obstetrics & gynecology,

2. CASE PRESENTATION
 A 58-year-old white vaginal multipara presents with pelvic
heaviness and sensation of something protruding from the
vagina. Symptoms worsen after prolonged physical exertion such
as lifting or standing. On occasion, she can feel and see
something bulging from the vaginal opening. Increasingly,
she is experiencing difficulties in emptying her bladder, and she
needs to reduce the bulge with her fingers in order to
empty her bladder. She does not have urinary leakage of any
type, including leakage during physical exercise. The patient is a
heavy smoker with a history of COPD and is obese.
 What is the most likely diagnosis?
 How will you proceed with this case?
 What are the advises you would like to give to this lady?
 What is the most probable cause of this disease in this patient?

3. Zarkaish Asmatullah Marwat
08-219
Batch L
Final year M.B.BS

4. Normal anatomy of vagina
 A fibromuscular canal, 7-9 cm long, extending from the CERVIX to the
vulva.•Four-walled structure with a vault superiorly into which projects
the cervix.• The vaginal vault is divided into four fornices by the cervix
 Relations:
 Anteriorly
base of the bladder and urethra
 Laterally
levator ani muscle
visceral pelvic fascia and ureters
 Posteriorly
 (inferior to superior): the anal canal, rectum and rectouterine pouch
 .Highly elastic structure, capable of distension duringdelivery of the
fetus.

5. Vagina

6. Normal anatomy of pelvic organs
of female

7. Normal anatomy of Uterus
The uterus is located inside the pelvis immediately
dorsal to the urinary bladder and ventral to the rectum
. The human uterus is pear-shaped and about 3 in.
(7.6 cm) long. The uterus can be divided anatomically
into four segments: The fundus, corpus, cervix and
the internal os.

8. Uterus and its surrounding
structures

9. Axes
 Normally the uterus lies in anteversion & anteflexion.
Anteversion is a forward angle between the axis of the
cervix and that of the vagina measuring about 90
degrees, provided the urinary bladder and the rectum
are empty. Anteflexion is a forward angle between the
body and cervix at the isthmus measuring about 125
degrees, provided the bladder and rectum are empty.

10. Axis

11. Normal support of uterus and
vagina
 The uterus and vagina lies in the middle of the pelvis.
 Anteriorly lie the urinary bladder and urethra.
posteriorly lie colon,rectum and anal canal.
 The perineal body is interposed between lower part of
posterior vaginal wall and the anal canal.

12. Supports of uterus
 Cardinal ligaments(Mackenrodt`s ligament
these are the major support of the uterus and vault of
vagina.they are pair of fan shape strong fibromuscular
ligaments which are formed by the condensation of
endopelvic fascia.
 Uterosacral ligaments
These are the extension of cardinal ligaments.
the rectouterine folds contain a considerable amount of
fibrous tissue and non-striped muscular fibers which are
attached to the front of the sacrum and constitute
the uterosacral ligaments
 Pubocervical ligaments is a ligament connecting the side
of the cervix to the pubic symphysis.

13. Support of uterus and vagina

14. Supports of uterus

15. Supports of vagina
 Cardinal ligaments
 Levator Ani muscles
 Urogenital diaphram and perineal muscles
 Pubocervical fascia
 Perineal body and rectovaginal fascia
 Posterior vaginal wall

16. Levater ani muscles

17. Urogenital diaphram

18. Urogenital diaphram

19. Pelvic organ prolapse
 A hernia of one or more pelvic organs(uterus, vaginal
apex, bladder, rectum)and its associated
vaginal segment from its normal location.

20. Uterovaginal prolapse
 It means downward descent of the vagina and uterus.there
may be prolapse of both or vagina only.
 Most women have prolapse but only 20% have
symptomatic prolapse.

