Uterine prolapse was first documented in ancient Egypt. The first successful vaginal hysterectomy to treat uterine prolapse was self-performed in 1670. Pelvic organ prolapse has a lifetime risk of around 11% requiring surgery. The uterus is normally supported by the endopelvic fascia, ligaments, and pelvic floor muscles. Prolapse can involve the bladder, uterus, rectum, or vagina descending from their normal positions. Conservative treatment includes pessaries while surgical repair is also used to manage uterine prolapse.

1. DR POLY BEGUM
ASSISTANT PROFESSOR
DEPERTMENT OF OBSTETRICS & GYNECOLOGY
DIABETIC ASSOCIATION MEDICAL COLLEGE
FARIDPUR
Utero-Vaginal Prolapse

2. INTRODUCTION
Uterine prolase was first recorded on the Kahun Papyri in
about 2000 BC. The first successful vaginal hysterectomy
for the cure of UP was self-performed by a peasant
woman named Faith Raworth, as described by Willouby
in 1670. She was so debilitated by UP that she pulled
down on the cervix and slashed off the prolapse with a
sharp knife. She survived the hemorrhage and continued
to live the rest of her life debilitated by UI. From the early
1800s through the turn of the century, other successful
surgical approaches were used to treat this condition.
August 31, 2015
2
Dr Poly Begum

3. Frequency
The exact prevalence of pelvic organ prolapse is
difficult to determination. However, it is
estimated that the lifetime risk of requiring at
least one operation to correct incontinence or
prolapse is approximately 11%.
August 31, 2015
3
Dr Poly Begum

4. ANATOMY
The uterus is normally anteverted, anteflexed.
Version: is the angle between the longitudinal
axis of cervix, and that of the vagina.
Flexion: is the angle between the longitudinal
axis of the uterus, and that of the cervix.
The external os lies at the level of ishchial
spines.
August 31, 2015
4
Dr Poly Begum

5. Supports of Uterus
The uterus is held in this position and at this level
by supports conveniently grouped under three tier
systems.
UPPER TIER: It primarily maintained the
anteverted position. The responsible structures are:
 Endopelvic fascia covering the uterus.
 Round ligaments.
 Broad ligaments with intervening pelvic cellular
tissues.
August 31, 2015
5
Dr Poly Begum

6. Supports of Uterus
MIDDLE TIER: The strongest support of uterus.
The responsible structures are :
Pericervical ring- it includes pubocervical
ligaments and vesicovaginal septum anteriorly,
cardinal ligaments laterally, uterosacral
ligaments and the rectovaginal septum
posteriorly.
Pelvic cellular tissues.
August 31, 2015
6
Dr Poly Begum

7. Supports of Uterus
INFERIOR TIER: This gives the indirect support
to uterus. It is principally given by the pelvic
floor muscles (Levator Ani), Endopelvic fascia,
Perineal body and Urogenital diaphragm.
August 31, 2015
7
Dr Poly Begum

8. August 31, 2015
8
Dr Poly Begum

9. August 31, 2015
9
Dr Poly Begum

10. Genital Prolapse
• Genital prolapse is the descent of one or more of
the genital organ (urethra, bladder, uterus,
rectum or Pouch of Douglas or rectouterine
pouch) through the fasciomuscular pelvic floor
below their normal level
• Vaginal prolapse can occur without uterine
prolapse but the uterus cannot descend without
carrying the vagina with it.
August 31, 2015
10
Dr Poly Begum

11. Anterior vaginal wall prolapse
Prolapse of the upper part of the anterior vaginal
wall with the base of the bladder is called
cystocele
 Prolapse of the lower part of the anterior
vaginal wall with the urethra is called
urethrocele.
Complete anterior vaginal wall prolapse is
called cysto-urethrocele.
August 31, 2015
11
Dr Poly Begum

12. Anterior vaginal wall prolapse
Weakness in the
Supports of the bladder neck
Urethero vesical junction
Proximal urethra
Caused by
Weakness of pubocervical fascia and
pubourethral ligaments
August 31, 2015
12
Dr Poly Begum

13. August 31, 2015
13
Dr Poly Begum

14. Middle compartment defect
Enterocele and eversion of vagina
Enterocele (Herniation of POD)
August 31, 2015
14
Dr Poly Begum

