Uterovaginal Prolapse

Moderator – SCS Dr. Aye Thida

RN – 285 , 286

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 Patient identification
Name – Daw X
Age - 82 yr
Marital status - Widow
Race & Religion - Burma , Buddhist
Parity - 10+0
Residence – North Okkalapa Township
She came to Gynae OPD at 4.12.2024 for her routine 3
monthly pessary ring review visit for uterine descent.

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 Menstrual History
Her menarche was 14years old.
Duration – 3/28 Cycle
Regular , Moderate flow & amount
No history of Dysmenorrhea
Her LMP was unknown.
Age of Menopause is at 45years of age.
No postmenopausal bleeding
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 Obstetric History
● Number of marriage – 2
● Age of 1st marriage – at 17yr , Age of 2nd marriage – at 30
yr
● 6 children were born with 1st marriage and 4 children with
2nd marriage
● Age of youngest child – 37 yr & Age of eldest child – 55 yr
● 9 of them were born by spontaneous vaginal delivery at
Home by Traditional Birth Attendants
● There were no history of precipitated & prolonged labour ,
no assisted delievery. 4
● The last child was born at NOGH by normal vaginal
delivery.
● History of precipitated labour present in delivery of this
child
● No history of prolonged labour , instrumental delivery
● There were no history of 3rd stage complications
throughout the delivery of all children.
● She didn’t work strenuous activities & had rest time about
2months after delivery of each children.
● 2yrs interval between each pregnancy.
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 Past Gynaecological History

No foul smelling discharge per vagina , No pruritus

No HPV Vaccination

No history of Pap smear for cervical cancer screening

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 Contraceptive History

No history of using contraceptives during her

reproductive age

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 History of present illness
 At 73years of age, she suffered something protruding
from the introitus for 5months duration & worsened
for 1 month.
 This is aggrevated by standing & movement , relieved
by lying down.
 Initial size is said to be betal nut size & gradually
increase in size & became [Link],she came to
NOGH Gynae OPD.
 No history of backache
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 No history of white discharge
 She had history of sense of incomplete micturition
, no history of fever with chill and rigor , no
dysuria , no history of stress incontinence.
 No history of difficulty in defecation , incomplete
bowel emptying.
 No history of edema , pallor , pruritus

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 Past Medical History

 History of Hypertension & DM at 80 years of age and

taking anti-hypertensive & anti-diabetic drugs for 2years
 No history of chronic cough , asthma , TB
 No history of piles
 No history of mass in abdomen
 No history of heart disease , stroke , metabolic
ketoacidosis
 No history of hospitalization
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Past Surgical History
 No relevant past surgical history

Personal and Social History

 History of smoking 2 cigarettes per day for 5 years

 History of Lifting heavy weights ( + )
 No history of alcohol drinking and betel chewing

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Family History
 No history of DM , Hypertension , Heart disease in
her 1st degree relatives

Drug History
 No known drug allergy
 History of taking Anti-diabetic & Anti-hypertensive
drugs for DM & Hypertension
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 Management

 She took pessary ring treatment

 She regularly visits to Gynae OPD for routinely
cleaning & changing rings every 3months since
73years of age.
 At first , she used 2 inches ring and now changed to 3
inches ring in her last visit.
 She has no complications after Pessary Ring
Treatment. 13
 Physical Examination
General Examination
 General condition – well conscious , well cooperated
 No fever ,No anaemia , No jaundice
 Average weight & height for her age and sex
 Not dyspnoeic
 Teeth and gum are healthy
 On both limbs, there is no pallor ,no cyanosis ,no oedema.
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 Abdominal Examination
Inspection
 Abdomen is flat and moves with respiration.
 Flanks are not full. Umbilicus is flat.
 No scar , No dilated vein
 On coughing, no visible cough impulse & hernia
orifices are intact.

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Light Palpation
 Temperature is normal.
 Abdomen is soft , not tender , no guarding , no
rigidity.
 There is no palpable mass.
Deep Palpation
 Liver & Spleen are not palpable.
 Kidneys are not blottable.
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Percussion
 Both flanks are resonant and so there is no clinically
detectable fluid in the abdomen.

Auscultation
 Normal bowel sound is present.

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 Vaginal Examination
Inspection
 Pubic hair are sparse.
 Labia majora and minora are atrophic.
 On separating the labia majora and minora , clitoris and
external urethral orifice are seen & they are normal .
 On coughing, there is no leakage of urine & no
demonstrable stress incontinence.

