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1. Prepared by:
Indira Bastakoti
Bsc.nursing

2. Introduction
 Uterine prolapse is a condition of downward
displacement of women’s uterus (womb) into the
vaginal canal or outside the vagina.
OR,
 Sagging or slipping down of the uterus from its
normal position to vaginal canal/birth canal is
uterine prolapse.

4. Types according to definition
 Incomplete prolapse
Slipping or falling down of the uterus(womb) into the
vagina (birth canal), creating a lump or bulge is called
incomplete prolapse.(fig: prolapse uterus)
 Complete prolapse
In more severe case, the uterus slips so far out of place
that some of the tissue drops outsides the vagina
called complete prolapse.(fig: severly prolapse
uterus)

6. Cont…
 Uterine prolapse is a second most common after
cystourethrocele ( bladder and urethral prolapse).

7. Support of uterus
 A group of muscles and ligaments supports the pelvis
in its place. i.e. pelvic floor muscles and ligaments
(round, broad,pubocervical,uterosacral)

8.  As this muscles and ligaments weaken, they become
unable to hold the uterus in position and it begins to
sag.

9. Causes
1. Aging and menopause:
Weakening of the pelvis muscles and the natural
reduction in estrogen at menopause contribute to
less elasticity or atonicity.
2. Pregnancy and childbirth:
Is one of the main cause of pelvic organ prolapse.
It can occur immediately after pregnancy or 30
years later.

10. Cont…
Different factors like delivery of large baby, physical
trauma of labor and birth stresses or bearing down
before full dilatation of cervix can strain the pelvic
muscles and ligaments.
3. Other factors:
Pressure on the pelvic muscles due to Obesity ,chronic
coughing(from smoking, asthma, bronchitis/postpartum
cough) or straining and chronic constipation may
contribute to the development of uterine prolapse.

11. Risk Factors
1. Large fibroids or tumors
2. Obesity
3. Chronic coughing, constipation or straining
4. Heavy lifting
5. Genetic condition: Women with a genetic collagen deficiency
(Marfan syndrome or Ehlers-Danlos syndrome) are at higher risk.

12. Contd..
6. Previous pelvic surgery
7. Spinal cord injury and other muscular atrophy
condition: muscular dystrophy and multiple sclerosis
increase the risk of prolapse.

13. Clinical Manifestation
 Symptoms :
Asymptomatic in mild case.
If present, they are less bothersome in the morning,
but worsen as the day passes by.

14. Contd..
Patients may complain one or more of the following:
• A feeling of heaviness or pressure in the pelvis and
discomfort during walking,
• Feelings as if sitting on a small ball or as if something
is falling out of the vagina
• Pain in the pelvis, abdomen or lower back
• Pain during intercourse
• A protrusion or bulging out of tissue from the vagina

15. Contd..
• Recurrent urinary tract infection(UTIs)
• Unusual or excessive discharge from the vagina
• Dyspareunia,
(In presence of cystocele)
• Difficulty with urination, including urinary
incontinence or urinary frequency or urgency due
to incomplete evacuation.
• Retention of urine

16. Signs
 If the prolapse is minor, it may become visible on
straining,
 Uterovaginal prolapse may be visible during
inspection of the vulva,
 Rectocele and enterocele can be differentiate through
rectal examination.

18. Stages
 Stages :
1. Stage I: descent of the uterus in the vagina
above the level of the hymen.
2. Stages II: descent to the level of hymen
3. Stages III: descent beyond the hymen
4. Stages IV: total eversion or procidentia.

19. Contd..
1. First-degree prolapse: cervix is situated
between the level of the ischial spines and the
vaginal introitus.

20. Contd..
2. Second-degree prolapse: cervix protrudes
through introitus, but corpus remains within the
vagina.

21. Contd..
3. Third-degree prolapse: complete prolapse,
cervix and body of the uterus protrude through
vagina and vagina inverted.

22. Diagnosis
1. A pelvic examination
Mild: cervix drops into the lower part of the vagina.
Moderate: cervix drops out of the vaginal opening.

23. Contd..
2. Laboratory studies: to detect infection, urinary
obstruction, hemorrhage, strangulation.
But are unnecessary in uncomplicated cases.
Complete blood count (CBC), basic metabolic
panel, urinalysis, pregnancy testing and cervical
cultures can be performed to exclude other
conditions in the differential diagnosis.

24. Contd..
b) A Papanicolaou test ( Pap smear cytology) or
biopsy may be indicated in rare cases of suspected
carcinoma, although this should be deferred to the
primary care physician or gynecologist.

25. Contd..
3. Imaging studies :
a) A pelvic ultrasound examination
b) Magnetic resonance imaging (MRI): not
indicated as emergency test.

