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Uterovaginal Prolapse
Dr. Nusrat Nisar
Department of Obstetrics & GynaecologyLiaquat University of Medical &
Health Sciences, Jamshoro
Uterovaginal prolapse is defined as protrusion of uterus or vagina beyond their normal anatomical confines
Incidence:
12 – 30% in multiparous women.
2% in nulliparous women.
Grading:
1st degree:Descent with in vagina.
2nd degree:Descent up to the introitus.
3rd degree:Descent out side the introitus also known as procidentia & usually accompanied by cystourethrocele & Rectocele.
Classification
Anterior vaginal wall prolapse;Urethrocele;
• Urethral descent.
Cystocele;• Bladder descent.
Cystourethrocele;• Descent of bladder & urethra.
Posterior vaginal wall prolapse; Rectocele;
• Rectal descent.
Enterocele;• Small bowel descent.
Apical vaginal prolapse;Uterovaginal;
• Uterine descent with inversion of vaginal apex.
Vault prolapse;Post hysterectomy inversion of vaginal apex.
Etiology
Extremely common in multiparous women.
Congenital; 2% symptomatic prolapse occur in nulliparous.
Congenital weakness of connective tissue.
Multiparity;Multiple vaginal deliveries;
• Causes damage to major supports of vagina,nerves,endopelvic fascia & levator ani.
Raised intra abdominal pressure;Chronic cough.
Constipation.
Post menopausal; Estrogen deficiency.
Post operative; Vault prolapse.
Diagnosis
Diagnosis is made by clinical examination; Clinical features; Symptoms;
Non specific;• Lump.• Local discomfort. • Backache.• Bleeding / infection if ulceration. • Dyspareunia or apareunia.• In sever cystourethrocele, uterovaginal or vault
prolapse renal failure may occur.
Specific; Cystourethrocele;
• Urinary frequency.• Urgency.• Voiding difficulty.• Urinary tract infection.• Stress incontinence.
Rectocele; • Incomplete bowel emptying.• Digitation.• Splinting.
Abdominal examination;Should perform to exclude organomegaly or abdomino-pelvic mass.
Vaginal examination;Prolapse may be obvious.
Ulceration.
Pelvic examination to exclude pelvic mass.
Combine rectal & vaginal examination to differentiate Rectocele from Enterocele.
Differential Diagnosis
Anterior wall prolapse;Congenital or inclusion dermoid vaginal cyst.
Urethral diverticulm.
Uterovaginal prolapse;Large uterine polyp.
Investigation;
No essential investigation.If urinary symptoms present;
Urine microscopy.Cystometry.Cystoscopy.
If renal failure suspected;B.Urea.S.Creatinine.U/s of renal areas.
Treatment
Depends upon patient`s wishes.
Correct obesity.
To treat chronic cough.
Constipation.
If ulceration then seven days course of local estrogen.
Prevention;Shortening the 2nd stage of labor.
Reducing traumatic delivery.
Use of episiotomy.
HRT in menopausal women.
Medical TreatmentConservative therapy;
Silicon rubber based ring pessaries.
Indications;Patient`s wish. As a therapeutic test.Child bearing not complete.Medically unfit for surgery.During & after pregnancy.While awaiting surgery.
Complications;Vaginal ulceration & infection.
Surgical Treatment
Aim of surgical repair is to restore anatomy & function.Cystourethrocele;
Anterior repair or colporrhaphy.
Rectocele;Posterior repair or colporrhaphy.
Enterocele;Anterior & posterior repair & peritoneal sac containing the small bowel should be excised.
Utero vaginal prolapse;Vaginal hysterectomy;
• If patient completed her family.
Manchester repair;• Involves partial amputation of cervix &
approximation of cardinal ligaments.
• Usually combined with anterior & posterior repair.
Sacrohysteropexy;Abdominal procedure,
Attachment of synthetic mesh from the utertocevical junction to the anterior longitudinal ligament of the sacrum.
Vault prolapse;Sacrocolopopexy;
• Similar to Sacrohysteropexy but the inverted vaginal vault is attached to the sacrum.
• Sacrospinous ligament fixation.
Fascial defect repairs;Fascial or muscle plication or attachment to ligaments to support the vagina in its presumed original position.