Uterine prolapse Define, Types,test, Treatment in Details in word file use in clinical teaching of OBG made By sonal Patel

1. 1
JG COLLEGE OF NURSING,
AHMEDABAD.
SUBJECT: OBSTETRIC AND GYNECOLOGICAL
NURSING-II
TOPIC : CLINICAL TEACHING
SUBMITTED TO: SUBMITTEDBY:
MS. REKHAMOL SIDHANAR, PATEL SONAL P.

2. 2
ASSISTANT PROESSOR, s.Y M.SC NURSING, J.G COLLEGE
OF NURSING J.G COLLEGE OF NURSING
AHMEDABAD. AHMEDABAD.
UTERINE PROLAPSE
Uterine prolapse is descent of the uterus toward or past the introitus. Vaginal prolapse is descent of the vagina or vaginal cuff
after hysterectomy. Symptoms include vaginal pressure and fullness. Diagnosis is clinical. Treatment includes reduction,
pessaries, and surgery.
Uterine prolapse is graded based on level of descent:
 1st degree: To the upper vagina
 2nd degree: To the introitus
 3rd degree: Cervix is outside the introitus
 4th degree (sometimes referred to as procidentia): Uterus and cervix entirely outside the introitus
Vaginal prolapse may be 2nd or 3rd degree.
Symptoms and Signs
Symptoms tend to be minimal with 1st-degree uterine prolapse. In 2nd- or 3rd-degree uterine prolapse, fullness, pressure,
dyspareunia, and a sensation of organs falling out are common. Lower back pain may develop. Incomplete emptying of the
bladder and constipation are possible.
Third-degree uterine prolapse manifests as a bulge or protrusion of the cervix or vaginal cuff, although spontaneous reduction
may occur before patients present. Vaginal mucosa may become dried, thickened, chronically inflamed, secondarily infected, and
ulcerated. Ulcers may be painful or bleed and may resemble vaginal cancer. The cervix, if protruding, may also become
ulcerated.
Symptoms of vaginal prolapse are similar. Cystocele or rectocele is usually present.
Urinary incontinence is common. The descending pelvic organs may intermittently obstruct urine flow, causing urinary retention
and overflow incontinence and masking stress incontinence. Urinary frequency and urge incontinence may accompany uterine or
vaginal prolapse.
Diagnosis
 Pelvic examination
Diagnosis is confirmed by speculum or bimanual pelvic examination. Vaginal ulcers are biopsied to exclude cancer.
Simultaneous urinary incontinence requires evaluation.
Treatment
 For mild symptomatic prolapse, pessaries
 Surgical repair of supporting structures if necessary, usually with hysterectomy
Uterine prolapse:
Asymptomatic 1st- or 2nd-degree uterine prolapse may not require treatment. Symptomatic 1st- or 2nd-degree prolapse can be
treated with a pessary if the perineum can structurally support a pessary.
Severe or persistent symptoms and 3rd- or 4th-degree prolapse require surgery, usually hysterectomy with surgical repair of the
pelvic support structures (colporrhaphy) and suspension of the top of the vagina (suturing of the upper vagina to a stable structure
nearby). Surgical options include a vaginal approach (vaginal repair) and an abdominal approach. Laparotomy or laparoscopy can
be used with an abdominal approach.
For 3rd- and 4th-degree prolapse, an abdominal approach (using laparotomy or laparoscopy) results in greater structural support

3. 3
than a vaginal repair and a lower risk of complications than mesh placed vaginally. Laparoscopic repair of prolapse poses less
risk of perioperative morbidity than laparotomy. Using mesh may lower the risk of prolapse recurrence after a vaginal repair, but
complications occur more frequently. Patients should be advised that all mesh may not be removed completely so that they can
make an informed decision.
Surgery is delayed until all ulcers, if present, have healed.
Vaginal prolapse:
Vaginal prolapse is treated similarly to uterine prolapse. The vagina may be obliterated if women are not
good candidates for prolonged surgery (eg, if they have serious comorbidities). Advantages of vaginal
obliteration include short duration of surgery, low risk of perioperative morbidity, and very low risk of
prolapse recurrence. Urinary incontinence requires concurrent treatment.
Definition/Description
Uterine prolapse is the condition of the uterus collapsing, falling down, or downward displacement of the
uterus with relation to the vagina.[1]
It is also defined as the bulging of the uterus into the vagina.[2] [3]
When in proper alignment, the uterus and the adjacent structures are suspended in the proper position by
the uterosacral, round, broad, and cardinal ligaments. The musculature of the pelvic floor forms a sling-
like structure that supports the uterus, vagina, urinary bladder, and rectum.[2]
Uterine prolapse is a result
of pelvic floor relaxation or structural overstretching of the muscles of the pelvic wall and ligamentous
structures.