26. Contd..
Differential diagnosis:
• Ovarian cyst
• Ectopic pregnancy
• Urinary tract infection female
• Neoplasm
• Vaginitis
• Abortion

27. Complication
Ulcers: displacement of vaginal lining may lead
to ulcer.
Incarceration: when uterus get trappped in the
lower pelvis or vagina edema occurs which may
further cause incarceration and even loss of blood
supply to the uterus.
Prolapse of other pelvic organs: it can lead to
difficulty in urinating and increased risk of UTIs.

28. Contd..
A prolapsed bladder bulges into the front part of
the vagina, causing a cystocele,
• Weakness of connective tissue overlying the
rectum rectocele difficulty in having
bowel movements.

29. Prevention/conservative treatment
A. To reduces the risk,
 Maintain healthy body weight,
 Perform Kegel exercises , 4 times a day, (20-30) min each
to tone up the pelvic muscles.

30. Contd…

31. Contd..
 Eat healthy diet balanced in protein, fat and carbohydrate.
5-9 servings of fruits and vegetables/day, food high in
dietary fibers and minimization of fat intake to 25-39 gm
helps to prevent constipation.

32. Contd..
 Stop smoking: Chronic cough can put extra strain on
pelvic muscle.
 Chronic constipation should be avoided.
 Do not lift heavy load, use correct lifting techniques.
 Consider Estrogen replacement therapy after menopause.

33. Contd..
B. Vaginal pessery
 This device fits under the cervix and holds the uterus in
place.
Used as temporary or permanent treatment,
Comes in different shapes and sizes,
Size depends upon the size of vagina,

34. Contd..
Types :

35. Management
A. Emergency department care:
 Early diagnosis
 Patient education about risk factors, preventive
measures,
 Early detection
 Regular consultation with obstetrician and gynecologist
for definitive management.

36. C. Surgical management
1. Vaginal hysterectomy with a vaginal vault suspension :
 Most common operation,
 Used in support of vaginal vault as utero-sacral and
cardinal suspension are preserved.

37. Contd..
Indications :
 Post menopausal prolapse,
 Uterine pathology like uterine fibroid or adenomyosis,
 Menstrual disorder such as dysfunctional uterine bleeding,
 Prolapse during child bearing age, after completion of
family.

38. Contd..
2. Abdominal hysterectomy:
 Performed followed by vaginal anterior or posterior
colporrhapy,
 Not advisable in pelvic inflammatory disease and previous
intra-abdominal operation for endometritis.

39. Contd..
3. Colpocleisis:
 Common in elderly women who are no longer sexually
active,
 Involves removal of strip of anterior and posterior vaginal
wall, with closure of margin of anterior and posterior wall
to each other.
 The procedure is performed with or without the presence
of uterus or cervix.
 Has 91- 100% successful rate.

40. Contd..
4. Manchester Repair:
 For repair of utero-vaginal prolapse,
 Carried out in women with child bearing age and haven’t
completed their families and insist on preservation of
uterus.

41. Contd..
5. Sacro-hysteropexy:
 Performed using strip of synthetic mesh to hold the uterus
in place,
 Done abdominally either through a cut 15cm just above
the pubic hair line or through laparoscopy.

42. D. Nursing management
Pre operative nursing care
 Explain procedure, expectation, its effects on future life,
 Take consent
 Laxative and cleansing edema (rectocele), a day prior the
procedure,
 Perineal shave

43. Contd..
During :
 Lithotomy position for surgery.
Post-operative :
 Encourage Patient to void 6 hours after surgery, catheter
if unavailable.

44. References
 D.C. DATTA’S; “A TEXTBOOK OF OBSTETRICS” SEVENTH EDITION;
PUBLISHED BY NEW CENTRAL BOOK AGENCY MEDICAL
PUBLISHERS(P) LIMITED; KOLKATA; P.NO. 312 TO 314.
 MYLES; ‘‘A TEXT BOOK FOR MIDWIVES’’ SIXTEENTH EDITION;
INTERNATIONAL EDITION;PUBLISHED BY SAUNDERS ELSEVIER;
EDITED BY JAYNE MARSHALL & MAUREEN RAYNOR P NO.-477 TO
479 & 486 TO 488.
 ANUPAMA TAMRAKAR’S; “A TEXTBOOK OF GYNECOLOGY FOR
NURSES” ;PUBLISHED BY JYAPEE BROTHERS MEDICAL
PUBLISHERS(P) LTD; NEW DELHI; P.NO. 174 TO 180.
WEBPAGE;
 ‘‘WWW.WIKIPEDIA.COM
 WWW.ENCYCLOPEDIA.COM’’; TOPIC OF UTERINE PROLAPSE.