15. Posterior compartment defect
Rectocele
Perineal body descent
August 31, 2015
15
Dr Poly Begum

16. August 31, 2015
16
Dr Poly Begum

17. Uterine descent
• Utero-vaginal (the uterus descends first
followed by the vagina): This usually occurs in
cases of virginal and nulliparous prolapse due to
congenital weakness of the cervical ligaments.
• Vagino-uterine (the vagina descends first
followed by the uterus):This usually occurs in
cases of prolapse resulting from obstetric trauma.
August 31, 2015
17
Dr Poly Begum

18. Degree of uterine descent
• 1st degree: The cervix descends below its
normal level on straining but does not protrude
from the vulva. The external os still remains
inside the vagina.
• 2nd degree: The external os protrudes outside
the vaginal introitus but the uterine body still
remains inside the vagina.
• 3rd degree: The uterine cervix and body
descends to lie outside the introitus.
• Procidentia- involves prolapse of the uterus
with eversion of the entire vagina.
August 31, 2015
18
Dr Poly Begum

19. August 31, 2015
19
Dr Poly Begum

20. August 31, 2015
20
Dr Poly Begum

21. Vault prolapse
Descent of the vaginal vault, where the top
of the vagina descends (or inversion of the
vagina) after hysterectomy.
August 31, 2015
21
Dr Poly Begum

22. August 31, 2015
22
Dr Poly Begum

23. Pelvic organ prolapse quantitative
(POPQ) exam
In 1996, by the ICS
POPQ system describes the location and
severity of prolapse using segments of the
vaginal wall and external genitalia, rather
than the terms cystocele, rectocele, and
enterocele
August 31, 2015
23
Dr Poly Begum

24. Aetiology of Prolapse
The primary cause of prolapse
is weakness of the supporting structures of the
uterus and vagina, usually as a result of the
trauma of childbirth
August 31, 2015
24
Dr Poly Begum

25. Precipitating factors
 ↑ intra abdominal pressure
 ↑ weight of the uterus
 Traction of the uterus by vaginal prolapse or by a large cervical
polyp
 Obesity(40%--75%)
 Smoking
 Pulmonary disease (chronic coughing)
 Constipation (chronic straining)
 Occupational activities
(frequent or heavy lifting)
August 31, 2015
25
Dr Poly Begum

26. Symptoms of Prolapse
• Pelvic floor disorders become symptomatic
through either of two mechanisms:
1. Mechanical difficulties produced by the
actual prolapse,
2. Bladder or bowel dysfunction, disrupting
either storage or emptying.
August 31, 2015
26
Dr Poly Begum

27. Clinical presentation
• Before actual prolapse. the patient feels a sensation of
weakness in the perineum. particularly towards the end
of the day
• Later the patient notices a mass which appears on
straining. and disappears when she lies down
• Urinary symptoms are common and trouble some even
with slight prolapse:
a) Urgency and frequency by day
b) Stress incontinence
c) Inability to micturate unless the anterior vaginal wall is
pushed upwards by the patient's fingers
d) Frequency when cystitis develops
August 31, 2015
27
Dr Poly Begum

28. • Rectal symptoms are not so marked. The patient
always feels heaviness in the rectum and a constant
desire to defaecate. Piles develop from straining.
• Backache, congestive dysmenorrhoea and
menorrhagia are common.
• Leucorrhoea is caused by the congestion and
associated by chronic cervicitis.
• Associated decubitus ulcer may result in discharge
which may be purulent or blood stained
August 31, 2015
28
Dr Poly Begum

29. Diagnostic approach
Beginning with a careful inspection of the vulva
and vagina to identify erosions, ulcerations, or
other lesions
The extent of prolapse should be systematically
assessed
August 31, 2015
29
Dr Poly Begum

30. Examination
• Local examination
• Per speculum examination
• Per vaginal/ Bimanual examination
• Bonney’s stress test
• Evaluation of tone of pelvic muscles
• Recto vaginal examination
• Position of patient for examination
- standing & straining
- dorsal lithotomy
August 31, 2015
30
Dr Poly Begum

31. Diagnostic approach
The maximal extent of prolapse is demonstrated
with a standing straining examination when the
bladder is empty.
Pelvic muscle function should be assessed after
the bimanual examination → palpate the pelvic
muscles a few centimeters inside the hymen,
along pelvic sidewalls at the 4 & 8 o’clock.
Resting tone & voluntary contraction of the
anal sphincters should be assessed during
rectovaginal examination.
August 31, 2015
31
Dr Poly Begum

