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.