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The uterus is not fixed organ. Minor variations in position in any direction occur constantly with
change in posture, with straining, with full bladder or loaded rectum. Only when the uterus rested
habitually in a position beyond the limit of normal variation should it be called displacement.
RETROVERSION
DEFINITION
Retroversion (RV) is the term used when the long axes of the corpus and cervix are in line and the
whole organ turn backward in relation to the long axis of the birth canal.Retroflexion signifies a
bending backwards of the corpus on the cervix at the level of internal os. The two conditions are
usually present together and whole organ turns backwards in relation to the long axis of the birth
canal are loosely called retroversion or retro displacement.
DEGREES
Conventionally, three degrees are described.
First degree - The fundus is vertical and pointing towards the sacral promontory.
Second degree - The fundus lies in the sacral hollow but not below the internal os.
Third degree - The fundus lies below the level of the internal os.
CAUSES
Developmental
Acquired
Developmental
Retrodisplacement is quite common in fetuses and young children. Due to developmental defect,
there is lack of tone of the uterine muscles. The infantile position is retained. This is often associated
with short vagina with shallow anterior vaginal fornix.
Acquired
Puerperal The stretched ligaments caused by childbirth fail to keep the uterus in its normal position.
A subinvoluted bulky uterus aggravates the condition.
Tumour: Fibroid, either in the anterior or posterior wall produces heaviness of the uterus and hence
it falls behind.
Pelvic adhesions : Adhesions either inflammatory, operative or due to pelvic endometriosis pull the
uterus posteriorly.
INCIDENCE
Retroversion is present in about 15-20 per cent of normal women.
CLINICAL PRESENTATION
The condition is classified either as
Mobile and fixed or Uncomplicated and complicated by pelvic diseases.
Mobile retroverted uterus
Symptoms
Mobile retroverted uterus is quite common and almost always remains asymptomatic. However, the
following symptoms may be attributed to it.
Chronic premenstrual pelvic pain
Backache.
Dyspareunia
Infertility
Positive pessary test.
Signs
Bimanual examination reveals
The cervix is directed upwards and forwards.
The body of the, uterus is felt through the posterior fornix.
It is found continuous with the cervix and it moves when the cervix is pressed up.
The size of the uterus is difficult to assess at times.
Speculum examination reveal
The cervix comes in view much easily and the external os points forwards.
Rectal examination
It is of help to confirm the diagnosis.
Fixed retroversion
Symptoms:
Symptoms are related to the associated pelvic pathology.
Menstrual abnormalities (menorrhagia),
congestive dysmenorrhoea,
chronic pelvic pain or dyspareunia are usually associated.
Whether the uterus is fixed or mobile can be elicited by attempting to replace it by moving
the cervix backwards and by pushing the fundus upwards.
Rectal examination may be more effective to elicit the findings.
It is indeed of paramount importance to identify the position of the uterus as it is often
necessary to identify prior to minor intrauterine manipulations such as insertion of IUCD or
introduction of uterine sound
Empty bladder prior to examination.
DIFFERENTIAL DIAGNOSIS
The retro displacement may be confused with hard fecal mass in the rectum, small fibroid on the
posterior wall of the uterus and small ovarian cyst in the pouch of Douglas.
PREVENTION
The following guidelines are of help during the weeks after abortion or childbirth.
To empty the bladder regularly.
To increase the tone of the pelvic muscles by regular exercise.
To encourage lying in prone position for half to one hour once or twice daily between 2 to 4
weeks postpartum.
CORRECTIVE TREATMENT
Pessary
Surgical
Pessary
Pessary is less commonly used in present day gynecologic practice. However, it may be indicated
for pessary test
in subinvolution of uterus
in pregnancy when spontaneous correction to anteversion fails by 12th week.
Usually Hodge-Smith pessary is used. The pessary acts by stretching the uterosacral ligaments so as
to pull the cervix backwards.
Surgical treatment
Surgical correction is indicated in :
1. Cases where the 'pessary test' is positive indicating that the symptoms are due to retroversion.
2. Fixed retro- verted uterus producing symptoms like backache or dyspareunia.
The principle of surgical correction is ventro- suspension of the uterus by plicating the round
ligaments of both the sides extra peritoneally to the under surface of the anterior rectus sheath.This
will pull the uterus forwards and maintains it permanently.
DEFINITION
It is a clinical entity which includes the descent of vaginal wall and or the uterus. It is infact a form
of hernia
Vaginal prolapse
Anterior wall •
Cystocele - The cystocele is formed by laxity and descent of the upper two-thirds of the
anterior vaginal wall. As the bladder base is closely related to this area, there is herniation of
the bladder through the lax anterior wall.
Urethrocele — When there is laxity of the lower-third of the anterior vaginal wall, the urethra
herniates through it. This may appear independently or usually along with cystocele and is
called cysto-urethrocele.
Posterior wall
Relaxed perineum — Torn perineal body produ-ces gaping introitus with bulge of the lower
part of the posterior vaginal wall.
Rectocele — There is laxity of the middle-third of the posterior vaginal wall and the adjacent
rectovaginal septum. As a result, there is herniation of the rectum through the lax area.
Vault prolapse
Enterocele — Laxity of the upper-third of the posterior vaginal wall results in herniation of
the pouch of Douglas. It may contain omentum or even loop of small bowel and hence called
enterocele. Traction enterocele is secondary to uterovaginal prolapse. Pulsion enterocele is
secondary to chronically raised intra-abdominal pressure.