4. 4
Uterine prolapse is characterized under a more general classification called pelvic organ prolapse
which encompasses descent of the anterior, middle and posterior structures into the vagina.
 Those organs that bulge anterior into the vagina are the urinary bladder which is called a
cystocele, the urethra, which is called a urethrocele or a combination, which is a cystourethrocele.
 The uterus and the vaginal vault, which is the apex of the vagina, make up the organs that
constitute the middle portion descent into the vagina. The vaginal vault often prolapses as a result
of a hysterectomy.
 The rectal bulge is called a rectocele and a bulge of part of the intestine and peritoneum is called
an enterocele, these make up the posterior portion of pelvic organ prolapse.
 The information from this point forward will focus on uterine prolapse.
Uterine prolapse is classified using a four part grading system:
Grade 1: Descent of the uterus to above the hymen
Grade 2: Descent of the uterus to the hymen
Grade 3: Descent of the uterus beyond the hymen
Grade 4: Total prolapse.
Prevalence
Each source presents with a different prevalence depending on the researcher and the population used.
One study stated that the prevalence of pelvic organ prolapse, a clinical classification for all of the pelvic
structures prolapse into the vagina, was 50% for women who have give birth, though most women are
asymptomatic. Another article cited that 50% of the female population in the United States are affected by
pelvic order prolapse with a prevalence rate that can vary from 30% to 93%, varying among different
populations. A questionnaire based study stated that 46.8% of the responses were positive for symptoms
of pelvic organ prolapse and of the response group, 46.9% were vaginally examined with 21% having
clinically relevant pelvic organ prolapse.

5. 5
Characteristics/Clinical Presentation
The primary symptoms of a uterine prolapse are backache, perineal pain, and a sense of "heaviness" in the
vaginal area. Pain associated with uterine prolapse can be located centrally or suprapubic, and can be
described as "dragging" in the groin. This pain is due to stretching of the ligamentous supports and
secondarily to abrasion of the prolapsed tissues. If the prolapse has progressed into a grade three or third
degree prolapse, the person may feel as though they have a lump at the vaginal opening and have
irritation and abrasion of the exposed mucous membrane of the cervix and vagina. This is possible both
during sexual intercourse and from wiping with toileting procedures. The person may report that the
symptoms are relieved by lying down and exacerbated with prolonged standing, walking, coughing or
straining. An associated and often common complication of uterine prolapse is urinary
incontinence. Other descriptions used are the feeling of sitting on a small ball and a report of repeated
bladder infections.
Summary from Differential Diagnosis for Physical Therapists:
 Lump in vaginal opening
 Pelvic discomfort, backache
 Abdominal cramping
 Symptoms relieved by lying down
 Symptoms made worse by prolonged standing, walking, coughing, or straining
 Urinary incontinence
Associated Co-morbidities
Obesity is a co-morbidity that often leads to progression and complication with uterine prolapse. In a
study by the NIH over a five year period, 55.7% of the women in the study gained weight and the rate of
prolapse increased from 40.9% to 43.8%. Looking specifically at uterine prolapse, when comparing
participants with healthy BMI’s to overweight and obese persons, the risk of prolapse increased by 43%
and 69%, respectively. However, the loss of weight did not presuppose a reversal of the uterine prolapse.
Other associated diseases that exacerbate uterine prolapse are chronic constipation and chronic
obstructive pulmonary disease (COPD) due to the relationship between increased intra-abdominal
pressure (bearing down) with increase in severity of the prolapse.

