obstetrics & gynecology,

1. Uterovaginal prolapseUterovaginal prolapse
By
Usman Saeed
08-204
Batch- k

2. Applied anatomy

3. Normal postion of uterus andNormal postion of uterus and
vaginavagina
The uterus and vagina lies in middle of pelvis.
Anteriorly: urinary bladder and urethra.
Posteriorly: colon,rectum and anal canal.
The perineal body is interposed b/w lower part
of the posterior vaginal wall and the anal
canal.
In 80 % of women the uterus is anteverted
and anteflexed
In 20% of women it may be retoverted

4. Position of uterusPosition of uterus
Retroverted uterus Anteverted uterus

5. Supports of uterus and vaginaSupports of uterus and vagina
uterine supportsuterine supports
 Cardinal ligaments: major support of uterus and vault of
vagina..
 Attached medially to supravaginal part of the cervix and vault
of vagina and laterally to lateral pelvic wall.
 Uterosacral ligament: responsible for keeping uterus in
anteverted postion
 Attached anteriorly to supra vaginal party of cervix and vault
of vagina and posteriorly to fascia in front of sacral vertebrae
Pubocervical fascia: extension of cardinal ligaments
 This fascia is attached to supravaginal part of cervix ,runs
forward below the base of bladder ,splits into two to allow for
the passage of urethra and is attached to the body of pubic
bones

6. Uterine supportUterine support

7. Pelvic ligaments under stretchPelvic ligaments under stretch
during prolpaseduring prolpase

8. Vaginal supportVaginal support
Cardinal ligments:on each side attached to vault of
vagina and supravaginal part of cervix.
Levator ani muscles:provide support to lower part of
vagina
Uroginetal diaphram and perianal muscles :
hold vagina in its postion
Pubocervical fascia: provide support to anterior vaginal
wall
Perineal body and rectovaginal fascia:
 the structures support the posterior vaginal wall
Posterior vaginal wall:
 provide support to anterior vaginal wall in erect postion

9. uterovaginal prolapseuterovaginal prolapse
 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.
There maybe prolapse of both uterus and vagina, or only of
vagina.

10. Uterine prolpaseUterine prolpase

11. terminologyterminology
1.anterior vaginal wall prolapse
2.posterior vaginal wall prolapse
3.uterine prolapse
4.vaginal vault prolapse(after hysterectomy)

12. ANTERIOR VAGINAL WALL PROLAPSEANTERIOR VAGINAL WALL PROLAPSE
 Cystocele :
Descent of upper 2/3 of the anterior vaginal wall all along
with base of the bladder
Urethrocele:
Descent of lower 1/3 of the anterior vaginal wall along with
the uretheral displacement
Cysto-urethrocele:
Prolapse of entire anterior vaginal wall

13. cystocele urethrocele
Anterior vaginal wall prolapseAnterior vaginal wall prolapse

14. Posterior vaginal wall prolpasePosterior vaginal wall prolpase
Enterocele :
Prolapse of the upper 1/3 of the posterior vaginal wall
Due to close proximity of pouch of douglas to the posterior
fornix of vagina , it also descents along with prolpase of
upper part of the vagina.
Rectocele:
Prolapse of lower 2/3 of the posterior vaginal wall along
with lower part of the rectum

15. Posterior vaginal wall prolpasePosterior vaginal wall prolpase
enterocele rectocele

16. classification and gradingclassification and grading
The anterior and posterior vaginal wall prolapse is
usually described as
Minor degree
Moderate degree
Major degree

17. Various termiologies have been used to classifyVarious termiologies have been used to classify
the UV prolpase .the latest was described in 1996the UV prolpase .the latest was described in 1996
which is as followswhich is as follows
Stage 0:no descent of pelvic organ during straining
Stage 1:leading surface of prolapse descends upto 1 cm
above the hymen ring
Stage 2 :leading surface of the prolapse descents upto
the point 1 cm below the hymen ring
Stage 3:descent s beyond the stage 2 but without
complete vaginal eversion
Stage 4 :the vagina is completely everted and the
fundus of uterus lies below the introitus of the vagina

18. Causes of uterovaginal prolapseCauses of uterovaginal prolapse
UV prolapse is primarily due to the
weakness of the support , it maybe
because of the following causes:
1.congenital weakness
2.acquired defect
3.menopause atrophy
4.activiting factors

19. EtiologyEtiology
Congenital weakness
Most important cause of uv prolapse in
nulliparous women
Inherent weakness of support in members
of same family
Racial and genetic factor(most common in
white races)
Patients with spina bifida are prone to
have have prolapse

20. EtiologyEtiology
Acquired defect
 Multiparous (99 percent)
 Due to overstretching of the ligaments or injury to nerves and
supports
 Vaginal birth not only weakens the uterine support but it also
predisposes to high risk of urinary and feacal incontinence
 Prolong labour
 Forcep delivery
 Pressure on fundus during delivery of the placenta(Crede’s
method)
 Puedendal nerve injury during child birth
 ventouse ( vaccum extractor)

21. causescauses
Menopausal atropy
 Atrophy of the genital tract and its supports due to
withdrawal of estrogen , after menopause
 The prolapse is seen usually within 1-2 years of menopause
 Null-parous UV prolapse also get worsen after the
menopause
Activiting factors
 Increased intra-abdominal pressure(chronic cough , chronic
constipation , ascities etc)
 Small fibroids
 Pelvic tumors

22. pathologypathology
 In the case of UV prolpase , in addition to descent of
uterus and prolapse of the vaginal wall , following changes
may take place
 Elongation and hypertropy of the cervix
 Keritinization of the vaginal epithelium
 Decubitus ulceration
 Incarcenation of of the prolpase part
 Complication of urinary tract
- residual urine increase (due to bladder downward
displacement)
- urinary tract infection (due to stagnation of urine)
- bladder hypertrophy due to straining during micturation

23. symptomssymptoms
Common complaints are
 Something coming out of vagina(commonest symptom)
 Lower abdominal pain (dull &dragging)
 Backache (relieved by lying in the bed)
 Vaginal discharge (luecorrhea)
 Urinary symptoms
 frequency of micturation
 difficulty in micturation
 stress incontinence
 acute retention of urine
 Difficulty in empting of bowels
 Coital difficulties

24. signssigns
Usually visible during inspection of vulva
Patients having stress incontinence should
be observed with full bladder
Rectal examination will also differentiate
between rectocele and enterocele.

