seminar

1. DISPLACEMENT
OF THE UTERUS

2. DISPLACEMENT OF THE
UTERUS
The uterus is not a fixed organ. Minor
variations in position in any direction occur
constantly with changes in posture, with
straining, with full bladder or loaded rectum.
Only when the uterus rests habitually in a
position beyond the limit of normal variation,
should it be called displacement.

3. RETROVERSION
Retroversion (RV) is the term used
when the long axes of the corpus and
cervix are in line, and the whole organ
turns backwards in relation to the long
axis of the birth canal.

5. Degrees
 First degree — The fundus is vertical and
pointing towards the sacral promontory.
 Second degree — The fundus lies in the
sacral hollow but not below the internal os.
 Third degree — The fundus lies below the
level of the internal os.

6. Causes
 Developmental
 Acquired

7. Acquired
 Puerperal
 Prolapse
 Tumor
 Pelvic adhesions

8. Incidence
 Retroversion is present in about 15–20
percent of normal women.

9. Clinical Presentation
 The condition is classified either as mobile
and fixed or uncomplicated and complicated
by pelvic diseases.

10. Mobile Retroverted Uterus
Symptoms
 Chronic premenstrual pelvic pain
 Back ache
 Dyspareunia
 Infertility

11. Signs
 Bimanual examination reveals —
 (a) The cervix is directed upwards and
forwards.
 (b) The body of the uterus is felt through the
posterior fornix.
 Speculum examination reveals — the cervix
comes in view much easily and the external
os points forwards.

12. Fixed retroversion
 The symptoms are related to the associated
pelvic pathology. Menstrual abnormalities
(menorrhagia), congestive dysmenorrhea,
chronic pelvic pain, or dyspareunia are
usually associated.

13. Differential Diagnosis
 The retrodisplacement may be confused with
hard fecal mass in the rectum, small fibroid on
the posterior wall of the uterus, and small
ovarian cyst in the pouch of Douglas.

14. Pregnancy in Retroverted
Uterus
 In pregnancy, spontaneous correction usually
occurs by 12–14 weeks. While the cause of
infertility is mainly mechanical as mentioned
earlier, repeated pregnancy wastage may be
due to disturbance in uterine vascularity or
due to thrust during intercourse especially in
abortion prone women.

15. Prevention
The following guidelines are of help during
the weeks after abortion or childbirth:
To empty the bladder regularly.
To increase the tone of the pelvic muscles
by regular exercise.
To encourage lying in prone position for
half to one hour once or twice daily
between 2 and 4 weeks postpartum.

16. Corrective Treatment
 Pessary
 Surgical

17. Pessary
 Pessary is less commonly used in present day
gynecologic practice. However, it may be indicated:
 (1) for pessary test
 (2) in subinvolution of uterus
 (3) in pregnancy when spontaneous correction to
anteversion fails by 12th week. Usually, Hodge-
Smith pessary is used. The pessary acts by
stretching the uterosacral ligaments so as to pull the
cervix backwards.

18. Surgical Treatment
 Surgical correction is indicated in:
 (1) Cases where the ‘pessary test’ is positive
indicating that the symptoms are due to
retroversion.
 (2)Fixed retroverted uterus producing
symptoms like backache or dyspareunia.

19.  The principle of surgical correction is
ventrosuspension of the uterus by plicating
the round ligaments of both the sides
extraperitoneally to the under surface of the
anterior rectus sheath. This will pull the uterus
forwards and maintains it permanently in the
same position.

20. PELVIC ORGAN PROLAPSE
(POP)
 Pelvic organ prolapse (POP) is one of the
common clinical conditions met in day-to-day
gynecological practice especially among the
parous women. The entity includes descent of
the vaginal wall and/or the uterus. It is infact a
form of hernia.

21. Supports of uterus
 The uterus is normally placed in anteverted
and anteflexed position. It lies in between the
bladder and rectum. The cervix pierces the
anterior vaginal wall almost at right angle to
the axis of the vagina. The external os lies at
the level of ischial spines.

22. Upper tier
 Endopelvic fascia covering the uterus.
 Round ligaments.
 Broad ligaments with intervening pelvic
cellular tissues.

