Uterine Prolapse

Prolapse uterus

Ans. is a i.e. Cystocoele 

Genital prolapse : refers to protusion of the pelvic organ into or out of the vaginal wall. Classification of prolapse

Anterior vaginal wall :  upper two thirds – cystocoele    

Cytourethrocoele lower one third – urethrocoele

Posterior vaginal wall : upper one third – enterocoele (pouch of Douglas Hernia)

Grade I       = Descent halfway to the hymen

Grade II      = Descent to the hymen

Grade IIt     = Descent halfway past the hymen

Grade IV     = Maximum possible descent for site

Bader walker Halfway system :

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Grade 0        = Normal postion for each reproesentative site

1. Uterine descent : Shaw’s classification (old classification) : 1°– descent of the cervix to the vagina

2° – descent of the cervix to the introitus

3° – descent of the cervix outside the introitus.

Procidentia : all of the uterus outside the introitus.

1. Utero vaginal Prolapse : It is the commonest type of prolapse. Cystocoele occurs first followed by traction on the cervix causing retroversion of the uterus and then uterus is pushed into the vagina.

Vault prolapse : it follows vaginal or abdominal hysterectomy, symptoms are-coital difficulty and difficulty in walking.

Congenital Prolapse : There is no cystocoele.

“Data from Women’s Health Initiative revealed anterior pelvic organ prolapse in 34.3%, posterior wall prolapse in 18.6% and uterine prolapse in 14.3% of women in the study.”   

Therefore, from the above data it is clear that cystocele (anterior organ prolapse) is the most common type of prolapse.

Friends, according to latest trends, prolapse is not classified as above, but compartmental classification is done. 

(It might be asked in forthcoming PGME exams).

Newer classification

Note:Sometimes the term apical prolapse is used – It includes :

• Uterine prolapse
• Vaginal vault prolapse (post hysterectomy)
• Enterocele

Ans. is b i.e. Venous congestion

“Ulceration of the prolapsed tissue is often said to be caused by friction with the thighs and clothing. Although this may be partly true, it is notable that the ulcer is nearly always on the most dependant part of the cervix or vagina and not at the sides where friction is greatest. It is to be regarded, therefore more as a result of circulatory and nutritional changes than of trauma.”

Treatment of decubitus ulcer : Reduction of the prolapse into the vagina and daily packing with glycerine and acriflavine.

Also know : Difference between Decubitus ulcer and Carcinoma Cervix : Decubitus ulcer shows a clean edge and heals on reposition and vaginal packing.

Ans. is b i.e. Fothergill’s repair with tuba! ligation             

Fothergill’s operation(Manchester Repair) is done in women below 40 years, who want to retain their menstrual function .

This lady fulfills all these criteria and so Fothergill’s repair is the ideal management for her.

Fothergill’s repair causes complications of pregnancy like incompetent os, habitual abortion and Cervical dystocia. Therefore tubal ligation should be done to prevent these complications i.e. fothergills should be avoided in women who want more children.

Components of Fothergill’s operation / Manchester operation :

1. Preliminary D & C (to facilitate creation of vaginal flaps and to rule out malignancy)
2. Amputation of cervix
3. Plication of Mackenrodt’s ligament in front of the cervix
4. Anterior colporrhaphy
5. Colpoperineorrhaphy.

Complications

1. Cervical amputation leads to :   

– Incompetent os

– Habitual abortion                       

— Premature rupture of membranes

— Decreased fertility

1. Excessive fibrosis causes stenosis leading to dystocia during labour.
2. Hematometra
3. Recurrence of prolapse.

Ans. is a i.e. Prolapse Uterus    

Risk factors assciated with prolapse :

• Menopause° (most important aetiological factor) It increasing chances of prolapse due to

–   Aging which decreases strength of uterine supports

–    Hypoestrogenism

• Birth injury° – due to excessive stretching of the pelvic floor mucles and ligaments.

–   Due to injury of pudendal nerve

Risk factors associated with birth injury :

–    Bearing down before full dilatation of cervix.

–      Ventouse extraction of fetus before the cervix is fully dilated Delivery of a big baby

–      Rapid succession of pregnancies

–      Resumption of heavy work, soon after delivery

• Chronically increased intraabdominal pressure :

–    COPD

–     Constipation

–      Obesity

• Pelvic floor trauma

latrogenic trauma as 

• in case of : – Abdomino perineal excision of the rectum Radical vulvectomy

–   Vaginal hysterectomy

• Genetic factors :

–      Race – Hipanic women have highest risk

–    Connective tissue disorders like warfan and Ehler Danlos Syndrome increase the risk.

• Increased risk in case of spina bifida.

