The document outlines the anatomy and classification of uterine and vaginal prolapse, detailing various types and degrees of prolapse, including their etiology and complications. Management strategies are discussed, encompassing medical treatments, such as observation and the use of vaginal pessaries, as well as surgical interventions for prolapse repair. Preventive measures during and after childbirth are also highlighted to mitigate the risks of developing prolapse.

1. Inversion of the Uterus
Sunil Kumar Daha

2. VAGINAL PROLAPSE
(Different degrees of prolapse, Preventive issues and management)

3. Pelvic floor/diagphram

4. 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.

5. Supports of the genital tract
• DeLancey introduced three level systems of support
Level I Uterosacral and cardinal ligaments support the
uterus and vaginal vault
Level II Pelvic fascias and paracolpos which connects the
vagina to the white line on the lateral pelvic wall
through arcus tendinous
Level III Levator ani muscle supports the lower one-third of
vagina

6. Muscular support/ Active
 Pelvic diaphragm
 Perineal body
 Urogenital diaphragm
Functional / mechanical support
 Transverse cervical/cardinal
ligament/ Mackenrodt
ligaments
 Pubocervical ligament
 Sacrocervical ligament

9. Classification

10. Genital Prolapse (down ward displacement)
Genital prolapse is the descent of one or more of the
genital organ (urethra, bladder, uterus, rectum or
Douglas pouch (rectouterine pouch”) through the
fasciomuscular pelvic floor below their normal level.
* Vaginal prolapse can occur without uterine prolapse
but the uterus cannot descent without carrying the
vagina with it.

11. Classification of Prolapse
 Anterior vaginal wall
• Upper 2/3rd : cystosele
• Lower 1/3rd : urethrocele
 Posterior vaginal wall
• Upper 1/3rd : enterocele
• Lower 2/3rd : rectocele
 Uterine prolapse

12. Varieties of Prolapses
Vaginal Prolapse
1) Anterior vaginal wall prolapse
a. Prolapse of the upper part of the anterior vaginal wall
with the base of the bladder is called cystocele.
b. Prolapse of the lower part of the anterior vaginal wall
with the urethra is called urethrocele.
c. Complete anterior vaginal wall prolapse is called
cysto-urethrocele.

15. 2) Posterior vaginal wall prolapse:
a) It is called enterocele (hernia of the pouch of Douglas)
if the upper third of the posterior vaginal wall
descends lined by the peritoneum of the Douglas
pouch and containing loops of the intestine
b)It is called rectocele if the anterior wall of the rectum is
also prolapsed with the middle third of the posterior
vaginal wall.

18. 3) Vault Prolapse:
(descent of the vaginal vault, where the top of the vagina
descends or inversion of the vagina) after hysterectomy
• Vault prolapse is more likely to occur after subtotal than
after total hysterectomy

19. Degrees of VV prolapse
• 1st degree: The vaginal apex is visible at the introitus
• 2nd degree: The vault protrudes through the
introitus
• 3rd degree: the entire vagina is outside the introitus

21. Uterine prolapse
• If the uterus prolapses, there is always some associated
descent of the anterior vaginal wall
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.

22. Degree of prolapse:
• 1st degree: cervix descend into the vagina
N.B.: The external os of the cervix is at the level of the
ischial spines.
• 2nd degree: external os protrudes outside the vaginal
introitus but uterine body still remains inside vagina.
• 3rd degree: cervix and body protrude outside the introitus
• Complex prolapse: prolapse with fecal incontinence,
nulliparous, recurrent, vaginal and rectal or prolapse in a
frail woman.

23. Uterine Prolapse

24. Etiology of prolapse
The most important aetiological factors in prolapse
• Atonicity and Asthenia that follow menopause
• Asthenia as a result of the trauma of childbirth
Main four factors
1. Congenital
2. Age
3. Endocrine
4. Child birth injury

25. • Congenital weakness of the pelvic floor muscles
– Spina bifida occulta
– Split pelvis
• Age
• Endocrine
- oestrogen and collagen deficiency in post
menopausal age

26. • Child birth injury:
– Ventouse extraction before the cervix is fully dilated
– Prolonged bearing down before full cervix dilatation
– Delivery of a big baby
– Rapid succession of pregnancies
– Pudendal nerve injury
• Others
– Raised intra-abdominal pressure
– Abdominoperineal excision of the rectum and radical
vulvectomy
– Multiple sex partner
– Resume heavy work soon after delivery

