.
 Clinical features of U-V prolapse
Patient profile(in our part of the world)
• Usually these patient are; grand multiparous,
postmenopausal women, who might have had
difficult vaginal deliveries or prolonged
labours(most of which were home deliveries),
coming with complaints of prolapsing mass in
the vagina
 CLINICAL FEATURES

• ASYMPTOMATIC/SYMTOMATIC
• VAGINAL MASS; sensation of mass in vagina which
increases with cough impulse
• LOWER ABDOMINAL DISCOMFORT
• URINARY SYMPTOMS : STRESS
INCONTINENCE,DIFFICULTY IN EMPTYING
BLADDER,INCREASED FREQUENCY OF
MICTURITION
• CONSTIPATION
• ULCERATION OF THE CERVIX OR VAGINA
• Vaginal discharge/bleeding pv
 Clinical feature cont.
Cystocel/Cystourethrocel;
• difficulty urination, urination only by digital
splinting of anterior vaginal wall
Rectocel ;
• incomplete emptying of bowel, able to
defecaete only by digitally splinting the
posterior vaginal wall
 Physical examination
• Usually elderly women
• Signs of chronic illness may be present; COPD,
malignancy, connective tissue disease
• Abdominal exam; for ascites, organomegally,
or abdominopelvic mass
 Vaginal examination
• Prolapse may be obvious when
examining the patient in the dorsal
position if it protrudes beyond the
introitus; ulceration and/or atrophy may
be apparent.
 CLINICAL EXAM;

Assesment of anterior and posterior vag wall prolapse;

• USUALLY IN SIMS POSITION (LEFT LATERAL)
• DEPRESSING POSTERIOR WALL OF VAGINA AND
ASKING THE PATIENT TO STRAIN REVEALS A
CYSTOCOELE OR URETHROCOELE
• DEPRESSING THE ANTERIOR WALL REVEALS
RECTOCELE OR ENTEROCELE.
• STRESS INCONTINENCE MUST BE DEMONSTRATED BY
ASKING PATIENT TO COUGH
• LOOK ALSO FOR DECUBITOUS ULCERS
• SIGNS OF HYPOESTROGENATION-LOSS OF VAGINAL
RUGAE
 Clinical exam cont.
• Combined rectal and vaginal digital
examination can be an aid to differentiate
rectocele from enterocele
 Defferential diag
• Congenital dermoid vaginal cyst
• Urethral diverticulum
• Gartner’s cyst—retention cyst of wolfian duct
• Endometrial polyp
• Cervical polyp(prolapsing fibroid) polyp
• Chronic uterine inversion
• Congenital elongation of cervix
Features of Gartner’s cyst are:
• Reminant of wolffian duct
•  Situated anteriorly or anterolaterally and of variable
sizes.
•  Rugosities of the overlying vaginal mucosa are lost.
•  Vaginal mucosa over it becomes tense and shiny.
•  Margins are well-defined.
•  It is not reducible.
•  There is no impulse on coughing.
•  The metal catheter tip introduced per urethra fails to
come underneath the vaginal mucosa.
Gartner’s cyst
Chronic uterine inversion
• • Leading protruding mass is broad.
• • No opening visible on the leading part.
• • looks shaggy.
• • Internal examination reveals — cervical rim
is on the top around the mass.
• • Rectal examination confirms the absence of
the uterine body and a cup-like depression is
present
Chronic uterine inversion
• Fibroid polyp
• • Mass is saggy with a broad leading part.
• • No opening is visible on the leading part.
• • Internal examination reveals the pedicle
coming out through the cervical canal or
arising from the cervix.
• • Rectal examination reveals presence of
normal shape and position of the uterus
Cervical polyp
Cervical polyp
Uv prolapse
Gartner’s cyst
 investigation
• FBC, SICKLING, GXM, BUE+Cr, LFT, FBS
• URINE RE, STOOL RE
• CXR,
• ABDOMEN AND PELVIC SCAN(USG), ECG
• BIOPSY OF ANY LESION IN VAGINA/CREVIX
FOR HISTOPATHOLOGY
• cystometry and cystoscopy for urinary
problems
• MRI proctography to demonstrate enterocele
 TREATMENT
Factors to consider
• Age
• Desire for presevation of reproductive
function
• Desire for preservation of coital function
• General medical status
• Symptomatology
• Degree of prolapse
 Treament modalities
Expectant management
• Observation, Pelvic floor exercise, Ring pessaries,
Surgical management
• Pelvic floor repair(PFR)---anterior colporraphy,
posterior colpoperineorrhaphy
• Manchester-Fortagil operation
• Vaginal hysterectomy with/without PFR
• Vaginal colpocleisis—Leforts operation
• Vaginal vault suspension-- SACRO-SPINOUS
FIXATION, SACRO-COLPOPEXY
 Treatment of comobidities cont.
Prior to specific treatment; correct the ff;
• Obesity
• Treat chronic couph, constipation,
• Treat decubitus ulcers in the
vagina/dependent portion of prolapse with
estrogen cream, with antibiotcs and
antiseptics
 Expectant mgt