6. 6
Medications
Hormone replacement therapy in the oral or vaginal form is indicated or a possible treatment to assist in
maintaining elasticity of the pelvic floor musculature.
Women who have damage to tissue during childbirth do not frequently notice the laxity and pelvic
relaxation until they enter menopause. Vaginal tissue and supporting structures depend on estrogen for
their strength and elasticity. As estrogen levels decrease in certain situations (menopause and
breast feeding mothers), the symptom become more apparent.
Estrogen replacement can come in the form of pills, vaginal rings, patches, or vaginal creams and are
often indicated for lower grades of prolapse as the primary form of treatment. More severe prolapse is less
likely to respond to estrogen therapy alone, however, it can be used as an adjunct to other treatments.
Estrogen replacement can also be used after surgery to maintain results of surgery and help to revitalize
dry and thin vaginal tissue.
Diagnostic Tests/Lab Tests/Lab Values
Observation is often the first means of diagnosis.Physical examination is the primary means for diagnosis.
A bimanual test is performed with a speculum while the person is at rest and when the person is straining.
If prolapse is not apparent with the first method, the person repeats the test while standing with one foot
on a chair. The person is then graded using a first through third degree categorization. A first degree
prolapse is characterized by descent of the uterus to above the hymen. A second degree prolapse is to the
level of the hymen and a third degree prolapse is below the level of the hymen and protrudes through the
vaginal opening. Urine culture is ordered if needed. If still unsure about the diagnosis, a pelvic
ultrasonography or cystography can be ordered.
Causes
Women most at risk for this condition are those who have had multiple pregnancies and deliveries in
combination with obesity. Associated risk factors are trauma to the pudendal or sacral nerves when giving
birth. The disorder has been attributed to prolonged labor, bearing down before full dilation, and forceful
delivery of the placenta. Decreased muscle tone due to aging, excessive strain during bowel movement
and complications of pelvic surgery have also been associated with prolapse of the uterus and adjacent
organs.[2]
Associated risk also exists with pelvic tumors and neurologic condition like spina bifida and
diabetic neuropathy which interferes with innervation of pelvic musculature.[2]
Genetics are suspected in
this condition due to multiple familial relations and generations with this and related conditions.[13]
A
recent article has found that Cesarean section may lower the risk for pelvic organ prolapse.[14]
Summary of Causes:
 Multiple pregnancies and deliveries
 Obesity, Trauma to pudendal or sacral nerves
 Aging related muscle changes
 Excessive strain during bowel movements

7. 7
 Pelvic tumors, Genetic
Medical Management (current best evidence)
Corrective Surgery
Corrective surgery was a once popular first step for uterine prolapse but has fallen second choice to
rehabilitation. When surgery is indicated, it is a management tool for second, third, and fourth-degree
uterine prolapse. Pelvic organ prolapse surgery has a success rate of 65% to 90% and has a repeated rate
of operation at 30%. Patients who have more than one compartment involved may need a combination of
surgeries and surgery can often predispose patients to prolapse in another compartment. Surgery can be
either open or laparoscopic of the abdomen or can be in the vagina using fasciae, mesh, tape or sutures to
suspend the organs. Another surgical procedure that is used in attempt to conserve the uterus is a
sacrohysteropexy which is a Y-shaped graft that attaches the uterus to the sacrum. One case study that
examined the effectiveness in laparoscopic sacrohysteropexy, stated that this procedure “maintains
durable anatomic restoration, normal vaginal axis and sexual function.” It also requires less time and less
adhesion formation due to the laparoscopic approach versus an abdominal route. Vaginal hysterectomy,
vesicourethral suspension, and abdominal hysterectomy are other possible approaches.Important
components for consideration of a surgical approach are:
 Degree of prolapse
 Desire for future pregnancies
 Other medical conditions
 The woman's desire to retain vaginal function
 The woman's age and general health[9]
Pessary
A pessary is a shaped device made to support the uterus in the vagina. This is often a non-surgical
approach used for both uterine prolapse and urinary incontinence. There is a supportive type for milder
prolapse and a space-occupying type for more serious prolapse. The goal of the pessary is to find the
largest fit that is comfortable. They are to be removed regularly for cleaning by the individual with correct
education or by a health care professional.[5]
There are rings, rings with a rubber support, cubes, donut
shapes and inflatable balls. Depending on the degree of prolapse will determine the type that is
chosen. [13]
Patients who are not eligible for use of a pessary are those who cannot perform maintenance
care of the pessary, those with vaginal ulcerations or lesions, severe atrophy of the vagina and women
who develop recurrent vaginitis.[18]
Signs of improper fit are: those who have pain when wearing the
pessary, vaginal ulceration and infection, and the inability to have a bowel movement or urinate.[13]
No Treatment
Surgical treatment is not appropriate when the woman has recently had a baby. Tissue damaged during
childbirth that has caused an associated prolapse, often begins to improve when undergoing tissue
healing. A symptomatic prolapse in the first few weeks after delivery, especially in breastfeeding mothers