23. Middle tier
 Pericervical ring
 Pelvic cellular tissue

24. Inferior tier
 This gives the indirect support to the uterus.
The support is principally given by the pelvic
floor muscles (levator ani), endopelvic fascia,
levator plate, perineal body, and the
urogenital diaphragm.

25. SUPPORTS OF VAGINA
 Positional support
 Pelvic cellular tissue

26. Supports of the Posterior
Vaginal Wall
 Endopelvic fascial sheath covering the vagina
and rectum.
 Attachment of the uterosacral ligament to the
lateral wall of the vault.

27. Etiology of Pelvic Organ
Prolapse (POP)
 Predisposing
 Acquired
 Congenital
 Aggravating

28. Acquired Predisposing factors:
 Overstretching of the Mackenrodt’s and uterosacral
ligaments
 Overstretching and breaks in the endopelvic fascial sheath.
 Overstretching of the perineum.
 Imperfect repair of the perineal injuries. Poor repair of
collagen tissue.
 Loss of levator function.
 Neuromuscular damage of levator ani during childbirth.
 Subinvolution of the supporting structures.

29. Congenital:
 Congenital weakness of the supporting
structures is responsible for nulliparous
prolapse or prolapse following an easy
vaginal delivery

30. CLINICAL TYPES OF PELVIC
ORGAN PROLAPSE
 The genital prolapse is broadly grouped into:
 • Vaginal prolapse
 • Uterine prolapse

31. Vaginal Prolapse
Anterior wall
 Cystocele
 Urethrocele

32. Posterior wall
 Relaxed perineum
 Rectocele

33. Vault prolapse
 Enterocele
 Secondary vault prolapse

34. Uterine prolapse
 Uterovaginal prolapse
 Congenital

35. Degrees of uterine prolapse
(clinical)
 Three degrees are described:
 First degree — The uterus descends down from its
normal anatomical position (external os at the level
of ischial spines) but the external os still remains
inside the vagina.
 Second degree — The external os protrudes
outside the vaginal introitus but the uterine body still
remains inside the vagina.
 Third degree — The uterine cervix and body
descends to lie outside the introitus.

36. Morbid Changes
 Vaginal mucosa
 Decubitus ulcer
 surface keratinization → cracks → infection →
sloughing → ulceration.

37. Management:
 Cervical cytology to exclude malignancy.
 Manual reduction of prolapse.
 Vaginal pack with roller bandage socked with
antiseptic lotion glycerin and acriflavin or
using estrogen cream (postmenopausal
women).

38. cont.. Morbid changes
 Vaginal part
 Supravaginal part
 Bladder
 Uterus
 Incarceration
 Peritonitis
 Carcinoma

39. Symptoms
 Feeling of something coming down per vaginum,
especially while she is moving about. There may
be variable discomfort on walking when the mass
comes outside the introitus.
 Backache or dragging pain in the pelvis. The
above two symptoms are usually relieved on lying
down.
 Dyspareunia.

40. Urinary symptoms
 Difficulty in passing urine, more the strenuous effort, the
less effective is the evacuation. The patient has to
elevate the anterior vaginal wall for evacuation of the
bladder.
 Incomplete evacuation may lead to frequent desire to
pass urine.
 Urgency and frequency of micturition may also be due
to cystitis.
 Painful micturition is due to infection.
 Stress incontinence is usually due to associated
urethrocele.
 Retention of urine may rarely occur.

41.  Bowel symptom (in presence of rectocele).
 Difficulty in passing stool. The patient has to push
back the posterior vaginal wall in position to
complete the evacuation of feces. Fecal
incontinence may be associated.
 Excessive white or blood-stained discharge per
vaginum is due to associated vaginitis or decubitus
ulcer

42. Clinical Examination and
Diagnosis of POP
 A composite examination — inspection and
palpation: Vaginal, rectal, rectovaginal or even
under anesthesia may be required to arrive at a
correct diagnosis.
 General examination — details, including BMI,
signs of myopathy or neuropathy, features of
chronic airway disease or any abdominal mass
should be done.
 Pelvic Organ Prolapse (POP) is evaluated by pelvic
examination in both dorsal and standing positions.