Ans. is c and d i.e. Cardinal ligament; and Uterosacral ligament   

Supports of uterus are classified as :

Primary supports

a. Muscular or active support                

1. 1. Pelvic diaphragm (formed by levator ani muscle)
2. Perineal body°
3. Urogenital diaphragm (deep transverse pereneii muscles).

b. Fibromuscular or mechanical support                 

1. 1. Uterine axis°
2.   2. Pubocervical ligament°
3. Transverse cervical ligament° (cardinal ligament)
4. Uterosacral ligament°
5. Round ligament of uterus.°

Broad ligament (fold of peritoneum) is a secondary support of uterus and its role as support is doubtful.

Other secondary supports are : – Utero vesical fold of peritoneum. – Rectovaginal fold of peritoneum.

“Main support which prevents descent of the uterus is transverse cervical ligament (cardinal ligament) and its posterior extension) the uterosacral ligament.” 

Note : If this question is asked in single response based PGME exams, then only cardinal ligament will be the answer of choice.

Also know : Supports of vagina –

Ans. is d i.e. Congenital prolapse of uterus   

Cervicopexy or sling operation (Purandare’s operation)

Indicated in congenital or nulliparous prolapse without cystocele where the cervix is pulled up mechanically through abdominal route. Strips of rectus sheath of either side passed extraperitoneally and stitched to the posterior surface of the cervix close to attachment of uterosacral ligaments and then the ends of the strips are brought forward retroperitoneally and attached to external oblique aponeurosis.

Ans. is c i.e. Shirodkar abdominal sling    

Abdominal sling operations are designed for young women suffering from second or third degree uterovaginal prolapse and who are desirous of retaining their childbearing and menstrual functions.

The objective of these operations is to buttress the weakened supports (Mackenrodt and uterosacral ligaments) of uterus by providing a substitute in the form of Nylone or Dacron tapes, used as slings to support the uterus.

The operations in common practice are :

• Abdomino-cervicopexy
• Shirodkar’s abdominal sling operation
• Khanna’s abdominal sling operation.

Also know :

More about treatment :

• For young nulliparous women with 2° or 3° uterovaginal prolapse

—  Abdominal sling operation (e.g. Purandare, Shirodkar, Khanna)

• For a parous women in early weeks of pregnancy.

—    Ring pessary in the first trimester of pregnancy.

• For a parous women in pregnancy with 2° or 3° prolapse at 28 weeks.

—    Ring pessary till child birth and few weeks after and then Fothergill’s repair.

• For < 40years multipara, desirous of retaining menstrual function and reproductive function with 2° or 3° prolapse.

—    Fothergill’s repair

• For women > 40 years completed family size

—    Mayoward’s vaginal hysterectomy (with ant. Colporrhaphy and posterior colpoperineorrhaphy) with pelvic floor repair.

• For elderly menopause patient with advanced prolapse

—    Lefort’s repair

• For enterocele

—   Moscowitz repair

• For vault prolapse

—   Right transvaginal sacrospinous colpopexy (in obese and elderly, not fit for abdominal surgery).

—  Transabdominal sacral colpopexy using Mersilene mesh extraperitoneally (in patient fit for abdominal surgery).

• Congenital prolapse of uterus / Nulliparous prolapse without cystocele : Purandare’s cervicopexy.

All of the above

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Fenton’s

Stress incontience

Fothergill’s operation with tubal ligation

All options correct

Reduction with tampoon

Shirodkar’s abdominal sling

Circulatory disturbances

Early pregnancy

• Ist degree: Descent of cervix in the vagina
• IInd degree: Descent of cervix into the introitus
• IIIrd degree: Descent of the cervix outside the introitus
• IVth degree: Whole uterus lies outside the utreus

• Upper two third: cystocele
• Lower one third: urethrocele

• Upper one third: enterocele
• Lower two third: rectocele

The uterus is supported mainly by the tone of the levator ani muscles and the condensations of pelvic fascia, which form three important ligaments.

The Levator Ani Muscles and the Perineal Body:

• They form a broad muscular sheet. They effectively support the pelvic viscera. The medial edges of the anterior parts of the levator ani muscles are attached to the cervix of the uterus by the pelvic fascia.
• Transverse cervical ligaments are fibromuscular condensations of pelvic fascia that pass to the cervix and the upper end of the vagina from the lateral walls of the pelvis.

Pubocervical Ligaments:

• The pubocervical ligaments consist of two firm bands of connective tissue that pass to the cervix from the posterior surface of the pubis. They are positioned on either side of the neck of the bladder, to which they give some support (pubovesical ligaments).

Sacrocervical Ligaments:

• The sacrocervical ligaments consist of two firm fibromuscular bands of pelvic fascia that pass to the cervix and the upper end of the vagina from the lower end of the sacrum. They form two ridges, one on either side of the rectouterine pouch (pouch of Douglas).
• The broad ligaments and the round ligaments of the uterus are lax structures, and the uterus can be pulled up or pushed down for a considerable distance before they become taut. Clinically, they are considered to play a minor role in supporting the uterus.

The round ligament of the uterus, which represents the remains of the lower half of the gubernaculum, helps keep the uterus anteverted (tilted forward) and anteflexed (bent forward) but is considerably stretched during pregnancy.