8. 8
have lower estrogen levels, does not necessarily predispose the mother to long term issues. Improvement
tends to occur after discontinuation of nursing and the return of normal hormone levels. Other women
and/or physicians do not elect for medical treatment for Stage 1 and Stage 2 prolapse and take a wait and
see approach.[13]
Physical Therapy Management (current best evidence)
Pelvic floor strengthening exercise is currently the front line treatment before surgery and also following
surgery, these include but are not limited to Kegel exercises.[2][5]
Other methods currently used are pelvic
floor musculature re-education, postural education, biofeedback and electrical stimulation.[2]
Pelvic Floor Training
Pelvic floor muscles are seventy percent slow-twitch muscle fibers, which assist in muscle endurance
with generation of slow and sustained contractions. These muscles are designed to have a less intense
contraction, whereas the other thirty percent, which are fast twitch, are designed for quick and forceful
contraction. An example of fast twitch muscles are the muscles that close the urethra during increased
intra-abdominal pressure. Pelvic floor training is progressive resistive exercises for the pelvic floor that
are often titled Kegel exercises. These exercises improve urethral resistance and pelvic visceral support
by increasing the voluntary periurethral muscles. Pelvic floor exercises enhance the voluntary closing
mechanisms. A thorough assessment of pelvic floor function is necessary to determine the muscular
strength and endurance by manual muscle test. Kegel exercises are often explained as contracting the
muscles that stop the flow of urine. A sustained pelvic contraction for a minimum of two seconds is likely
to ensure a better response to physical therapy. A five point rating scale is used to describe the contractile
strength during pelvic musculature examination.
Five-Point Rating Scale
Description
0 No contraction
1 Flicker, only with muscles stretched
2 Weak squeeze, 2 second hold
3
Fair squeeze with definite "lift" (in which the contraction can be felt to
move in an upward direction)
4
Good squeeze, good hold with lift (the contraction must be able to be
repeated a few times)
5 Strong squeeze, good lift, repeatable
One important observation with success of Kegel exercise is the identification of the correct musculature
contraction by a specialized Physical Therapist. Approximately 19% to 31% of women who believe they
perform Kegels actually perform them correctly. The woman is instructed to contract her muscles
around the examiners fingers while the examiner determines if the patient is using auxiliary muscles like
the abdomen, gluteals, or thighs. Bearing down is a common mistake when asked to perform a pelvic
muscle contraction. Once the women has achieved holding the outer layer of the pelvic floor
(bulbocavernosus and ischiocavernosis) in conjunction with higher level muscles like the levator ani, she
should attempt to hold both for ten seconds. An article by Lianne Herbruck listed a chart of instructions
that summate the correct Kegel exercise procedure for pelvic floor muscle training.
Proper Performance of Kegel Exercises for Pelvic Floor Muscle Training

9. 9
Kegel exercises are performed to strengthen the muscles of the pelvic floor to help increase
support of the bladder and the urethra. They also can be used postpartum to facilitate
circulation to the perineum, which promotes faster healing and increases pelvic floor muscle
tone.
Have the woman contract the muscles in the perineum/pelvic floor as if she is trying to
prevent passage of intestinal gas. (The old adage of "stopping the flow of urine" can actually
encourage retention and cause dysfunction of the micturation reflex).
She should feel the muscles draw upward and inward.
She should avoid straining or bearing-down motions while performing the contractions.
(This can be avoided by exhaling gently with an open mouth as she contracts the muscles.)
Contractions should be intense, but should not involve abdomen, thighs, or buttocks.
The woman should be able to hold this contraction for 5 to 10 seconds, but may need to
work up to that.
The woman should rest for 10 seconds between contractions.
Kegels should be performed at least 10 times, 3 times a day, or from 30 to 80 times a day.
Current research prescribes a frequency of 30 contraction per day with an emphasis on increasing the strength
and intensity of the contraction. A greater emphasis is placed on devoting a particular time to exercise and
gradually increasing the amount and intensity of the exercise. Though these exercises can improve function,
they cannot reverse a Grade 3 or 4 uterine prolapse. These exercises are often indicated as treatment for stress
urinary incontinence, pelvic organ prolapse, pelvic pain and defecatory dysfunction.
Vaginal Cones
This exercise is used as a adjunct to contraction exercises of the pelvic floor. The patient inserts weighted
cones into the vagina and is instructed to maintain the position of the weighted cone. This method provides
proprioceptive feedback to desired pelvic sustained contraction.[21]
This is thought to help improve the tone
through active and sustained muscle contraction.[20]
Colpexin Sphere
The Colpexin Sphere is an intravaginal device that provides support to the pelvic floor musculature and assists
in elevation for more effective pelvic floor musculature exercises. "The Colpexin Sphere is a smooth, round
sphere made of medical grade polycarbonate plastic with an attached braided nylon string for easy removal. It
provides dual benefits for the management of pelvic organ prolapse and improvement of pelvic floor muscle
weakness. The Colpexin Sphere is available only by prescription."[24]
This is especially helpful for those who
have urinary incontinence in association with uterine prolapse. This device is appropriate for candidates who
prefer a conservative approach to pelvic floor prolapse management and urinary incontinence.
Biofeedback
Biofeedback is used to detect and amplify internal physiological events and conditions using a monitoring
instrument. This training helps to develop conscious control over these body processes. The objectives are to
assist patients in gaining greater awareness and voluntary control over muscular control and contraction. This