25. differential diagnosesdifferential diagnoses
Cystic swelling in the vagina
Polypoidal growth
Chronic inversion of the uterus
Hypertropy of the cervix
All other causes of low backache and
urinary symptoms

26. treatmenttreatment
The treatment of UV prolapse is described
under the following headings.
1.prevention
2.physiotherapy
3.pessary
4.surgical treatment

27. preventionprevention
Repeated childbirth with short intervals cause UV prolapse
• Women should be advised to avoid pregnancies in quick succesion
Labour
• 1st
stage
▫ Avoid bearing down
▫ Breech or forceps delivery before full dilatation of cervix shouldn’t be
attempted
• 2nd
stage
▫ Avoid prolongation of this stage
▫ Perform episiotomy if tears or overstretching of perineum is feared
• 3rd
stage
▫ Avoid Crede’s method
▫ Episiotomy or tears should be carefully sutured
Puerperium
• Treat chronic cough and constipation
• Avoid strenuous exercises and standing for prolonged time

28. physiotherapyphysiotherapy
 Early cases of UV prolapse are helped by pelvic floor
exercises Particularly during puerperium and while waiting
to undergo surgical treatment.
 Kegel exercises are used to tone up pelvic musculature
These exercises are done 3 times a day for 20 min each

29. pessary treatmentpessary treatment
 A mechanical device for correcting and controlling UV prolapse
 A pessary does not cure UV prolpase
 It only holds the genital tract in position
 Advised for patients who cannot undergo surgery
Types
 1.Ring pessary
 2.Hodge pessary
Indications
 During pregnancy (1st trimester)
 During puerperium
 Unfit for surgical treatment
 Patient’s choice

30. pessary treatmentpessary treatment
Management
 Choice of pessary ( ring pessaries commonly used)
 Size (depends upon size of vagina)
 Sterilization
 Insertion
before insertion the pessary is kept in hot water for few
minutes so that pessary become soft and easy to insert
Follow up
 pessary should be removed ,cleaned and reinserted at
regular intervals of 6-12 months.

31. different types of pessariesdifferent types of pessaries

32. pessariespessaries

33. Surgical treatmentSurgical treatment
 Only curative treatment
 Unless there is any contraindication for surgical
treatment ,all cases of UV prolapse should be treated
surgically
Preparation before surgery
1.general health:
good physical and mental health is essential for post op recovery
2.medical and surgical disease
chronic cough and any other illness should be treated before hand
3.RFTS , ultrasound , MRI & pelvic flouroscopy to find
relationship b/w the prolpase and urinary symptoms
4. local infection like vaginitis & cervicitis should be treated
5. hormonal treatment especially in postmenopausal prolpase

34. Surgical treatmentSurgical treatment
operationsoperations
 Anterior Colporrhaphy – for anterior vaginal wall prolapse.
 Posterior Colporrhaphy – for repair of the posterior vaginal
wall and perineum.
 Manchester Repair (Fothergill’s Operation) – for repair of
uterovaginal prolapse. Carried out in women of child bearing age
and haven’t completed their families and insist on preservation of
uterus

35. Surgical treatmentSurgical treatment
 Vaginal Hysterectomy – most common operation and its
indications are:
- Post-menopausal prolapse
-Uterine pathology like small fibroids or adenomyosis
-Menstrual disorders such as dysfunctional uterine bleeding
-Prolapse during childbearing age , after completion of family
 Burch Operation – for relief of symptoms of cystocele.

36. Surgical treatmentSurgical treatment
 Sling Operations – for cervical descent of young and nulliparous
patients. It has following types:
 Shirodkar’s sling operation
 Purandare’s cervicopexy
 Sling operation for vaginal vault prolapse
 Laproscopic Repair – sacrocolpopexy, a simple procedure to
cure enterocele and vault prolapse.
 Le Forte’s Operation – for treatment of UV prolapse in very old
patients. Perfectly devised to reduce operating time.

37. Outcome of surgical treamentOutcome of surgical treament
 Cures approximately 90 percent of patients.
 Only 10 percent may require a second operation or other
treatment.
 2-3% may get stress incontinence as a result of operative
treatment.
 25% of patients may complain of dyspareunia, that has
undergone colporrhaphies , due to narrowing of the introitus and
vagina.

38. Pregnancy after operationPregnancy after operation
 High incidence of infertility following manchester repair.
 Other comlications include
◦ Abortion due to cervical incompetence
◦ Premature Labour
◦ Precipitate Labour or Cervical dystocia
◦ Prolonged Second Stage
◦ Tears of vagina and perineum due to failure of dilatation
◦ Recurrence of prolapse due to overstreched of uterine and vaginal
support.
Management of pregnancy
 Patient can get pregnant following a Manchester repair.
 The patient may deliver normally but in view of the risk the mode
of delivery is decided.
 To avoid recurrence of prolapse C-section must be performed.

39. THANK YOUTHANK YOU