Uterine prolapse

1. UTEROVAGINAL
PROLAPSE
BY
DR H. DANIEL

2. UTEROVAGINAL PROLAPSE
 INTRODUCTION
 CLASSIFICATIONS
 ANATOMY OF PELVIC SUPPORT
 AETIOLOGY / PREDISPOSING
FACTORS
 CLINICAL PRESENTATION
 INVESTIGATIONS
 COMPLICATIONS

3. INTRODUCTION
 Definition
 Due to defect in the pelvic supporting structures hence
 Uterus and/or adjacent organs descend from their anatomic confines to
positions within or outside the vaginal introitus
 ◘ Components / Varieties
 ANTERIOR VAGINAL WALL
 Urethra urethrocele
 Bladder - cystocele
 Uterine prolapse / vault prolapse
 POSTERIOR VAGINAL WALL
Rectovaginal pouch - Enterocele
 Rectum - Rectocele

4. Introduction cont.
 Note:
 May occur in combinations, e.g.
 ○ Cystourthrocele: most common
 ○ Eneterocele + Rectocede
 ○ Uterine prolapse + enterocele
 Vaginal prolapse may occur without uterine prolapse
 Uterus cannot prolapse without carrying the upper vagina
 ◘ Prevalence
 Incidence in UPTH- 3.75% ( Ugboma ,Okpani et al)
 Estimates
 ○ Multiparous 12 – 30%
 ○ Nullipara - 2%
 Less among black women compared with white
 Increase in the elderly / postmenopausal women

5. CLASSIFCATION
 2. CLASSIFICATION: staging systems
 ◘ Conventionally
 Cervix is reference point
 Degrees (grades)
 ○ 1st degree – cervix within vagina
 ○ 2nd degree – cervix at introitus
 ○ 3rd degree – outside introitus, at the vulva- procidentia
 ◘ Shaw’s classification- same as above
-Additional 4th degree – procidentia
 ◘ Baden’s Classification
 Hymen is reference point
 Grades 0 to 4 for each component

6.  POP – Q (Pelvic Organ Prolapse Quantification) Staging
System
 Devised by International Continence Society (ICS) in 1996
 Standardization of terminology / reports lacked in other grading
systems.
 Hymen is the fixed reference point from which measurements are
made
 Staging
 ○ Measurements (in cm) – defined sites (9) on the vag. walls
and perineum
 ○ Stages 0: No prolapse (-3cm)
 I : > 1cm above Hymen (< -1cm)
 II: ≤ 1cm above or below Hymen (≥ -1cm but ≤ +1cm)
 III: > 1cm below Hymen but 2cm less than TVL
 (> + 1cm but < + [TVL -2]cm)
IV: ≥ + (TVL -2)cm
○ Specify condition of exam & position of patient
 (eg straining down, traction, standing)

7. ANATOMY OF PELVIC SUPPORT
 Peritoneum: not contributory
 Pelvic fascia
 Pelvic floor muscles
 ◘ Pelvic floor fascia
 Fascia over pelvic floor muscles
 Endopelvic fascia: main support
 ○ Lateral cervical (transverse cervical, cardinal
or Mackenrodt) ligament lat. aspect of cervix /
upper vagina to pelvic side walls
 ○ Uterosacral ligament back of uterus to front
of sacrum

8. ANATOMY CONT.
 ○ Pubocervical ligament (fascia) ant. Aspect of cervix to back of
body of pubis
 ○ Posterior Pubourethral Ligament post. inf. of symphysis pubis
to ant. of middle ⅓ of urethra & bladder
 Pelvic Floor muscles
 ○ Levator ani muscle - (pelvic diaphragm)
 * Pubococcygeus
 * iliococcygeus
Puborectalis
 ○ Coccygeal muscle
 ○ Urogenital diaphragm
 * Superficial Transverse perineal muscles
 * Deep Transverse perineal muscles

9. AETIOLOGY/PREDISPOSING
FACTORS
 ◘ Aetiology
 ▪ Weakness in one or more supports of the uterus and vagina
-Transverse cervical / uterosacral complex uterine prolapse
 -Pubocervical cystocele
- Pubocervical + post. Pubourethral urethrocele
 -Recto vag. fascia / defects in ® and (L) levator ani
 Inherent defect in supports - strong familial incidence
 Acquired factors
 ○ Child birth
 * Single most important factor
 * 7 times high in para 7+
 * Bad obst. Practice

10. AETIOLOGY CONT.
 Ageing
 Menopause
 Increase intra-abdominal pressure
 -COAD
-Ascites
-Tumors *
-Pregnancy: rare
 Surgery – post-hysterectomy
 Congenital factors
 -Weakness of pelvic fascia and conn. Tissues e.g. Ehlers – Danlos
syndrome
 -Congenital shortness of the vagina
 -Deep uterovesical / uterorectal pouches

11. Clinical presentation
◘ History : Symptoms
 Lump in vagina or protruding out of it
 Lower backache
 Frequency of micturition
 Urgency
 Feeling of incomplete voiding / retention of urine
 Stress incontinence
 Difficulty evacuating the bowel
 Digitations rectally or vaginally to empty the bowel
 Discharge / bleeding p/v – decubitus ulcers
 Inquiry of predisposing factors, eg.
 COAD, Parity / mode of deliveries etc.

12. Physical examination
 General – state of health, anaemia, chest/cvs, abd
etc.
 Vaginal examination / speculum examination
 ○ State of vulva / vagina
 ○ Stress incontinence
 ○ Ulcerations – decubitus ulcers
 Identify components – speculum exam
 Rectal exam

13. Differential diagnosis
 ○ Cervical polyp
 ○ Endometrial polyp
 ○ Pedunculated myoma
 ○ Cervical cancer
 ○ Metastasis of uterine cancer
 ○ Urethral diverticulum
 ○ Vaginal wall cyst

14. Investigations
 FBC
 E/U/C
 FBS
 Genotype
 Blood group, X-match
 URINALYSIS /MCS
 CXR
 ECG
Others
 IVP
 Imaging
 Ultrasonography
 Computed tomography (CT)
 MRI
 Videocystourethrography

15. complications
◘Keratinization of vagina
◘Hypertrophy of the cervix
◘Decubitus ulcers – ischaemic changes
◘Recurrent UTI
◘Acute urinary retention
◘Hydorureters / Hydronephrosis
◘Renal failure
◘Incarceration of the prolapse
◘Malignant change: rare

16. THANK YOU