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On straining
 Cervix is protruded through the introitus with identified os ( anterior &
posterior lips of cervix )
 Multip os ( slit like ) , no discharge through the os
 Cervix is smooth surface, pinkish in colour , no growth , no ulcer.
 Anterior, lateral and posterior vaginal walls are healthy.
 There is also outpouching of anterior vaginal wall between transverse
sulcus & cervix ( Cystocele ) , No urethrocele , No rectocele.
 Old 2nd degree perineum tear
 No pile, no growth, no tumor at the anus

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Palpation
 The examining fingers can’t get above the swelling , so it is 2nd
degree uterovaginal prolapse.

Bimannual examination after reduction of UVP

 Cervix is downward and forward , firm in consistency , not tender ,
surface is smooth, no growth, no ulcer, cervical os is closed.
 Uterus is retroverted, normal size, firm in consistency, not tender,
mobile from side to side, restricted from below upwards.
 Both culs & POD are clear, no straining on VE fingers.

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Provisional Diagnosis

82 years old , Parity 10+0 , 2nd degree uterovaginal prolapse

with cystocele

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Point for diagnosis
 Age – 82 yrs
 Parity – 10+0
 History of something protruding from the introitus for 5 months
 History of sense of incomplete micturition
 Vaginal examination - cervix is protruded through the introitus.
 There is outpouching of anterior vaginal wall between
transverse sulcus and cervix.( Cystocele )
 The examining fingers can’t get above the swelling.( 2 nd degree
UVP )
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Literature Review
( Uterovaginal Prolapse )

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Definition
● Pelvic organ prolapse is when 1 or more of the organs in the pelvis slip
down from their normal position and bulge into the vagina.
Classification of uterovaginal prolapse
Uterine Prolapse
• 1st degree – descent of cervix below ischial spine inside the introitus
• 2nd degree – descent of cervix outside the introitus
- part of the body of uterus is still inside the introitus
- fingers cannot get above the swelling
• 3rd degree – descent of cervix & whole body of uterus outside the introitus
- fingers can get above the swelling ( Uterine Procidentia )
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Vaginal Prolapse
• Anterior wall prolapse
Urethrocele – prolapse of lower anterior vaginal wall
involving the urethra
Cystocele – prolapse of upper anterior vaginal wall
involving the bladder
• Posterior wall prolapse
Rectocele – prolapse of lower posterior vaginal wall
involving anterior wall of rectum
Enterocele – prolapse of upper posterior vaginal wall or
herniation of POD usually involving loops of small bowel
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Normal support of uterus
Positional support
• Anteflexion – uterus is flexed forward on itself at the isthmus
• Anteversion – uterus is inclined forward so that long axis of
uterus is right angle to that of vagina

Muscular support
• Levator ani support vagina directly & cervix and uterus
indirectly
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Ligamentous support
• Cardinal ligament ,Uterosacral ligament ,
Pubocervical ligament

Fascial support
• Pubocervical fascia , Rectovaginal fascia

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Aetiology
 Congenital – congenital weakness of connective tissue ( 2 % of
prolapse )
 Acquired causes
1. Obstetric causes – multiparity,prolonged labour,precipitate
labour,instrumental history,macrosomic baby
2. Aging – due to oestrogen deficiency
3. Increased intra-abdominal pressure e.g – chronic cough,
straining at micturition and defecation,ascites,intra-abdominal
malignancy, weight lifting jobs
4. Post operative causes - UVP after hysterectomy ( 1% of
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hysterectomy )
Clinical feature
Symptoms
• History of risk factors ( e.g. multiparity,easy and
precipitated labour,heavy weight lifting,post menopausal
age, chronic straining, chronic heavy smoker )
• Something protruding at the introitus
• Backache – dragging sensation in lumbosacral region
which is aggravated by standing and relieved by lying
down
• Bleeding or purulent discharge due to decubitus ulcer
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• Dyspareunia and apareunia
• Due to cystourethrocele : urinary frequency and
urgency , voiding difficulty , sense of incomplete
micturition , UTI , stress incontinence
• Due to rectocele : difficulty in defecation ,
incomplete bowel emptying

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 Signs
Abdominal examination
● To exclude abdominal or pelvic mass

