UV PROLAPSE

1. DR AMRIN
ASSISTANT PROFESSOR
DEPERTMENT OF OBSTETRICS & GYNECOLOGY
Utero-Vaginal Prolapse

2. 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.

3. 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.
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4. Supports of Uterus
MIDDLE TIER: The strongest support of uterus.
The responsible structures are :
● Pericervical ring- it includes pubocervical
ligaments and vesicovaginal septum anteriorly,
ligaments laterally, uterosacral
and the rectovaginal septum
cardinal
ligaments
posteriorly.
● Pelvic cellular tissues.
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5. 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.
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Dr PolyBegum August 31, 2015

8. 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.
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9. 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.
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10. 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
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Dr PolyBegum August 31, 2015

12. Middle compartment defect
● Enterocele and eversion of vagina
● Enterocele (Herniation of POD)
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13. Posterior compartment defect
● Rectocele
● Perineal body descent
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15. Uterine descent
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.
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• Utero-vaginal (the uterus descends

16. 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.
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19. Vault prolapse
●Descent of the vaginal vault, where the top
of the vagina descends (or inversion of the
vagina) after hysterectomy.
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21. ● 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
Pelvic organ prolapse quantitative (POPQ)
exam
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22. 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
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23. 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)
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24. 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.
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25. 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
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26. • 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
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27. 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
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28. 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
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29. 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.
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30. 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).
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31. 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.
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32. MANAGEMENT
A) Preventive.
B) Conservative.
C) Surgery.
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33. 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
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34. Prevention
Dr PolyBegum August 31, 2015
● 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.
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35. Treatment of Prolapse
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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.

36. 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
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37. Pessary
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August 31, 2015
Dr Poly Begum

38. Pessary in situ
August 31, 2015
Dr Poly Begum
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39. Complications of pessary
● Constipation
● Urinary incontinance
● B.vaginitis, ulceration of vaginal wall
● Cervicitis
● Carcinoma of vaginal wall
● Impaction of pessary
● Strangulation of prolapsed tissue
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40. 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
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41. Aim of pelvic reconstructive surgery
To restore anatomy, maintain or restore
visceral function, and maintain or restore
normal sexual function.
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42. Uterine descent- surgeries
m
● Vaginal hysterectomy
● Sling surgeries
⦁ Shirodkar
⦁ Khanna’s
⦁ Purandares
● Fothergill’s surgery
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43. 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
PROM
Operative interference
Chorioamniotis
Prolong labour
Sub-involution
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44. 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.
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45. Thank You
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