indication
• Mild degree of prolapse;
• Not completed family
• Severe illness,
• early pregnancy with prolapse
• Those who do not consent to surgery
 Expectant/conservative Mgt cont.
No need of surgery
• Educate patient on the condition
• Teach them how to perform pelvic or KEGEL
exercise
• To stop all kinds of physical exertion
• Consider ring pessaries
• Treat other chronic illnesses
• Encourage weight reduction
 PESSARY TREATMENT as expectant Mgt

• FOR PALLIATION
• THERAPEUTIC TEST
• PROLAPSE SEEN IN PREGNANCY, and
PUERPERIUM
• PATIENTS UNFIT FOR SURGERY
• PRESENCE OF DECUBITUS ULCERS TO PROMOTE
HEALING BEFORE SURGERY
 PESSARIES-2

• RING PESSARIES, COMMONEST , RANGE SIZE

50MM TO 120MM
• STEM PESSARIES: SHAPED LIKE CUP WITH A STEM
TO SUPPORT, USED WHEN PERINEUM IS TOO
WEAK TO SUPPORT THE SIMPLE RING PESSARY
• TO INSERT: SELECT THE CORRECT SIZE BY
ASSESSING THE SIZE OF THE VAGINA
• FITTING RINGS USED FOR THE SELECTION OF THE
DIAPHRAGM MAY BE HELPFUL
• STERILIZE AND LUBRICATE WITH K-Y JELLY
Pessaries for uv prolapse
 FOLLOW-UP
• REMOVE, STERILIZE, AND RE-INSERT AT
REGULAR INTERVALS OF 3-6 MONTHS.
• COMPLICATIONS: ULCERATION OF VAGINAL
VAULT, IMPACTION OF THE PESSARY,
CONSTIPATION, STRESS INCONTINENCE.
 COMPLICATIONS OF VAGINAL
HYSTERECTOMY
• HAEMORRHAGE
• URINARY RETENTION
• VAGINAL VAULT PROLAPSE
• VAGINAL VAULT INFECTION
• THROMBOEMBOLISM
• DYSPAREUNIA
 Prevention of genital organ prolapse

• How do we prevent uv prolapse?

 prevention

• Adequate antenatal and intrapartum care

•  To avoid injury to the supporting structures during
• the time of vaginal delivery either spontaneous or instrumental.
• Adequate postnatal care
•  To encourage early ambulance.
•  To encourage pelvic floor exercises by squeezing
• the pelvic floor muscles in the puerperium.
• General measures
•  To avoid strenuous activities, chronic cough,
• constipation and heavy weight lifting.
•  To avoid future pregnancy too soon and too many
• by contraceptive practice.
• THANKS FOR LESTINING