Utero-Vaginal Prolapse

Background
The pelvis encloses organs that
primarily function in storage,
distension and evacuation. The pelvic
viscera must maintain their normal
anatomic relationships within this
cavity so that these physiological
functions can be sustained.

Background
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

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.

Supports of the uterus

DeLancey in 1994 defined three
levels of vaginal support, reviving the
importance of the connective tissue
structures and giving a working basis
for the present day understanding of
the anatomy and surgical treatment.

Three level of Supports

of Uterus
Level I: The cardinal uterosacral
ligament complex
Level II: The pubo- cervical and rectovaginal fascia
Level III: The pubo-urethral ligaments
anteriorly & the perineal body
posteriorly

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.

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

Middle compartment
defect
Enterocele and eversion of vagina
Enterocele (Herniation of POD)

Posterior compartment
defect
Rectocele
Perineal body descent

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.

Degree of uterine
descent

1st degree: The cervix desends below

its normal Ievel on straining but does not
protrude from the vulva (The extemal os
of the cervix is at the level of the ischial
spines)
2nd degree: The cervix reaches upto the
vulva on straining
3rd degree: The cervix protrudes from
the vulva on straining
Procidentia- whole of the uterus is
prolapsed outside the vulva and the
vaginal wall becomes most completely
inverted over it. Enterocele is usually
present

Vault prolapse
Descent of the vaginal vault, where
the top of the vagina descends )or
inversion of the vagina) after
hysterectomy

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

Aetiology
Erect posture causes increased stress on
muscles, nerves and connective tissue
Acute and chronic trauma of vaginal delivery
Aging
Estrogen deprivation
Intrinsic collagen abnormalities
Debilitation
Iatrogenic

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)
Recreational or occupational activities
(frequent or heavy lifting)

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.

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

 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

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
Suspicious lesions should be biopsied

Examination

Local examination
Per speculum examination
Per vaginal/ Bimanual examination
Bonneys stress test
Evaluation of tone of pelvic muscles
Recto vaginal examination
Position of patient for examination
- standing & straining
- dorsal lithotomy

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 oclock
Resting tone & voluntary contraction of the
anal sphincters should be assessed during
rectovaginal examination

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).

Bladder evaluation
For all patients with prolapse following
information should be obtained
Screening for urinary tract infection
Postvoid residual urine volume
Presence or absence of bladder sensation
Bonneys stress test performed following
reduction of prolapse
If test positive incontinence surgery should
be performed at the time of prolapse surgery

Testing for Integrity of anal

sphincter
Should be assessed for resting tone
and voluntary squeeze and
sensation around the vulva with the
bulbo-cavernous reflex and crude
sensory testing for evidence of
pudendal neuropathy

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

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

Treatment
Physiotherapy
Kegels pelvic floor exercise
Kegels perineometer
Influence only the voluntary muscles
No action to the fascial supporting system

Vaginal cones of increasing weight .

Associated decubitus
ulcer
To relieve congestion, the prolapse
can be reposited in the vagina with
the help of tompoons ar pessary and
this helps in healing of the ulcer
Hygroscopic agents like acriflavinglycerine can help reduce the
congestion further

Pessary
During pregnancy
Immediately after pregnancy, during
lactation
When future childbearing is intended
in near future
Refusal to operation by patient
As a therapeutic test
To promote healing in a decubital ulcer

Pessary in situ

Complications of pessary

Constipation
Urinary incontinance
B.vaginitis, ulceration of vaginal wall
Cervicitis
Carcinoma of vaginal wall
Impaction of pessary
Strangulation of prolapsed tissue

Principles of
Management
Physical examination must not be
used in isolation to develop
treatment strategy.
Any decision for surgical
intervention should take account of
how prolapse is affecting lifestyle.

Aim of pelvic reconstructive

surgery
To restore anatomy, maintain or
restore visceral function, and
maintain or restore normal sexual
function

Uterine descentsurgeries
Vaginal hysterectomy
Sling surgeries
Shirodkar
Khannas
Purandares

Fothergills surgery

Vault prolapse
Separation of the rectovaginal fascia
from pubocervical fascia.
In post hysterectomy patients it is
important to reattach the rectovaginal
fascia to the pubocervical fascia and
to provide good support to the vaginal
apex by reattaching the vaginal cuff
to the uterosacral cardinal ligament
complex.

Surgery for prolapsed

vaginal vault
Vaginal surgery
Decreased operative time
Decreased incidence of adhesion formation
Quicker recovery time
Abdominal surgery.
Failed previous vaginal approach
Have foreshortened vagina
Young patients with advanced prolapse
With other co existing conditions
Obliterative procedures

Vaginal surgery
Mc Call culdoplasty
Internal
external

Sacrospinous ligament fixation

High uterosacral ligament
suspension with fascial
reconstruction
Iliococcygeus fascia suspension

Abdominal repairs
Abdominal sacral colpopexy
High uterosacral ligament suspension
Laparoscopic approach

Obliterative procedures
Le forte partial colpocleisis
Colpectomy and colpocleisis

Diagnosis of Stress
Incontinence
with Pelvic Organ Prolapse
Loss of urine during coughing, sneezing, laughing
or lifting something heavy
These activities cause an increase in "belly
pressure forces the urine out of the bladder
Stress incontinence occurs almost exclusively in
women & thought to be due to "pelvic (vaginal)
relaxation" from childbirth or aging

Treatment of Stress Incontinence

with Pelvic Organ Prolapse
Conservative therapy
- Pelvic floor exercises
- Urinary meatel occlusion devices
- Collagen injections
Urinary incontinence surgery
- Ant repair & Kellys plication
- Pubo-vaginal sling procedure
- TVT sling procedure
- Burch Urethropexy

Thank you