1. Uterovaginal Prolapse
Dr. Nusrat Nisar
Department of Obstetrics & Gynaecology
Liaquat University of Medical &
Health Sciences, Jamshoro

2. Uterovaginal prolapse is defined as protrusion of uterus or vagina beyond their normal anatomical confines

3. Incidence:
12 – 30% in multiparous women.
2% in nulliparous women.

4. Grading: 1st degree: 2nd degree: 3rd degree: Descent with in vagina.
Descent up to the introitus.
3rd degree:
Descent out side the introitus also known as procidentia & usually accompanied by cystourethrocele & Rectocele.

6. Classification Anterior vaginal wall prolapse; Urethrocele; Cystocele;
Urethral descent.
Cystocele;
Bladder descent.
Cystourethrocele;
Descent of bladder & urethra.

7. Posterior vaginal wall prolapse;
Rectocele;
Rectal descent.
Enterocele;
Small bowel descent.
Apical vaginal prolapse;
Uterovaginal;
Uterine descent with inversion of vaginal apex.

8. Vault prolapse;
Post hysterectomy inversion of vaginal apex.

9. 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.

10. Raised intra abdominal pressure;
Chronic cough.
Constipation.
Post menopausal;
Estrogen deficiency.
Post operative;
Vault prolapse.

11. 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.

12. Specific; Cystourethrocele; Rectocele; Urinary frequency. Urgency.
Voiding difficulty.
Urinary tract infection.
Stress incontinence.
Rectocele;
Incomplete bowel emptying.
Digitation.
Splinting.

13. 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.

14. Differential Diagnosis
Anterior wall prolapse;
Congenital or inclusion dermoid vaginal cyst.
Urethral diverticulm.
Uterovaginal prolapse;
Large uterine polyp.

15. 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.

16. Treatment Depends upon patient`s wishes. Correct obesity.
To treat chronic cough.
Constipation.
If ulceration then seven days course of local estrogen.

17. Prevention; Shortening the 2nd stage of labor.
Reducing traumatic delivery.
Use of episiotomy.
HRT in menopausal women.

18. Medical Treatment Conservative therapy; Indications; Complications;
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.

19. 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.

20. 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.

21. Sacrohysteropexy; Abdominal procedure,
Attachment of synthetic mesh from the utertocevical junction to the anterior longitudinal ligament of the sacrum.

22. Vault prolapse; Sacrocolopopexy;
Similar to Sacrohysteropexy but the inverted vaginal vault is attached to the sacrum.
Sacrospinous ligament fixation.

23. Fascial defect repairs;
Fascial or muscle plication or attachment to ligaments to support the vagina in its presumed original position.

33. The End