27. Complications of uterovaginal prolapse
– Kinking of ureter with resultant renal damage can
occur in procidentia and enterocele.
– Cervical infections and bleeding during pregnancy
– Urinary tract infection in large cystocele with residual
urine
– Cancer of vagina rarely reported over the decubitus
ulcer and if ring pessary is left over a long period of
time

28. Decubitus Ulcer
• Keratinization and pigmentation of the vaginal mucosa
as well as ulceration of the prolapsed tissue are caused
by friction, congestion and circulatory changes in
dependent part of the prolapse
• Needs to be differentiated from cancer of cervix
• Apart from cytology and biopsy distinguishing features
are clean edge and heals with reposition and vaginal
packing(gauge with cream)

29. Management

30. Treatment
Medical
• Observation
• Exercise
• Estrogen replacement
• Vaginal pessaries
Surgical

31. Observation:
• is appropriate for women whose symptoms are not
sufficiently bothersome to warrant active
management
• There is no indications for treatment, particularly
surgery, for women with asymptomatic prolapse
– An important consideration is her efficiency of bladder emptying
Exercise : kegel exercise

32. Estrogen replacement:

33. Pessaries
• A device which is inserted into the upper part of the
vagina to provide support to the pelvic structures
Indication for use of pessary
1. Young woman planning a pregnancy
2. During early pregnancy
3. Puerperium
4. A woman unfit for surgery
5. A woman refuses for surgery

36. Limitation of pessary
• Never curative & can only be palliative
• Can cause vaginitis
• Pessary needs to be changed every 3 months
• Not comfortable to some women
• Forgotten pessary can be the cause of ulcer
• Doesn’t cure urinary stress incontinence

37. Surgical
Operations for Vaginal Prolapse
1. Anterior repair (anterior colporrhaphy)
• Correct cystocele or cystourethrocele
• The vaginal skin is divided in the midline, the bladder is
reflected upwards & the pubocervical fascia on either
side inforced with inturrupted sutures, redundant
vaginal skin is excised & vaginal skin is closed
• Post operative urinary retention is common

39. 2. Posterior Colporrhaphy (colpoperineorrhaphy)
• Correct rectocele and repair deficient perineum
• A vertical vaginal wall incision is used to descent the
posterior vaginal wall from the rectum, the edges of
the levator ani muscles are sutured together in the
midline & the posterior vaginal skin is closed

40. 3.Manchester/Fothergill Operation
• Combines anterior colporrhaphy with amputation of
cervix
• Preserves menstrual and child bearing functions
• usually done for the sake of expediency in patients
who are poor surgical risks and who do not desire
future fertility
4.Uteropexy
• suturing mesh or fascia to the uterosacral ligaments
and then to the anterior longitudinal ligament of the
sacrum

41. 5.Vaginal Hysterectomy
• Suitable for women over the age 40
• The advantage of vaginal hysterectomy is that
it allows other vaginal surgery (e.g., anterior and posterior
colporrhaphy or enterocele repair) to be performed at the
same time, without the need for a separate incision or for
repositioning the patient
6. Abdominal Sling Operation (Purandare’s operation)
• Designed for young women with 2nd or 3rd degree prolapse
who are desirous of retaining their child bearing and
menstrual function

42. Prophylaxis of prolapse
1. Proper ante-natal care (before delivery)
• Antenatal physiotherapy, relaxation exercises and
attention to weight gain and anemia
2. Proper intra-natal care (during delivery)
• Avoid aetiological factors as straining during the first
stage(before full cervical dilatation); avoid the
application of forceps before full cervical dilatation.

43. 3. Proper post-natal care (after delivery)
• Accurate repair of perineal tears or episiotomies,
encourage pelvic floor exercises and other postnatal
ex's.
• Provision of adequate rest for 6 months after
delivery
• Reasonable intervals between pregnancies

44. • Konar.H, DC Dutta’s Textbook of obstetrics 8th
edition, Jaypee publication
• Cunningham ,Bloom, Spong, Dashe, Hoffan, Casey,
Sheffield, Williams obstetrics, 24th edition , Mc Graw
Hill education
• Manual of Obstetrics, 3rd Edition
References

45. Thank You