43. Cont..
 A negative finding on inspection in dorsal position
should be reconfirmed by asking the patient to
strain on squatting position.
 Prolapse of one organ (uterus) is usually
associated with prolapse of the adjacent organs
(bladder, rectum).
 Etiological aspect of prolapse should be evaluated.

44. Cystocele :
 There is a bulge of varying degree of the anterior
vaginal wall, which increases when the patient is
asked to strain. This may be seen on inspection. In
others, to elicit this, one may have to separate the
labia or depress the posterior vaginal wall with
fingers or using Sims’ speculum, placing the patient
in lateral position.

45. Cystourethrocele
 The bulging of the anterior vaginal wall involves the
lower-third also. One may find the urine to escape
out through the urethral meatus when the patient is
asked to cough — stress incontinence. To elicit the
test, the bladder should be full.

46. Relaxed perineum:
 There is gaping introitus with old scar of
incomplete perineal tear. The lower part of the
posterior vaginal wall is visible with or without
straining.

47. Rectocele and enterocele:
 When the two conditions exist together, there is
bulging of the posterior vaginal wall with a
transverse sulcus between the two. The midvaginal
one being rectocele with diffuse margins and
reducible. This is visualized by retracting the
anterior vaginal wall by Landon’s retractor.

48. Uterine prolapse:
 In second or third degree of prolapse,
inspection can reveal a mass protruding out
through the introitus, the leading part of which
is the external os.

49. Differential Diagnosis
 Cystocele:
 The cystocele is often confused with a cyst in
the anterior vaginal wall, the commonest
being Gartner’s cyst (retention cyst in
remnants of Wolffian duct).

50.  Features of Gartner’s cyst are:
 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.

51. Uterine Prolapse
 Congenital elongation of the cervix
 • It is unassociated with prolapse (usually).
 • Vaginal part of the cervix is elongated.
 • External os lies below the level of ischial spines.
 • Vaginal fornices are narrow and deep.
 • Cervix looks conical.
 • Uterine body is normal in size and in position.

52.  Chronic inversion
 • Leading protruding mass is broad.
 • There is no opening visible on the leading part.
 • It 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 felt.

53.  Fibroid polyp
 • The 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 normal shape and
position of the uterus.

54. MANAGEMENT OF PROLAPSE
 Preventive
 Conservative
 Surgery

55. Preventive
 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.

56. Conservative
 Indications of conservative management are:
  Asymptomatic women.
  Mild degree prolapse.
  POP in early pregnancy.

57.  Meanwhile, following measures may be taken:
  Improvement of general measures
  estrogen replacement therapy may improve
minor degree prolapse in postmenopausal
women.
  Pelvic floor exercises in an attempt to
strengthen the muscles (Kegel exercises).
  Pessary treatment.

58. Pessary Treatment
 Indications of use are:
  Early pregnancy — The pessary should be placed
inside up to 18 weeks when the uterus becomes
sufficiently enlarged to sit on the brim of the pelvis.
 Puerperium — to facilitate involution.
  Patients absolutely unfit for surgery especially with
short life expectancy.
  Patient’s unwillingness for operation.
  While waiting for operation.
  Additional benefits: Improvement of urinary
symptoms (voiding problems, urgency).

59. Surgical management of
prolapse
 (A)Restorative—
 correcting her own support tissues
 compensatory — using permanent graft material
 (B) Extirpative — removing the uterus and
correcting the support tissues.
 (C) Obliterative — closing the vagina.

60. Types of operation
 Anterior colporrhaphy –
 This operation is designed to correct
cystocele and urethrocele. The underlying
principles are to excise a portion of the
relaxed anterior vaginal wall, to mobilize the
bladder and push it upwards after cutting the
vesicocervical ligament.

61.  Paravaginal defect and its repair
 Paravaginal defect is characterized by
presence of rugae on the anterior vagina and
absence of sulci on the lateral vagina;
Anterior vaginal wall prolapse (cystocele) is
repaired by anterior colporrhaphy and
plicating the endopelvic fascia in the midline
under the bladder neck.

