Uterine prolapse is the downward displacement of the uterus into the vaginal canal. It is caused by weakness or damage to the ligaments and fascia that support the uterus and vagina. Risk factors include multiple vaginal births, menopause, chronic coughing, and genetic factors. Symptoms include a feeling of something falling out of the vagina, pressure, pain, and urinary or bowel issues. Treatment options include pelvic floor exercises, pessaries, and surgery such as hysterectomy, anterior and posterior colporrhaphy, or sacrocolpopexy depending on the severity of prolapse and patient factors. Surgical treatment is generally very effective but some risk of recurrence or incontin

1. Uterovaginal prolapse

2. Uterine Prolapse is the downward displacement of the
uterus into the vaginal canal or a gradual descend of the
uterus in the axis of the vagina taking the vaginal wall with it.
Definition

3. Applied anatomy

4. Normal postion of uterus and
vagina
>The uterus and vagina lies in middle of pelvis.
Anteriorly: urinary bladder (upper half)
urethra & para urethral glands
(lower half)
Posteriorly: colon,rectum and anal canal.
>The perineal body is interposed b/w lower part
of the posterior vaginal wall and the anal
canal.

5. Position of uterus
<In 80 % of women the uterus is anteverted and anteflexed
<In 20% of women it may be retroverted
Retroverted uterus Anteverted uterus

6. Supports of uterus and vagina
Uterine 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

7. Uterine support

8. Pelvic ligaments under stretch
during prolpase

9. Vaginal 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 : Holds vagina in its postion
<Pubocervical fascia: provides 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

10. Uterovaginal 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.

11. Uterine prolpase

12. Terminology
1.Anterior vaginal wall prolapse
2.Posterior vaginal wall prolapse
3.Uterine prolapse
4.Vaginal vault prolapse(after hysterectomy)

13. ANTERIOR VAGINAL WALL PROLAPSE
<Cystocele :
Descent of upper 2/3 of the anterior vaginal wallall 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

14. cystocele urethrocele
Anterior vaginal wall prolapse

15. Posterior vaginal wall prolpase
<Enterocele ( POUCH OF DOUGHLAS HERNIA )
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

16. Posterior vaginal wall prolpase
Enterocele Rectocele

17. Classification and grading
The anterior and posterior vaginal wall prolapse is
usually described as
<Minor degree
<Moderate degree
<Major degree

18. Usually, prolapse is also rated by
degrees:
First-degree prolapse: the cervix rests in the
lower part of the vagina.
Second-degree prolapse: the cervix is at
the vaginal opening.
Third-degree prolapse: the uterus
protrudes through the introitus.

19. First degree
prolapse

20. Second degree
prolapse
!

21. Third degree
prolapse
!

22. Various termiologies have been used to classify
the UV prolapse .The latest was described in 1996
which 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

23. Causes 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

24. Etiology
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

25. Etiology
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
<Forceps delivery
<Pressure on fundus during delivery of the placenta(Crede’s
method)
<Pudendal nerve injury during child birth

26. Causes
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
Activating factors
<Increased intra-abdominal pressure(chronic cough , chronic
constipation , ascities etc)
<Small fibroids
<Pelvic tumors

27. Pathology
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
>Keratinization of the vaginal epithelium
>Decubitus ulceration
>Incarceration 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

28. Symptoms
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

29. signs
>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.

30. Differential Diagnoses
<Cystic swelling in the vagina
<Polypoidal growth
<Chronic inversion of the uterus
<Hypertrophy of the cervix
<All other causes of low backache and
urinary symptoms

31. Treatment
The treatment of UV prolapse is described
under the following headings.
1.Prevention
2.Physiotherapy
3.Pessary
4.Surgical
Treatment

32. Prevention
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
• 2ndstage
▫ 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

33. Physiotherapy
*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

34. Pessary 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

35. Pessary 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.

36. Pessaries

37. Surgical treatment
Operations
<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

38. Surgical 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.

39. Surgical 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
<Laparoscopic 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.

40. Outcome 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.

41. Pregnancy 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.

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