Pelvic examination
On inspection ,
● Swelling at the introitus (2nd or 3rd degree
UVP,cystocele,rectocele)
● Keratinization of vagina
● Decubitus ulcer
● Demonstration of stress incontinence 35
On Palpation ,
● Descent of cervix outside the introitus and fingers can get above the
swelling - third degree UVP
● Descent of cervix outside the introitus and fingers cannot get above
the swelling - second degree UVP
● Descent of cervix below ischial spine level - first degree UVP

Speculum examination
● Cusco’s speculum – for 1st degree
● Sim’s speculum – for enterocele

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Bimanual examination after reduction of UVP

● Uterine size
● Pelvic mass

Investigation
‘Diagnosis is mainly clinical and no essential
investigation is needed.’
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Investigation for Management

● USS abdomen and pelvis - to exclude pelvic or

abdomen mass
● Urine RE, Urine for C & S - if the urinary incontinence
is present
● CXR, ECG, Urea and electrolyte, FBC - to access
fitness for surgery

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Complications
● Keratinization of vagina
● Decubitus ulceration
● Hypertrophy of cervix
● Incarceration (irreducible prolapse)
● Urinary tract problem
- bilateral hydroureters and hydronephrosis due to ureteric
kinking
- UTI due to urine stasis
- CRF in severe cases 39
Differential diagnosis
For uterine descent
Cervical or endometrial polyp
Congenital elongation of cervix
Chronic inversion of uterus

For anterior vaginal wall prolapse

Congenital anterior vaginal wall cyst ( Gartner’s duct cyst )
Urethral diverticulum
Metastasis form uterine tumor ( choriocarcinoma )
Inclusion dermoid cyst following trauma or surgery
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For posterior wall prolapse
Bartholin’s cyst
Metastatic Nodule ( e.g. choriocarcinoma )

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Management
General Management
 Correct precipitating factors ( e.g. treat ascites, chronic cough )
 Avoid heavy weight lifting
 Physiotherapy ( Kegel exercise ) – to strengthen pelvic floor muscle
 Tx of Decubitus Ulcer
- Reposition of uterus and cervix into normal position
- Inserting of Ring pessary
- Local estrogen and antibiotic cream
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Specific management
Conservative Treatment
Pessary treatment – to provide mechanical support
Indications
 Pregnancy , Lactation
 Unfit or refusal for operation
 While waiting for operation
 To allow healing of decubitus ulcer

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Operative treatment
For cystourethrocele
• Anterior colporrhaphy ( AC )
- incision of anterior vaginal wall
- suturing of pubocervical fascia , ligament
- excision of redundant anterior vaginal wall
- closure of incision

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For rectocele
Posterior colpoperineorraphy
- incision of posterior vaginal wall
- suturing of rectovaginal fascia & perineal m/s
- excision of redundant posterior vaginal wall
- closure of incision

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For enterocele
Herniotomy & Herniorrhaphy
- open the POD & reduction of herniated small intestines
- suturing of uterosacral ligament
- excision of redundant peritoneum
- closure of incision

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For uterine prolapse
Hysterectomies
(a)Vaginal Hysterectomy Repair (Treatment of choice)
Indications – 2nd or 3rd degree UVP
- >45yrs
- complete family
VH : removal of uterus & cervix through vagina
Repair( AC+PCP) : repair of important ligaments & m/s of pelvic floor

(b)TAH & sacrocolpexy

(c) Subtotal abdominal hysterectomy &Sacrocervicopexy

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Uterine Preserving Surgery
Manchester Operation
 Indications – 1st & 2nd degree UVP
- < 45yrs
- patient who wish to preserve uterus
 Amputation of elongated vaginal cervix & Sturmdorf suture
 Fothergill’s stitch – tying the transverse cervical ligaments in front of
cervix
 AC + PCP
Sacrohysteropexy – attachment of uterus to sacrum using synthetic
mesh
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For Vaginal Vault Prolapse
 Sacrospinous ligament fixation
Suturing of vaginal vault to sacrospinous ligament

 Sacrocolpopexy
Attachment of uterus to sacrum using synthetic
mesh

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Prevention

Obstetrics care
- shortening second stage of labour
- reducing traumatic delivery

General lifestyle changes

- smoke cessation
- use of Kegel's pelvic floor exercises
- regular physical activity
- weight reduction if BMI increased
- avoid constipation and repetitive heavy lifting
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References

1. Gynaecology by Ten Teachers ( 21st edition )

2. Oxford handbook of Obstetrics and Gynaecology ( 4th

edition )

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