62.  Perineorrhaphy/Colpoperineorrhaphy
 It is an operation designed to repair the prolapse
of posterior vaginal wall. Its uses and extent of
repair are employed in:
 Relaxed perineum — The operation is extended to
repair the torn perineal body.
 Rectocele — The repair is extended to correct
rectocele by tightening the pararectal fascia.
 Enterocele — High perineorrhaphy is to be done
right up to the cervicovaginal junction along with
correction of enterocele.

63.  Repair of enterocele and vault prolapse
 Enterocele is almost always associated with
genital prolapse. Along with repair operation,
enterocele is to be corrected transvaginally.

64.  Pelvic floor repair (PFR)
 Usually, the prolapse of the anterior vaginal
wall is associated with any form of posterior
wall prolapse and relaxed perineum. As such,
the corrective operation is known as pelvic
floor repair. This includes :
 Anterior colporrhaphy
 Colpoperineorrhaphy.

65.  Fot hergill’s or Manchester operation
 The operation is designed to correct uterine
descent associated with cystocele and rectocele
where preservation of the uterus is desirable
 Preliminary dilatation and curettage
 Amputation of the
 Plication of the Mackenrodt’s ligaments in front of
the cervix. This facilitates their shortening and
raising the cervix so as to place it in its normal
position.
 Anterior colporrhaphy.
 Colpoperineorrhaphy.

66.  Vaginal hysterectomy with pelvic floor repair
 The operation is often designated as Ward Mayo’s
operation named after Mayo (1915) and Ward
(1919) both from United States. Removal of the
uterus per vaginum (vaginal hysterectomy) is
mostly done in cases of uterine prolapse. It should
be emphasized that hysterectomy is not the
surgery for the prolapse. It is the associated repair
of the pelvic floor (PFR), which is the corrective
surgery for prolapse.

67.  Indications
 Uterovaginal prolapse in postmenopausal women.
 Genital prolapse in perimenopausal age group
along with diseased uterus
 As an alternative to Fothergill’s operation where
family is completed.
 As an alternative to abdominal hysterectomy in
undescended uterus
 As an alternative to laparoscopic assisted vaginal
hysterectomy (LAVH)

68.  Vault Prolapse
 Posthysterectomy (vaginal or abdominal) vault
prolapse is usually accompanied by an enterocele
(70%). However, cystocele and or rectocele may
be present. The vault prolapse in such cases may
be effectively repaired transvaginally maintaining
the same principle of repair of enterocele along
with anterior colporrhaphy and
colpoperineorrhaphy

69.  Management of vault prolapse
 Conservative: Pessary treatment—generally not
recommended.
 Surgical:
 Transvaginal approach
 � Repair of enterocele along with pelvic floor repair
 � Le Fort operation.
 � Colpocleisis (cases following hysterectomy).
 � Sacrospinous colpopexy.
 Abdominal approach
 � Vault suspension (sacral colpopexy).

70.  Le Fort operation:
 The procedure is almost obsolete. It may be done
in old age with procidentia when the patient is
unfit for longer duration of surgery as vaginal
hysterectomy with PFR. There should not be any
uterine or pelvic pathology. Cervical cytology (pap
smear) should be normal. The operation can be
done under local anesthesia.

71.  Colpocleisis (after hysterectomy)
 Denudation of vaginal mucosa is done all round.
Successive purse string absorbable sutures are
placed from above downwards to appose the
vaginalwalls. It is a simple, safe and effective
operation for a woman who is no longer
interested in coital function.

72.  Sacrospinous colpopexy:
 The sacrospinous ligament is attached
medially to the sacrum and coccyx and
laterally to the ischial spine. It is within the
body of coccygeus muscle. Vaginal vault is
fixed to the coccygenus sacrospinous
ligament complex (CSSL) of the right side.

73. Abdominal approach
 Vault suspension (Sacral colpopexy):
 Principle of the operation is to suspen the
vaginal vault to be anterior longitudinal
ligament in front of the 3rd sacral vertebra.
Non-absorbable suture material (Mersilene or
Gore-Tex mesh) is used.