21. Epidemiology
Genital prolapse occurs in about 316 million women
worldwide as of 2010 (9.3% of all females)
Reference
Vos, T (2012 Dec 15). "Years lived with disability (YLDs) for 1160 sequelae of 289
diseases and injuries 1990-2010: a systematic analysis for the Global Burden of
Disease Study 2010.". Lancet 380(9859): 2163–96. PMID 23245607

22. Epidemiology continue...
 12-30%of multiparous women•
 2%of nulliparous women
 •Less among Blacks compared withCaucasians
 •More common amongelderly/postmenopausal women
 International
 Mortality/Morbidity
 Significant morbidity can occur, usually secondary to alterations in
bowel, bladder, or sexual function. No reliable data are available on
mortality related directly to uterine prolapse.
 Race
 Studies show that white and Hispanic women have the highest rate
of pelvic organ prolapse, followed by Asian and black women. Little
information is available about the incidence of prolapse in women of
other (or more specific) ethnic groups

23. Terminology
 Anterior vaginal wall
1. Cystocele(bladder) descend of upper two third of the
anterior wall of vagina along with the base of the
bladder.

24. 2.Urethrocele
 Descent of the lower one-third of the anterior vaginal
wall along with the urethral displacement.
3.Cystourethrocele
 Prolapse of entire anterior vaginal wall

25. Urethrocele

26. Posterior vaginal wall
 Enterocele(rectovaginal pouch)
Prolapse of upper one 3rd of posterior vaginal wall .
 Rectocele
Prolapse of lower 2/3rd of posterior vaginal wall.

27. Rectoocele

28. Enterocele

29. Classification
 ANTERIOR and POSTERIOR vaginal prolapse is usually
described in Baden Walker and Beecham system as
Three degrees of prolapse are described and the lowest or
most dependent portion of the prolapse is assessed
 whilst the patient lying in the left lateral position and is
straining.
 1st degree: cervix within vagina
 2nd degree: cervix at introitus
 3rd degree: descent outside the introitus, at the
vulva(procidentia)

30. Pelvic Organ Prolapse
Quantification(1996)
Stage Type of descent
0 No descent of pelvic organ during straining.
1 Descent of the uterus to any point in the vagina above the
hymen.
2 Descent of uterus near vaginal opening.
3
4
Protrusion of uterus out of the vagina.
Uterus completely out of the vagina.

32. Etiology
 Congenital weakness (Ehlers-Danlos syndrome, congenital
shortness of vagina, deep uterovesical/uterorectal pouches)
 Acquired defects (multiparity(7),prolong labour)
• Prolong labour,bearing down/forceps before full dilatation of
cervix,pressure on fundus during delivery of placenta.
 Menopausal Atrophy (esterogen withdrawn)
1-2 years after menopause
 Activating factors
 Increase intra abdominal pressure(chronic
cough,constipation,lifting heavy weights)
 Small fibroids or traction on the uterus(cervical polyps)
 Pelvic tumors.

33. Pathological changes associated
with prolapse
 Elongation and hypertrophy of cervix
 Keratinisation of vaginal epithelium(thick and white)
 Decubitus ulcerations
 Incarceration
 Complications of urinary tract include
Residual urine increased
Urinary tract infections and calculi due to stagnation of
urine
Due to straining during micturition bladder hypertrophy
takes place.
Hyder0ureter and hydronephrosis leading to renal failure
in long standing cases.

34. Clinical presentation
History;
LUMP in vagina or something protruding out of
vagina
Lower abdominal pain
Lower backache
Vaginal discharge(leukorrhoea)
Urinary symptoms
Frequency
Difficulty in micturiton
Stress incontinence

35. Continue...
 Acute retention of urine
Difficulty in emptying the bowel
Coital difficulties
Digitation rectally or vaginally to empty the bowel
Note; always inquiry the predisposing factors like
parity,modes of delivery,copd etc.

36. Important questions to ask
 do you feel tissue protrusion/vaginal bulge?
 is it worsened by heavy lifting?
 do you have to manually reduce the bulge to urinate?
 do you have to manually reduce the bulge to
defaecate?
 do you feel vaginal pain/discomfort?