32. Evaluation of pelvic floor tone
Place 1 or 2 fingers in the vagina and instruct the patient
to contract her pelvic floor muscles (i.e., the levator ani
muscles). Then gauge her ability to contract these
muscles, as well as the strength, symmetry, and duration
of the contraction.
The strength of the contraction can be subjectively
graded with a modified Oxford scale (0 = no contraction,
1 = flicker, 2 = weak, 3 = moderate, 4 = good, 5 =
strong).
August 31, 2015
32
Dr Poly Begum

33. COMPLICATIONS
Keratinization of the vagina.
Decubitus ulceration
Hypertrophy of the cervix
Obstructive lession of urinary tract, Hydroureter,
Hydronephrosis.
UTI, Renal failure
Incarceration of the prolapse.
August 31, 2015
33
Dr Poly Begum

34. MANAGEMENT
A) Preventive.
B) Conservative.
C) Surgery.
August 31, 2015
34
Dr Poly Begum

35. Prevention
During labour & puerperium
 Avoid premature bearing down
 Avoid long second stage
 Repairs all tears &incisions accurately in layers
 Use delayed absorbable suture
 Do not express the uterus when attempting to
deliver placenta
 Encourage pelvic floor exercise
 Avoid puerperal constipation-decreases bearing
down
August 31, 2015
35
Dr Poly Begum

36. Prevention
At hysterectomy
Vault suspension with uterosacral and cardinal
ligaments.
Obliteration of deep cul-de –sac by
Moschowitz sutures.
Sacropexy in high risk situations like collagen
disorders.
Increase acceptability of estrogen replacement
therapy.
August 31, 2015
36
Dr Poly Begum

37. Treatment of Prolapse
Conservative treatment:
Palliative treatment by wearing a pessary is indicated in the following
conditions:
1) Slight degrees of prolapse in young patients. Operation should be postponed
until the woman has had a sufficient number of children as long as the
symptoms are mild.
2) Prolapse of the uterus in early pregnancy. The pessary is worn until the end
of the fourth month until size of the uterus will be sufficient to prevent its
descent.
3) Contraindications to operations as lactation, severe cough , or
patients refusing surgical repair.
4) Bad surgical risks as old patient with advanced diabetes or severe
hypertension.
August 31, 2015
37
Dr Poly Begum

38. Pessary
During pregnancy
Immediately after pregnancy, during lactation
When future childbearing is intended in near
future
Refusal to operation by patient
To promote healing in a decubitas ulcer
August 31, 2015
38
Dr Poly Begum

39. Pessary
August 31, 2015Dr Poly Begum
39

40. Pessary in situ
August 31, 2015
40
Dr Poly Begum

41. Complications of pessary
Constipation
Urinary incontinance
B.vaginitis, ulceration of vaginal wall
Cervicitis
Carcinoma of vaginal wall
Impaction of pessary
Strangulation of prolapsed tissue
August 31, 2015
41
Dr Poly Begum

42. Associated decubitus ulcer
To relieve congestion, the prolapse can be
reposited in the vagina with the help of
tompoons or pessary and this helps in
healing of the ulcer
Hygroscopic agents like acriflavin-
glycerine can help reduce the congestion
further
August 31, 2015
42
Dr Poly Begum

43. Aim of pelvic reconstructive surgery
To restore anatomy, maintain or restore
visceral function, and maintain or restore
normal sexual function.
August 31, 2015
43
Dr Poly Begum

44. Uterine descent- surgeries
Vaginal hysterectomy
Sling surgeries
 Shirodkar
 Khanna’s
 Purandares
Fothergill’s surgery
August 31, 2015
44
Dr Poly Begum

45. Genital Prolapse in Pregnancy
Effects on prolapse:
There is aggravation of the morbid anatomical changes in
prolapse such as marked hypertrophy and edema of cervix
First degree become second degree
Cystocoele and Rectocoele become pronounced.
Effects on pregnancy:
There is increased chance of -
Abortion Chorioamniotis
PROM Prolong labour
Operative interference Sub-involution
August 31, 2015
45
Dr Poly Begum

46. Treatment
During pregnancy:
If the cervix is outside the introitus - it is to be replaced
inside the vagina and is kept in position by a ring
pessary.
The patient is to lie in bed with the foot end raised.
During Labour:
The patient should be in bed.
If the head is high up and /or cervix remains
odematous, thick or undilated – Caesarean section is a
safe procedure.
August 31, 2015
46
Dr Poly Begum

47. Thank You
August 31, 2015
47
Dr Poly Begum