74.  Cervicopexy or Sling operation
(Purandare’s operation)
 The operation is indicated in congenital or
nulliparous prolapse without cystocele where
the cervix is pulled up mechanically through
abdominal route. Strips of rectus sheath of
either side passed extraperitoneally are
stitched to the anterior surface of the cervix by
silk.

75. Management of POP using
mesh
 Synthetic and biological mesh have been used. They
are found to work better compared to traditional
method of repair. Some synthetic (polygalactin) and
all biological materials (fascia lata, dermis, rectus
seath) are absorbable. Non-absorbable mesh are
synthetic (polypropylene, polytetrafluoroethylene).

76. Complications of vaginal repair
operations
 Complications of PFR
 Operative
 Hemorrhage — The hemorrhage may at times
be brisk. The hypovolaemic state can be tackled
by infusion and blood transfusion.
 Trauma — The bladder in anterior colporrhaphy
or rectum in perineorrhaphy may be injured. The
injury should be effectively repaired else, either
VVF or RVF may develop later on.

77.  Retention of urine is a common complication.
This is due to:
 (i) Spasm, edema, and tenderness of
pubococcygeus muscle.
 (ii) edema of the urethral wall.
 (iii) Reflex from the wounds.
 Infection leading to cystitis.

78.  Hemorrhage
 Primary hemorrhage occurs within 24 hours.
It is due to imperfect hemostasis at operation
or due to slipping of the ligature.
 Secondary hemorrhage occurs usually
between 5–10th day but may occur even in
the 3rd week. It is due to sepsis of the wound.
 Sepsis: Infection occurs on the vaginal or
perineal wounds. Rarely, disruption of the
perineal wound occurs.

79.  Late:
 Dyspareunia
 Recurrence of prolapse
 VVF following bladder injury
 RVF following rectal injury

80.  Complications of vaginal hysterectomy with
PFR
 All the complications mentioned in PFR operation
may occur, at times with increased intensity.
Additional complications include:
 Immediate
 � Vault cellulitis
 � Pelvic abscess
 � Thrombophlebitis
 � Pulmonary embolism
 Late :
 � Vault prolapse

81. CHRONIC INVERSION
 Definition:
 Inversion is a condition where the uterus
becomes turned inside out; the fundus
prolapsing through the cervix.

82.  Causes
 Incomplete obstetric inversion.
 Submucous myomatous polyp arising from the
fundus.
 Sarcomatous changes of fundal fibroma.
 Senile inversion.

83.  Types: Two types are described in chronic
inversion.
 � Incomplete — The fundus protrudes
through the cervix and lying inside the vagina.
 � Complete — Whole of the uterus including
the cervix are inverted. The vagina may also
be
 involved in the process.

84.  Symptoms
 � Sensation of something coming down per
vaginum.
 � Irregular vaginal bleeding.
 � Offensive vaginal discharge.

85.  Signs:
 Inspection : The protruding mass has got the
following features :
 Globular
 No opening in the leading part,
 Shaggy look
 Tumor may be present at the bottom.

86.  Per vaginum:
 (a) The cervical rim is felt high up in incomplete
variety but not felt in complete one.
 (b) Cup-shaped depression at the fundus is felt or
the uterus is not felt in position.
 Rectal examination:
 Rectoabdominal examination is more informative to
note the fundal depression or displacement of the
uterus.
 Sound test:
 Demonstration of shortness or absence of uterine
cavity using an uterine sound is reasonably
confirmative.

87.  Differential Diagnosis
 Fibroid polyp
 Uterine prolapse
 Prolapsed hypertrophied ulcerated cervix
 Fungating cervical malignancy.

88.  Treatment
 General measures: The patients are usually
anemic. Prior improvement should be made if
necessary, by blood transfusion. Local sepsis
is to be controlled.

89.  Definitive treatment: There is no place of
manipulative replacement by taxis. Rectification
should be done by surgery. Preservation or
removal of the uterus is determined by such
factors like age, parity, associated complicating
factors. If hysterectomy is contemplated, it should
be done following rectification.

