Supports conveniently grouped under
three tier system
1. UPPER TIER
Endopelvic fascia covering the uterus
Broad ligaments with intervening
pelvic cellular tissues
Support of the uterus
Cervico vaginal junction
• Fibromuscular tissue surrounding the vessels and
nerves this is important direct support of the uterus.
Pelvic cellular tissues
• In this connective tissue and smooth muscles .
• The blood vessels and nerve supply to uterus,
bladder and vagina pass through it from the lateral
• The pelvic cellular tissue condense surrounding
them and give direct support
• This condensation of the tissues surrounding the
supravaginal cervix and vagina down to the superior
layer of the fascia covering the levator ani constitute
a tough endopelvic facia covering the cervico vaginal
• It condenced and reinforced by plain muscles to
form ligaments – mackendrot’s, uterosacral and
3. INFERIOR TIER
Musculofacial tone of the hollow vagina by the facial
condensation at the vault and by the pelvic floor.
Positional support to the anterior wall
Pelvic floor tissue
• Strong condensation of pelvic floor tissue
• Below – posterior urethral ligament.
• Laterally – pubocervical ligament
Support of posterior vaginal wall
• Endopelvic fascial sheath covering the vagina and
• Uterosacral ligament to lateral wall of the vault
• Levator ani with its facial covering
Support of vagina
Vaginal delivery with consequent
injury to the supporting structure
overstretching of the mackenrodt’s
and uterosacral ligament.
overstretching of the perineum
subinvolution of the supporting
Congenital weakness of the supporting
structures is responsible for the
•increased paravaginal tissue laxity
•occult spina bifida associated with
increased increases intra abdominal
presser as in chronic cough&
increased weight of the uterus as in
fibroid or myohyperplasia
asthenia & undernutrition
traction by anterior vaginal wall or
cystocele: formed by
laxity & descent the
2/3 rd of anterior
vaginal wall as the
bladder is closely
related to the area,
there is herniation of
the bladder through
the lax anterior wall.
formed by laxity &
descent the 1/3 rd
of lower anterior
vaginal wall as the
urethra is closely
related to the area,
there is herniation
of the urethra
thorough the lax
with the buldge
of the lower
part of the
Enterocele: formed by laxity of the
upper 1/3 rd of posterior wall.,
there is herniation of the pouch of
Douglas through the lax wall, may
contain omentum or gut hence
May occur following either vaginal or
This is the commonest type. cystocele
occurs first by traction effect on the
cervix causing retroversion of the
uterus. Intra abdominal presser has got
piston like effect on the uterus thereby
pushing it down into vagina.
There is no cystocele. the uterus
descends down along with the inverted
upper vagina often seen in nulliparous.
First degree: The cervix droops into
the vagina. The uterus descends
down from its normal
position(external os at the level of
the ischial spine)but external os
still remains inside the vagina.
Degree of uterine prolaps
The external os protrudes out the
vaginal introitus but the uterine
body still remains inside the
vagina. The cervix sticks to the
opening of the vagina.
The uterine body descends to lie
outside the inroitus. The cervix
is outside the vagina.
Minor prolapse of the uterus may not cause any
More severe prolapse can cause:
• Increased vaginal discharge.
• Feeling that something is coming out of the vagina
• Dragging sensation in the lower abdomen and back.
If cystocele is present, symptoms include:
• Difficulty in starting and stopping urination, Urinary
• A feeling that the bladder needs emptying again soon after
• Problems controlling the bladder.
• Frequent urinary infections may result if the bladder never
SIGNS & SYMPTOMS
If Rectocele is present, symptoms include:
Difficulty emptying the bowel, in spite of a constant feeling
that the rectum is full and needs to be emptied.
Constipation can become a problem.
Some common Symptoms of Uterine Prolapse:
Difficult or painful sexual intercourse
Feeling of rectal fullness.
Sensation of heaviness or pulling in the pelvis.
Frequent urinary tract infections.
Sensation of fullness in the vagina.
Protrusion of pink tissue from the vagina that may be irritated
EFFECTIVE ANTENATAL CARE:
-nutritional supplements, antenatal hygiene &
physiotherapy with relaxation exercises
to prevent premature bearing down efforts
to prevent premature application of forceps before the
cervix is fully dilated
to avoid prolonged 2nd stage
to avoid too much fundal pressure to expel out the
to perform timely & adequate episiotomy
to repair the perineal injuries immediate & accurately.
-to prevent undue distension of bladder
-to encourage early ambulance
-to encourage the pelvic floor exercises
-to avoid the strenuous activities 6 months following
-to avoid future pregnancy too soon
2. improvement in nutritional status
Special exercises, called Kegel exercises, can help
strengthen the pelvic floor muscles.
4. Vaginal pessary
1. Anterior colporraphy
Correct cystocele and urethrocele.
To exercise a portion of the relaxed anterior
vaginal wall to mobilize the bladder push it
upwards after cutting the vesico-vaginal
To repair the prolaps of posterior vaginal wall.
It repair torn perineal body
Tightening of the pararectal facia.
3. Pelvic floor repair
4. fortergill’s operation
Preliminary dilatation and curratge
Amputation of the cervix
Palication of the mackenrodt’s ligament in front
of the cervix.
5. Vaginal hysterectomy