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CASE :
A 62 years old woman complains of low back
pain and perineal pressure for 1 and half years. She
has been prescribed a pessary which she is reluctant
to wear. On pelvic examination a 2nd degree uterine
prolapse with cystocele and rectocele is observed.
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.”
ANATOMY:
In the pelvic floor, pelvic diaphragm is divided into
anterior triangle and posterior triangle.
Anterior triangle consist of urethra and vagina.
Posterior triangle consist of rectum.
SUPPORTS OF THE UTERUS:
1. Cardinal ligament(mackenrodt’s, transcervical,lateral
Cx ligament)
2. Uterosacral ligament
3. Pubocervical fascia
SUPPORTS OF VAGINA:
1. Cardinal ligament
2. Pubo cervical ligament
3. Pelvic floor muscles
4. Perineal body
HISTORY:
First recorded in about 2000 BC.
First ever successful vaginal hysterectomy for prolapse
was done by a peasent woman on her own. She cut
down her uterus,but end up with urinary incontinence.
TYPES OF VAGINAL PROLAPSE
• a.Urethrocele b.cystocele
• c.Cystourethrocele
Anterior vaginal
wall prolapse
• a.Rectocele
• b.Enterocele
Posterior vaginal
wall prolapse
• a.Uterovaginal
• b.vault prolapse
Apical vaginal
prolapse
Degrees of prolapse of uterus:There is usual a Right angle Relationship between
uterus and vagina.
How the uterus changes into the same plane as the vagina?
As the uterus gets start descending, the uterus starts moving down and down and down until
Outside of the body.
When it almost outside the body is called procidentia: marked prolapse
Grade I: cervix is not in vagina.
Grade II: cervix is now in vaginal opening.
Grade III: (procidentia)
The uterus is hanging outside and here it is wrapped by anterior and posterior wall of vagina.
ETIOLOGY of Pelvic Relaxation
It is most commonly related to
CHILD BIRTH.
When you push a nine pounds baby through a pelvic floor,
injury is not uncommon.
1-EVALUATION
1-HISTORY
a-non specific symptoms
b-specific symptoms
c-also ask about
PARITY
MODE OF DELIVERIES
2-PHYSICAL EXAMINATION
1-GENERAL EXAMINATION
2-SPECULUM/VAGINAL EXAMINATION
Sim’s position
3-RECTAL EXAMINATION
3-INVESTIGATIONS
A-BASE LINE
FBC,UCE,FBS,Blood group
X match,Urine microscopy,CXR,ECG
B-ADDITIONAL
RFTs,U/S,CT, MRI
DIFFERENTIAL DIAGNOSIS
Cervical polyp
Large endometrial polyp
Cervical cancer
Metastasis of ut.cancer
Pedunculated myoma
Urethral diverticulum
Vaginal wall cyst
COMPLICATIONS
Decubitus ulcers
Keratinization of vagina
Hypertrophy of cervix
Recurrent UTI
Acute urinary retention
Hydroureter/hydronephrosis
Renal failure
Incarceration
MANAGEMENT
According to age of the patient,level of fitness,her wish
for future fertility.
a-counselling
b-prevention
c-treatment
*Uterovaginal prolapse
1-CONSERVATIVE
a-Manchester repair
b-Sling operation
2-RADICAL
a-Vaginal hysterectomy
*Vault prolapse
1-Le fort’s operation
2-Utero sacral ligament suspension
3-Sacro spinous ligament fixation