90.  Conservative surgery: Rectification may be
done abdominally (Haultain’s operation —
after cutting the posterior ring of the cervix) or
vaginally (Spinelli‘s operation — after cutting
the
 anterior ring of the cervix). Following
Haultain’s operation, some form of
suspension operation has to be done to
prevent posterior adhesions.

91. NURSING CARE PLAN
 Nursing Diagnosis
 Situational Low Self-Esteem
 May be related to
 Concerns about inability to have children, changes in
femininity, effect on sexual relationship
 Religious conflicts
 Desired Outcomes
 Client will verbalize concerns and indicate healthy ways
of dealing with them.
 Client will verbalize acceptance of self in situation and
adaptation to change in body/self-image.

92.  Intervention
 Provide time to listen to concerns and fear of patient and
so. Discuss patient’s perceptions of self related to
anticipated changes and her specific lifestyle.
 Assess he emotional stress the patient is experiencing.
Identify the meaning of loss for patient and so. Encourage
patient to vent feeling appropriately
 Provide accurate information, reinforcing information
previously given
 Ascertain individual strength and identify previous positive
coping behaviours.
 Provide an open environment for the patient to discuss
concerns about sexuality.
 Note withdrawn behavior, negative self talk, use of denial,
or over concern with actual and/ or perceived changes.
 Refer to professional counseling as necessary

93.  Impaired Urinary Elimination
 Nursing Diagnosis
 Impaired Urinary Elimination
 May be related to
 Mechanical trauma, surgical manipulation,
presence of local tissue edema, hematoma
 Sensory/motor impairment: nerve paralysis
 Desired Outcomes
 Client will empty the bladder regularly and
completely.

94.  Intervention
 Note voiding pattern and monitor urinary output
 Palpate bladder. Investigate reports of discomfort, fullness,
inability to void.
 Provide routine voiding measures: privacy, normal position,
running water in the sink, pouring warm water over the
perineum
 Provide and encourage good perineal cleansing and
catheter care
 Assess urine characteristics, nothing color, clarity, odor.
 Catheterize when indicated or per protocol if the patient is
unable to void or is uncomfortable
 Decompress bladder slowly
 Maintain patency of indwelling catheter; keep drainage
tubing free of kinks
 Check residual urine volume after voiding as indicated.

95.  Risk for Ineffective Tissue Perfusion
 Nursing Diagnosis
 Risk for Ineffective Tissue Perfusion
 Risk factors may include
 Hypovolemia
 Reduction/interruption of blood flow: pelvic congestion,
postoperative tissue inflammation, venous stasis
 Intraoperative trauma or pressure on pelvic/calf vessels:
lithotomy position during vaginal hysterectomy
 Desired Outcomes
 Client will demonstrate adequate perfusion, as evidenced by
stable vital signs, palpable pulses, good capillary refill, usual
mentation, individually adequate urinary output.
 Client will be free of edema, signs of thrombus formation.

96.  Intervention
 Monitor vital signs: palpate peripheral pulses, and note
capillary refill: assess urinary output and characteristics.
Evaluate changes in menstruation
 Inspect dressing and perineal pads, noting color, amount,
and odor of drainage. Weigh pads and compare with dry
weight if the patient is bleeding heavily.
 Turn the patient and encourage frequent coughing and deep
breathing exercises
 Avoid high fowlers position and pressure under the knees or
crossing of legs.
 Assist and instruct in foot and leg exercises and ambulate as
soon as able.
 Check Homan’s sign. Note erythema, swelling of extremity, or
report of sudden chest pain with dyspnea.
 Administer IV fluid, blood product as indicted.
 Apply anti embolism stockings.
 Assist with or encourage the use of incentive spirometer.

97. Research study
 Women's knowledge regarding pelvic
organ prolapse

98. Bibliography
 Rashad M, Fadel EA, El-Nemer A. Women’s
knowledge regarding pelvic organ prolapse.
Mansoura Nursing J. 2019;6:57-67.
 D.C Dutta, text book of Gynecology, 6th
edtion, page no : 189-216

99. Thank you…..