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Uterine Prolapse/Pelvic relaxation/Pelvic floor hernia

•a descent or herniation of the uterus into or beyond the vagina•considered under the broader heading of "pelvic organ prolapse" which also includes cystocele, urethrocele, enterocele, and rectocele.•anatomically, the vaginal vault has 3 compartments:

- an anterior compartment (consisting of the anterior vaginal wall) - a middle compartment (cervix)

- posterior compartment (posterior vaginal wall). •UP involves the middle compartment

Four stages of uterine prolapse are defined:

stage I - descent of the uterus to any point in the vagina above the hymen

stage II - as descent to the hymen stage III - as descent beyond the

hymen stage IV - as total eversion or

procidentia∆ Uterine prolapse always is accompanied by some degree of vaginal wall prolapse…..

Assessment A complete pelvic examination is required,

including a rectovaginal examination to assess sphincter tone.

A Sims speculum or a standard bivalve speculum with the anterior blade removed may facilitate diagnosis.

Physical findings may be enhanced by having the patient strain during the examination or by having her stand or walk prior to examination. Standing with an empty bladder may result in a 1-2 stage difference in the degree of prolapse noted on examination when compared to a supine position with a full bladder.

Mild uterine prolapse may be recognized only when the patient strains during the bimanual examination.

Evaluate all patients for estrogen status. Signs of decreased estrogens

Loss of rugae in the vaginal mucosa Decreased secretions Thin perineal skin Easy perineal tearing

Physical examination should also be directed toward ruling out serious conditions that may rarely be associated with uterine prolapse, such as infection, urinary outflow obstruction with renal failure, and hemorrhage. If urinary obstruction is present, the patient

may exhibit suprapubic tenderness or a tympanitic bladder.

If infection is present, purulent cervical discharge may be noted.

Lab Studies Imaging Studies

Laboratory studies are unnecessary in uncomplicated cases….

Cervical cultures - cases complicated by ulceration or purulent discharge

Papanicolaou test (Pap smear cytology) or biopsy - in rare cases of suspected carcinoma

BUN and creatinine measurement - if PE findings suggest urinary obstruction

Pelvic ultrasound examination

Ultrasonography MRI - to grade pelvic

organ prolapse

Signs and Symptoms

Pelvic heaviness or pressure Protrusion of tissue: A patient who reports of a

"bulge" has been found to be a valuable screening tool for the detection of pelvic organ prolapse (81% PPV, 76% NPV).

Pelvic pain Sexual dysfunction, including dyspareunia, decreased

libido, and difficulty achieving orgasm Lower back pain Constipation Difficulty walking Difficulty urinating Urinary frequency Urinary urgency Urinary incontinence Nausea Purulent discharge (rare) Bleeding (rare) Ulceration (rare)

Pathophysiology

AgeRace (Hispanic)Pelvic structure (Anthropoid)Uterine structure

AgeRace (Hispanic)Pelvic structure (Anthropoid)Uterine structure

Lifestyle (occupation)MultiparusMenopause

Lifestyle (occupation)MultiparusMenopause

Decreased estrogen levelDecreased estrogen levelObstetrical

traumaObstetrical

trauma

Weakening of the pelvic tissues, muscles, ligaments

Weakening of the pelvic tissues, muscles, ligaments

GI:•Dysuria•Constipation•Urinary frequency•Nausea & vomiting•Urinary incontinence•Urinary urgency

GI:•Dysuria•Constipation•Urinary frequency•Nausea & vomiting•Urinary incontinence•Urinary urgency

Circulatory:•Bleeding

Circulatory:•Bleeding

Musculoskeletal:•Pelvic heaviness•Pelvic pain•Low back pain

Musculoskeletal:•Pelvic heaviness•Pelvic pain•Low back pain

Reproductive:•Sexual dysfunction•Decreased libido

Reproductive:•Sexual dysfunction•Decreased libido

Integumentary:•Protrusion of tissue•ulceration

Integumentary:•Protrusion of tissue•ulceration

Complications: Urinary retention Constipation Hemmorhoids Cervical ulceration Infection (possible) Cystitis

Treatment/Medical Mngt:

Pessaries + fitted into the vagina to hold the uterus in

place+ temporary or permanent form+ fitted individually for each woman+ attaining and maintaining optimal weight is

recommended

Surgery + uterus sutured back into place &

+ colpopexy - involves the use of surgical mesh for supporting the uterus

+ hysterectomy – removal of uterus

Nursing management:

preventive measures: Early visits to HC provider = early detection Teach Kegel’s exercises during PP period

preoperative nursing care: Thorough explanation of procedure, expectation

and effect on future sexual f(x) Laxative and cleansing edema (rectocele) –

independently, at home a day prior procedure Perineal shave prescribed also Lithotomy position for surgery

postop nursing care: Pt. is to void few hours after surgery;

catheter if unable (after 6 hrs)

Pain

Administer analgesic as prescribed.Provide comfort measures such as backrub.Provide diversional activities such as guided imagery and socialization.

Constipation Administer stool softeners/laxatives as prescribed.

Encourage increase in fluid and fiber intake.

Encourage early ambulation.

Urinary IncontinenceDetermine if client is aware of

incontinence. Developmental issues/ medical conditions that can impair patient’s awareness and sensory perception of voiding.

Determine patient’s particular symptoms (e.g. continuous dribbling).

Implement bladder training for incontinence management by providing ready acces to bathroom or commode, encouraging adequate fluid intake, and establishing voiding/bladder emptying.

Sexual dysfunctiono Provide factual information about individual condition involved to promote informed decision making.

o Provide for ways to obtain privacy to allow for sexual expression for individual and/or between partners with out embarrassment and/or objection of others.

o Establish therapeutic nurse-client relationship to promote treatment and facilitate sharing of sensitive information.

Risk for Infection

Observe for localized signs of infection.

Note for signs and symptoms for sepsis.

Stress proper hand hygiene.