10. 10
allows for a refined control of pelvic floor musculature for functional training. This technique uses a color
video screen connected to a computerized unit which monitors different channels using intravaginal probe or
surface electrodes depending on the muscles being selected.[21]
The identification of the levator ani is
important with contraction during the Kegel exercises. If they are weak or absent, physical therapy is indicated.
Behavioral modification
This technique is used to bring attention to the possible interactions between the patient's symptoms and their
environment and provide techniques for behavioral modification. Such techniques consist of conditioning,
fluid intake regulation, and use of devices. Bladder training is used for patients with associated incontinence
for bladder prompted training, bladder drills, bladder habit training, and bladder retraining. In bladder
retraining the patient is to keep a record of voiding activity over seven days and gradually increase increments
between urination toward a normal three hour interval. The patient attempts to resist the urge to urinate by
squeezing the pelvic floor and sphincter muscles until the urge resolves.
Electrical Stimulation
Electrical stimulation is used to inhibit the micturition reflex and contract pelvic floor muscles. Using a vaginal
or anal probe, the electrical stimulation produces a contraction of the levator ani muscle. Electrical stimulation
is also used based on the theory that low-level electrical currents might re-innervate the pelvic floor and
change the ratio of slow-to-fast-twitch muscle fibers. Electrostimulation is used in treatment of stress
incontinence, enhancing the periurethral sphincter and urge incontinence, inhibiting the overactive detruser
muscle. There are no side-effects except some discomfort but it is contraindicated for pregnancy, vaginal
infection, retention and demand pacemaker.
Education
Other Advice
Methods considered in association with pelvic floor muscle strengthening are:
 weight loss for preventative measures, smoking cessation.
 treatment of constipation to decrease intra-abdominal pressure.
 adequate hydration, increased fiber intake.
 developing regular bowel habits, regular exercise.
 hormone replacement therapy.
 Education for the use of tight undergarments to help support and relieve symptoms of the
prolapse.
Differential Diagnosis
Cystocele: herniation of the urinary bladder into the vagina
Retrocele: herniation of the rectum into the vagina. Part of the rectum protrudes into the posterior wall of
the vagina forming a pouch in the intestine.

11. 11
Cystourethrocele: bladder and urethra prolapse into the vagina
Urethrocele: bladder neck prolapses into the vagina
Enterocele: Part of the intestine and peritoneum prolapses into the vagina.
Bibliography:-
1. Basvanthappa B.T : “TEXT BOOK OF MIDWIFERY AND REPRODUCTIVE
HEALTH NURSING”; first edition 2006, Jaypee brother publication, New Delhi.
Page no; 110-118.
2. Dutta D.C : “TEXT BOOK OF OBTETRICS” ; 6 TH Edition , 2004; New central
book agency publication, Calcutta. Page no: 279-290.
3. Jacob Anamma : “A COMPREHENSIVE TEXT BOOK OF MIDWIFEREEY”;
1stedition 2005; Jaypee brother medical publication; New Delhi, page no:264-
272.
4. Kumari Neelam; (2010); 1st edition; “MIDWIFERY AND GYNAECOLOGICAL
NURSING”; S.vikas and company; Jalandhar city; Page no :356-364.
5. Myles “ TEXT BOOK OF MIDWIVES” ; Fourteenth edition, 2003; Elsevier
publisher, Philadelphia. Page no; 285-287.
6. Rao Kamini “TEXT BOOK OF MIDWIFERY AND OBSTETRICS FOR
NURSES”; First edition, 2011, Elsevier publisher, Philadelphia. Page no: 277-
281.
Internet resources:-
1. http://www.en.wikipedia
2. http://www.medscape.com/viewarticle/551032_4
3. http://www.healthline.com
4. http://www.ncbi.nlm.nih.gov/pubmed/19089770
5. http://www.lexic.us
6. http://www.empowher.com/media
7. http://www.pregmed.org