Utero vaginal prolapse
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This document discusses uterovaginal prolapse (UVP), including its anatomy, causes, symptoms, diagnosis, and treatment options. The main supports of the uterus and vagina are the cardinal and uterosacral ligaments. UVP is usually caused by weakening of these supports due to childbirth, menopause, or congenital factors. Common symptoms include a feeling of something coming out of the vagina and urinary or bowel issues. Treatment involves pelvic floor exercises, pessaries, or surgery depending on the severity of prolapse. Surgery is the only curative treatment for UVP.
Utero vaginal prolapse
- 1. Uterovaginal prolapseUterovaginal prolapse By Usman Saeed 08-204 Batch- k
- 3. Normal postion of uterus andNormal postion of uterus and vaginavagina The uterus and vagina lies in middle of pelvis. Anteriorly: urinary bladder and urethra. Posteriorly: colon,rectum and anal canal. The perineal body is interposed b/w lower part of the posterior vaginal wall and the anal canal. In 80 % of women the uterus is anteverted and anteflexed In 20% of women it may be retoverted
- 4. Position of uterusPosition of uterus Retroverted uterus Anteverted uterus
- 5. Supports of uterus and vaginaSupports of uterus and vagina uterine supportsuterine supports Cardinal ligaments: major support of uterus and vault of vagina.. Attached medially to supravaginal part of the cervix and vault of vagina and laterally to lateral pelvic wall. Uterosacral ligament: responsible for keeping uterus in anteverted postion Attached anteriorly to supra vaginal party of cervix and vault of vagina and posteriorly to fascia in front of sacral vertebrae Pubocervical fascia: extension of cardinal ligaments This fascia is attached to supravaginal part of cervix ,runs forward below the base of bladder ,splits into two to allow for the passage of urethra and is attached to the body of pubic bones
- 7. Pelvic ligaments under stretchPelvic ligaments under stretch during prolpaseduring prolpase
- 8. Vaginal supportVaginal support Cardinal ligments:on each side attached to vault of vagina and supravaginal part of cervix. Levator ani muscles:provide support to lower part of vagina Uroginetal diaphram and perianal muscles : hold vagina in its postion Pubocervical fascia: provide support to anterior vaginal wall Perineal body and rectovaginal fascia: the structures support the posterior vaginal wall Posterior vaginal wall: provide support to anterior vaginal wall in erect postion
- 9. uterovaginal prolapseuterovaginal prolapse Uterine prolapse :is the condition of the uterus collapsing, falling down, or downward displacement of the uterus with relation to the vagina. It is also defined as the bulging of the uterus into the vagina Vaginal prolapse :is characterized by a portion of the vaginal canal protruding from the opening of the vagina. There maybe prolapse of both uterus and vagina, or only of vagina.
- 11. terminologyterminology 1.anterior vaginal wall prolapse 2.posterior vaginal wall prolapse 3.uterine prolapse 4.vaginal vault prolapse(after hysterectomy)
- 12. ANTERIOR VAGINAL WALL PROLAPSEANTERIOR VAGINAL WALL PROLAPSE Cystocele : Descent of upper 2/3 of the anterior vaginal wall all along with base of the bladder Urethrocele: Descent of lower 1/3 of the anterior vaginal wall along with the uretheral displacement Cysto-urethrocele: Prolapse of entire anterior vaginal wall
- 13. cystocele urethrocele Anterior vaginal wall prolapseAnterior vaginal wall prolapse
- 14. Posterior vaginal wall prolpasePosterior vaginal wall prolpase Enterocele : Prolapse of the upper 1/3 of the posterior vaginal wall Due to close proximity of pouch of douglas to the posterior fornix of vagina , it also descents along with prolpase of upper part of the vagina. Rectocele: Prolapse of lower 2/3 of the posterior vaginal wall along with lower part of the rectum
- 15. Posterior vaginal wall prolpasePosterior vaginal wall prolpase enterocele rectocele
- 16. classification and gradingclassification and grading The anterior and posterior vaginal wall prolapse is usually described as Minor degree Moderate degree Major degree
- 17. Various termiologies have been used to classifyVarious termiologies have been used to classify the UV prolpase .the latest was described in 1996the UV prolpase .the latest was described in 1996 which is as followswhich is as follows Stage 0:no descent of pelvic organ during straining Stage 1:leading surface of prolapse descends upto 1 cm above the hymen ring Stage 2 :leading surface of the prolapse descents upto the point 1 cm below the hymen ring Stage 3:descent s beyond the stage 2 but without complete vaginal eversion Stage 4 :the vagina is completely everted and the fundus of uterus lies below the introitus of the vagina
- 18. Causes of uterovaginal prolapseCauses of uterovaginal prolapse UV prolapse is primarily due to the weakness of the support , it maybe because of the following causes: 1.congenital weakness 2.acquired defect 3.menopause atrophy 4.activiting factors
- 19. EtiologyEtiology Congenital weakness Most important cause of uv prolapse in nulliparous women Inherent weakness of support in members of same family Racial and genetic factor(most common in white races) Patients with spina bifida are prone to have have prolapse
- 20. EtiologyEtiology Acquired defect Multiparous (99 percent) Due to overstretching of the ligaments or injury to nerves and supports Vaginal birth not only weakens the uterine support but it also predisposes to high risk of urinary and feacal incontinence Prolong labour Forcep delivery Pressure on fundus during delivery of the placenta(Crede’s method) Puedendal nerve injury during child birth ventouse ( vaccum extractor)
- 21. causescauses Menopausal atropy Atrophy of the genital tract and its supports due to withdrawal of estrogen , after menopause The prolapse is seen usually within 1-2 years of menopause Null-parous UV prolapse also get worsen after the menopause Activiting factors Increased intra-abdominal pressure(chronic cough , chronic constipation , ascities etc) Small fibroids Pelvic tumors
- 22. pathologypathology In the case of UV prolpase , in addition to descent of uterus and prolapse of the vaginal wall , following changes may take place Elongation and hypertropy of the cervix Keritinization of the vaginal epithelium Decubitus ulceration Incarcenation of of the prolpase part Complication of urinary tract - residual urine increase (due to bladder downward displacement) - urinary tract infection (due to stagnation of urine) - bladder hypertrophy due to straining during micturation
- 23. symptomssymptoms Common complaints are Something coming out of vagina(commonest symptom) Lower abdominal pain (dull &dragging) Backache (relieved by lying in the bed) Vaginal discharge (luecorrhea) Urinary symptoms frequency of micturation difficulty in micturation stress incontinence acute retention of urine Difficulty in empting of bowels Coital difficulties
- 24. signssigns Usually visible during inspection of vulva Patients having stress incontinence should be observed with full bladder Rectal examination will also differentiate between rectocele and enterocele.
