This document discusses uterine prolapse, including its definition as the downward displacement of the uterus from its normal position. The supports of the uterus are described in three levels, with the first level being the uterosacral and cardinal ligaments. Aetiology of prolapse includes factors like mismanaged childbirth, hormonal changes after menopause, pelvic trauma, and conditions that increase intra-abdominal pressure. Symptoms involve a feeling of protrusion, backache, urinary issues, and difficulties with intercourse. Examination involves inspecting for cystocele, urethrocele, enterocele or rectocele, and assessing the reducibility and tone of the prolapsed tissues.

1. UTERINE PROLAPSE
DHYAN DAVID SV

2. Contents
o Definition
o Supports of Uterus
o Aetiology
o Classification of Prolapse
o Symptoms
o Clinical Examination

3. Definition
o Uterine prolapse is the Downward displacement of uterus
from its normal position.
o Associated with prolapse of anterior and posterior vaginal
wall, due to its close relationship.
o Common condition among elderly women.

4. Supports of Uterus – “Position of Uterus”
Anteversion & Anteflexion

5. Supports of Uterus – “Mechanical”
DeLancey’s three levels of Supports of Uterus.
o LEVEL 1 – Uterosacral Ligament & Cardinal Ligament. (Supports the
Uterus and Vaginal vault)
o LEVEL 2 –
Pubocervical Fascia (Anteriorly)
Rectovaginal Fascia (Posteriorly)
Levator Ani Muscle (arcus tendinous fasciae pelvis)
Connects the vagina to the lateral pelvic wall through this fascia
o LEVEL 3 – Levator Ani Muscle (Lower one-third of Vagina)

8. Aetiology
o Mismanaged Child Birth
o Withdrawal of hormonal Support (Oestrogen – after
menopause)
o Pelvic Trauma (Rare)
o Nerve damage in pelvis (Rare)
o Conditions causing increased Intra-abdominal pressure –
Chronic Constipation, Chronic obstructive airway disease.

9. Aetiology
o Prolonged labour
o Congenital weakness
o Perineal tear
o Pudendal nerve Injury
o Big Baby
o Multiparity

10. Mismanaged Child Birth
o Prolonged BEARING DOWN EFFORTS in First stage
of Labour before full dilatation of cervix
o Forceps Application before full dilatation of cervix
o Birth of Big-sized baby
o Early resumption of physical activity.
o Lifting heavy weights.

11. Menopause
o In Reproductive age, the muscles and the ligaments
are kept in tone under the influence of oestrogen.
o IN MENOPAUSE
o DECLINE IN ESTROGEN LEVEL
o LOSS OF TONE IN MUSCLE & RELAXATION OF
LIGAMENTOUS SUPPORT
o PROLAPSE

12. Classification of Prolapse
Two Classification System are used.
o Uterovaginal Prolapse System
o Pelvic Organ Prolapse Quantification system

13. Uterovaginal Prolapse System.
A. Anterior Vaginal Wall
B. Posterior Vaginal Wall
Upper Two-third – CYSTOCELE
Lower One-third – URETHROCELE
Upper One-third – ENTEROCELE (POD)
Lower Two-third – RECTOCELE

15. Uterovaginal Prolapse System.
 Uterine Descent
Descent of CERVIX INTO VAGINA
Descent of CERVIX UPTO INTROITUS
Descent of CERVIX OUTSIDE THE INTROITUS
Entire Uterus OUTSIDE INTRITUS - PROCIDENTIA

17. POP – Q System

18. DECUBITUS ULCER
o Keratinization and pigmentation of the Vaginal mucosa
with ulceration of the prolapsed tissue due to FRICTION,
CONGESTION & CIRCULATORY CHANGES in the dependent
part of the prolapse.
o Treated with reduction of the prolapse and packing with
Tampon soaked in Acriflavin or Betadine solution.

19. SYMPTOMS OF PROLAPSE
o Patient complains of protrusion of a mass within the
vagina or outside the vagina
o Aggravated on straining and coughing
oReduces itself on when the patient lies down.
o Vague mid-sacral discomfort and backache (end of the
day)
o Vaginal Discharge – due to inflamed lacerated cervix or
decubitus ulcer.

20. SYMPTOMS OF PROLAPSE (cntnu…
o Urinary Complaint – Damage in 3rd Level Support
 Incomplete evacuation of bladder
 Increased frequency of micturition
 Stress Incontinence of Urine
 In case of Large Cystocele – Difficulty in micturition [the more
they strain the difficult to micturate]
 Splinting – able to pass urine after repositioning prolapse in the
vagina with the help of finger.

21. SYMPTOMS OF PROLAPSE (cntnu…
o Rectal difficulties and Constipation rare (3rd level support
damage)
o Coital difficulties – 3rd Level Support damage and
Procidentia

22. EXAMINATION [Gynae Examination]
INSPECTION
o External genitalia – normal or atrophic
o Cervix - Descent of Cervix and its level [ Level of introitus
or outside the introitus]. Any ulcer in the cervix.
o Vagina - Rugosity and Dryness of vagina (Post-
menopausal features). Look for any ulcers and pigmentation

23. EXAMINATION [Gynae Examination]
INSPECTION
LOOK FOR :
o Cystocele
o Urethrocele
o Enterocele
o Rectocele

24. EXAMINATION [Gynae Examination]
PALPATION :
o Check the reducibility of the mass.
o Get above the fundus of the uterus [ Approximation of the
thumb and other fingers]
o Ulcer – any bleeding? Induration?
 Procidentia – Can be approximated
 3rd Degree Prolapse - Cannot be approximated

25. EXAMINATION [Gynae Examination]
PALPATION :
o Levator ani muscle tone assessment [by palpating the
pubovaginalis muscle]  placing THUMB over the labia
majora and TWO FINGERS on the lower one-third of the
vagina(lateral wall)  ask the patient to contract the muscle
(act of holding the micturition)  thus the tone is assessed.

26. EXAMINATION [Gynae Examination]
PALPATION :
o Perineal body Integrity  TWO FINGERS in the Posterior
vaginal wall THUMB IN PERINEUM above anus
BIMANUAL EXAMINATION – to assess uterine size and
position
PER RECTAL EXAMINATION – to assess Rectocele

27. Thank You