37. Signs
 Examination
 Left lateral position, with Sims speculum; get patient to
cough or strain.
 Uterovaginal prolapse is visible during inspection of vulva.
 In case of minor prolapse it may be visible on straining.
 Patients who complain of stress incontinence should be
examined with full bladder to demonstrate it.
 A rectal examination will also differentiate between
rectocele and enterocele.
 Ulceration can be seen on speculam examination –
decubitus ulcers

38. Treatment
 Treatment of uv prolapse is described under the following
headings
Prevention
Physiotherapy
Pessary
Surgical treatment

39. Prevention
Proper managment of labour and puerperium plays an
important part in prevention of uterovaginal
prolapse.following measures are suggested.
 Pregnancy
Avoid pregnancy in quick succession
 Labour
 Stage 1
 Bearing down during ist stage of labour should be avoided.
 Breech/forceps delivery before full cervical dialatation should not be
attempted.
 Stage 2
 Prolongation of 2nd stage should be avoided if necess ary it should be
cut short by ventuse/forceps.
 Episiotomy should be performed when tears are feared.(controversial)

40. Prevention ...
 Stage 3
 Delivery of placenta by compression should be avoided(crede`s
method)
 Placenta should be delivered by brandt andrews method.
 Episiotomy and tear if any,should be carefully sutured
Puerperium
 Chronic cough and constipation should be avoided.
 Early ambulation help to tone up the pelvic muscles.
 Pelvic floor excercise should be advised.
 Strenous physical activity should be avoided at least for 3-6 months after
delivery.
 After menopause: Hormone replacement may be helpful. (Your
doctor will be able to advise you on this). Avoid prolonged standing,
heavy lifting and chronic cough. Restart pelvic floor exercises daily.

41. Physiotherapy
 Early cases of uterovaginal prolapse are helped by pelvic
floor excercise.these are particular helpful during
puerperium while awaiting for surgery.
 Kegel designed pelvic floor excercise to tone up pelvic
musculature.
 These are isometric excercises done 3 times a day for 20
minutes each.

42. Benefits of pelvic floor excercise

43. Pessary treatment
 A pessary is a mechanical device for correcting and
controlling uterovaginal prolapse.
 This is palliative treatment.a pessary does not cure
uterovaginal prolapse.it only holds the genital tract in its
possition.this method is advised for those patients who
cannot undergo surgery surgical treatment or when the
surgery has to be postpond.
 Types of pessaries
 Ring pessary
 Hodge pessary

44. Pessaries

45. Pessaries

46. Surgical treatment
 Objectives of surgery is to restore the anatomy,vaginal
function,and relief of symptoms
 Preoperative preparations
 General health
 Medical and surgical treatment
 Urinary tract investigations
 Local conditions
 Hormones

47. Types of surgeries
 Anterior colporrhaphy
 Posterior colporrhaphy
 Manchester repair(child bearing age)
 Vaginal hysterectomy, Anterior colporrhaphy
 Posterior colporrhaphy
 Burch operation
 Laparoscopic repair.
 Sling operations
 le Fort`s operation(in very old and weak patients)
Rarely performed now a days,septum is created in vagina and
double barrel vagina will support the cervix.

48. Differential diagnosis
 Cystic swelling in vagina
Gartner`s duct cysts of vagina
Epidermoid cysts
Urethral diverticulam
Periurethral cysts
Urethral caruncle
• Polypoidal growth
• Chronic inversion of uterus
• Hypertrophy of the cervix
• Vaginitis
• Cervical carcinoma
• Metastasis of uterine cancer
• Pedunculated myoma

49. Complications
 Keratinisation of vagina
 Hypertrophy of the cervix
 Decubitus ulcers-ischemic changes
 Recurrent UTI
 Acute urinary retention
 Hydroureter/hydronephrosis
 Renal failure
 Incarceration of prolapse
 Malignant changes -rare