- 25. differential diagnosesdifferential diagnoses Cystic swelling in the vagina Polypoidal growth Chronic inversion of the uterus Hypertropy of the cervix All other causes of low backache and urinary symptoms
- 26. treatmenttreatment The treatment of UV prolapse is described under the following headings. 1.prevention 2.physiotherapy 3.pessary 4.surgical treatment
- 27. preventionprevention Repeated childbirth with short intervals cause UV prolapse • Women should be advised to avoid pregnancies in quick succesion Labour • 1st stage ▫ Avoid bearing down ▫ Breech or forceps delivery before full dilatation of cervix shouldn’t be attempted • 2nd stage ▫ Avoid prolongation of this stage ▫ Perform episiotomy if tears or overstretching of perineum is feared • 3rd stage ▫ Avoid Crede’s method ▫ Episiotomy or tears should be carefully sutured Puerperium • Treat chronic cough and constipation • Avoid strenuous exercises and standing for prolonged time
- 28. physiotherapyphysiotherapy Early cases of UV prolapse are helped by pelvic floor exercises Particularly during puerperium and while waiting to undergo surgical treatment. Kegel exercises are used to tone up pelvic musculature These exercises are done 3 times a day for 20 min each
- 29. pessary treatmentpessary treatment A mechanical device for correcting and controlling UV prolapse A pessary does not cure UV prolpase It only holds the genital tract in position Advised for patients who cannot undergo surgery Types 1.Ring pessary 2.Hodge pessary Indications During pregnancy (1st trimester) During puerperium Unfit for surgical treatment Patient’s choice
- 30. pessary treatmentpessary treatment Management Choice of pessary ( ring pessaries commonly used) Size (depends upon size of vagina) Sterilization Insertion before insertion the pessary is kept in hot water for few minutes so that pessary become soft and easy to insert Follow up pessary should be removed ,cleaned and reinserted at regular intervals of 6-12 months.
- 31. different types of pessariesdifferent types of pessaries
- 33. Surgical treatmentSurgical treatment Only curative treatment Unless there is any contraindication for surgical treatment ,all cases of UV prolapse should be treated surgically Preparation before surgery 1.general health: good physical and mental health is essential for post op recovery 2.medical and surgical disease chronic cough and any other illness should be treated before hand 3.RFTS , ultrasound , MRI & pelvic flouroscopy to find relationship b/w the prolpase and urinary symptoms 4. local infection like vaginitis & cervicitis should be treated 5. hormonal treatment especially in postmenopausal prolpase
- 34. Surgical treatmentSurgical treatment operationsoperations Anterior Colporrhaphy – for anterior vaginal wall prolapse. Posterior Colporrhaphy – for repair of the posterior vaginal wall and perineum. Manchester Repair (Fothergill’s Operation) – for repair of uterovaginal prolapse. Carried out in women of child bearing age and haven’t completed their families and insist on preservation of uterus
- 35. Surgical treatmentSurgical treatment Vaginal Hysterectomy – most common operation and its indications are: - Post-menopausal prolapse -Uterine pathology like small fibroids or adenomyosis -Menstrual disorders such as dysfunctional uterine bleeding -Prolapse during childbearing age , after completion of family Burch Operation – for relief of symptoms of cystocele.
- 36. Surgical treatmentSurgical treatment Sling Operations – for cervical descent of young and nulliparous patients. It has following types: Shirodkar’s sling operation Purandare’s cervicopexy Sling operation for vaginal vault prolapse Laproscopic Repair – sacrocolpopexy, a simple procedure to cure enterocele and vault prolapse. Le Forte’s Operation – for treatment of UV prolapse in very old patients. Perfectly devised to reduce operating time.
- 37. Outcome of surgical treamentOutcome of surgical treament Cures approximately 90 percent of patients. Only 10 percent may require a second operation or other treatment. 2-3% may get stress incontinence as a result of operative treatment. 25% of patients may complain of dyspareunia, that has undergone colporrhaphies , due to narrowing of the introitus and vagina.
- 38. Pregnancy after operationPregnancy after operation High incidence of infertility following manchester repair. Other comlications include ◦ Abortion due to cervical incompetence ◦ Premature Labour ◦ Precipitate Labour or Cervical dystocia ◦ Prolonged Second Stage ◦ Tears of vagina and perineum due to failure of dilatation ◦ Recurrence of prolapse due to overstreched of uterine and vaginal support. Management of pregnancy Patient can get pregnant following a Manchester repair. The patient may deliver normally but in view of the risk the mode of delivery is decided. To avoid recurrence of prolapse C-section must be performed.