UTERINE PROLAPSE

“I had just given birth to my first child and was working in the fields near my village. Suddenly I felt as if my insides were dropping out of me,” the 66-year-old recalled Baffled by what had happened, she told no-one - not even her husband – hoping the problem would go away. But over the years, her prolapsed uterus got worse, to the point that it protruded from her vagina completely, making it difficult for her to walk or even sit upright. She required surgery; a fact prompting this uneducated mother-of-five to finally seek help.

UTERINE PROLAPSE

Definition

Protrusion of uterus into and out of the vagina from its normal position
The pelvic structures are divided into 3 compartments : anterior, middle and posterior
Anterior : urethra /bladder
Middle : uterus/vault
Posterior : rectum/anus

Prolapse

According to the structure underlying it the prolapse is termed as urethrocele

cystocele

uterine prolapse

enterocele

rectocele

vault prolpase

Degree of prolapse

First degree: slight descent of uterus from its normal position but still within the vagina
Second degree: descent of uterus upto the introitus
Third degree: protrusion of part of the uterus out of the introitus.
Procidentia : when the whole of the uterus prolapses out of the introitus.The whole vagina or at least the whole of its anterior wall is inverted

Normal supports

Axis of the uterus and vagina: anteverted and anteflexed
Uterus projects into the ant wall of the vagina at an angle so uterus is not in axis with the vagina.
upper and lower vagina also meet at an angle of 130degree such that the upper half rests on the levator plate

Normal axis of uterus/vagina and the levator plate

Normal anatomy

Supports of the uterus /vagina

Bony cage

ligaments : Mackenrodts ligament,uterosacral ligament, pubocervical ligament,broad ligament, round ligament

Fascia: endopelvic fascia, Fascia of Denonvillier

Muscles : levator ani and sacrococcygeus (pelvic diaphragm)

urogenital diaphragm

Supports

The muscles of the pelvic floor form the MAIN support of the uterus and vagina .The normal resting tone and voluntary intermittent contraction ,along with contraction of the bulbocavernous muscle constrict the vaginal lumen and elevate the ant. vaginal wall. This is the basis for the Kegel’s exercise.

Levator plate is the median raphe between the anus and the coccyx: the shelf on which the pelvic organs rest. Laxity of this plate leads to prolapse

Muscles of the pelvic floor

Consequences

Aetiology

Congenital : Ehler Danlos Syndrome associated with connective tissue defects; congenital elongation of the cervix

Obstetric : excessive stretching, tearing ,nerve damage that can occur in pregnancy/labour

Menopausal

Iatrogenic : post major surgeries like vaginal and TAH, abdominoperineal resection of rectum etc

Aggravating factors

Chronic constipation, heavy exercise, obesity, chronic cough, weightlifting and pelvic tumours all aggravate the already weak supports

Presentation

Degree of prolapse bears little relationship to the presenting complaint
80% present with complaint of something coming down per vagina
dragging or bearing down sensation
backache > on standing, progresses towards the day, relieved on lying down
difficulty in coitus
Discharge PV
tenesmus and constipation sometimes relieved by digital reduction of prolapse – rectocele
frequency ,incomplete voiding, dysuria, stress incontinence- cystocele

Examination

vulva examination : laxity of introitus, prolapse type and degree, atrophy changes, ulcer and discharge, rectocele, urethrocele and cystocele

ask patient to cough or strain : stress incontinence

check whether 3rd degree or procidentia,pinch tissue at introitus

PV examination: size of uterus, degree of decent, levator tone, any associated pathology. Diagnose enterocele

Investigation

No specific investigation for diagnosis
Most of investigation aaimed at ruling out aggravating factors or complications

eg Urine RE and culture, IVU

chest Xray

swab from discharge

biopsy of non healing ulcer

pap smear

endometrial biopsy in case of bleeding PV

Management

EXPECTANT

PESSARIES

SURGERY

Expectant

Cases with mild prolapse ,those diagnosed during gynecological examination with minimal or no symptoms

inform patient of condition

pelvic exercise

aggravating factors treatment

HRT in menopausal women

Pessaries

Used as early as 2000BC by Egyptians
Various types have been used over the century
Main purpose is to stretch the vault and hold the uterus up. Some amount of inherent tone is needed for the ring to remain in place
Ring Pessary commonly used : rubber
changed every 3 monthly
temporary method of treatment

Types of pessaries

pessary

If patient refuses surgery
Patient medically unfit for surgery
Temporary measure while patient waits for surgery
Ulcer : helps in healing of the ulcer
in pregnancy : early pregnancy
in puerperium

Its use is not without problems

Surgery

Type of surgery depends on the reproductive goal, age of patient , surgical fitness, type of prolapse and severity, need for preservation of coital function, assocaited other pelvic disease
symptomatic cases especially those with mod to severe degree of prolpase

uterus preserving

anterior colporrhapy

post colpoperineorraphy

Manchester Operation

Colpocleisis

Le Forts Operation

Sling operations

Fothergill or Manchester operation

Dilation and curretage
anterior plication of the cardinal ligaments
amputation of cervix and reconstruction
ant colporraphy
PFR

ideal in women with congenitaly elongated cervix

Lefort operation:

rectangular folds of vaginal wall from ant and post wall are removed and the raw surfaces are sutured together

can even be done under LA ,suitable in old medicaly unfit lady with prolapse

Colpocleisis : concentric sutures placed in vagina which is used to close the vagina and so hold up the prolapse

Sling operations

for young women with severe prolapse who want to conserve the uterus
objective of operation is to buttress the weakened supports of the uterus with substitutes like fascial or synthetic material.

eg : sacrohysteropexy: post junction of uterus and cervix is attached by mesh to the ant longitudinal ligament of sacral vertebrae

abdominocervicopexy: musculofascial strips from ant abd wall inserted onto isthmus of uterus

Operations