Secondary vault prolapse — This may occur following either vaginal or abdominal
hysterectomy. Undetected enterocele during initial operation or inadequate primary repair
usually results in secondary vault prolapse .
Uterine prolapse
There are two types:
Uterovaginal prolapse is the prolapse of the uterus, cervix and upper vagina. This is the
commonest type. Cystocele occurs first followed by traction effect on the cervix causing retroversion
of the uterus. Intra-abdominal pressure has got piston like action on the uterus thereby pushing it
down into the vagina.
Congenital -There is usually no cystocele. The uterus herniates down along with inverted upper
vagina. This is often met in nulliparous women and hence called nulliparous prolapse. The cause is
congenital weakness of the supporting structures holding the uterus in position.
TYPES OF GENITAL
PROLAPSE
Vaginal Uterine
Primary Secondary
Enterocele Following
Vaginal Abdominal
Hysterectomy hysterectomy
PELVIC ORGAN PROLAPSE ACCORDING TO COMPARTMENTS
MORBID CHANGES
Vaginal mucosa
The mucosa becomes stretched and if exposed to air, becomes thickened and dry with surface
keratinisation. There may be pigmentation.
Decubitus ulcer
It is a trophic ulcer, always found at the dependent part of the prolapsed mass lying outside the
introitus. There is initial surface keratinisation cracks infection sloughing ulceration.
There is complete denudation of the surface epithelium. The diminished constriction of the prolapsed
mass by the vaginal opening and narrowing of the uterine vessels by the stretching effect.
Cervix
Vaginal part - There is chronic congestion which may lead to hyperplasia and hypertrophy of the
fibromusculoglandular components. These lead to vaginal part becoming bulky and congested.
Addition of infection leads to purulent or at times blood stained discharge from ulceration.
Supravaginal part - The supravaginal part becomes elongated due to the strain imposed by the pull of
the cardinal ligaments to keep the cervix in position, whereas the weight of the uterus makes it ill
through the vaginal axis. Chronic interference of venous and lymphatic drainage favours elongation.
Urinary System
Bladder - There is incomplete emptying of the bladder due to sharp angulations of the urethra against
the pubourethral ligation during straining. As a result there is hypertrophy of the bladder wall and
trabecultion.
Ureters
The ureters are carried downward along with elongated Mackenrodt’s ligament and thus
mechanically obstructed by the hiatus of the pelvic floor.
Incarceration :
At times, infection of the para vaginal and cervical tissues makes the entire prolapsed mass
oedematous and congested. As a result, the mass may be irreducible.
Peritonitis :
Rarely, the peritoneal infection (pelvic peritonitis) may occur through the posterior vaginal wall.
Carcinoma : Carcinoma rarely develops on decubitus ulcer.
SYMPTOMS
The symptoms are variable. Even with minor degree, the symptoms may be pronounced;
paradoxically there may not be any appreciable symptom even in severe degree. However, the
following symptoms are usually associated.
a) Feeling of something coming down per vaginam specially while she is moving about. There
may be variable discomfort on walking when the mass comes outside the introitus.
b) Backache or dragging pain in the pelvis. The above two symptoms are usually relieved on
lying down.
c) Dyspareunia.
d) Urinary symptoms (in presence of cystocele).
Difficulty in passing urine, more the strenuous effort the less effective is the
evacuation. The patient has to elevate the anterior vaginal wall for evacuation of the
bladder.
Incomplete evacuation may lead to frequent desire to pass urine.
Urgency and frequency of micturition may also be due to cystitis.
Painful micturition is due to infection.
Stress incontinence is usually due to asso-ciated urethrocele.
Retention of urine may rarely occur.
e) Bowel symptom (in presence of rectocele).
Difficulty in passing stool. The patient has to push back the posterior vaginal wall in
position to complete the evacuation of faeces. Fecal incontinence may be associted.
f) Excessive white or blood stained discharge per vaginam is due to associated vaginitis or
decubitus ulcer.
DIFFERNTIAL DIAGNOSIS
Cystocele:
The cystocele is is often confused with a cyst in the anterior vaginal wall, the commonest being
Gartner’s cyst.
Features of Gartner’s cyst are
Situated anteriorly or anteriolaterally and of variable size
Rugosities of the overlying vaginal rnucos, are lost.
Vaginal mucosa over it becomes tense and shiny.
Margins are well-defined.
It is not reducible.
There is no impulse on coughing.
The metal catheter tip introduced per urethra fails to come underneath the vaginal
mucosa,
Uterine prolapse
a) Congenital elongation of the cervix
it is unassociated with prolapse (usually).
Vaginal part of the cervix is elongated.
External os lies below the level of ischial spines.
Vaginal fornices are narrow and deep.
Cervix looks conical.
Uterine body is normal size and in position.
b) Chronic inversion
Leading protruding mass is broad.
There is no opening visible on the leading part.
It looks shaggy.
Internal examination reveals — cervical rim is on the top around the mass.
Rectal examination confirms the absence of the uterine body and a cup-like
depression is felt.
c) Fibroid polyp
The mass is saggy with a broad leading part.
No opening is visible on the leading part.
Internal examination reveals the pedicle coming out through the cervical canal or
arising from the cervix.
Rectal examination reveals normal shape and position of the uterus.
MANAGEMENT OF PROLAPSE
Preventive • Conservative • Surgery
PREVENTIVE
The following guidelines may be prescribed to prevent or minimize genital prolapse.
Adequate antenatal and intranatal care
To avoid injury to supporting structure during vgnal delivery
Adequate postnatal care
Encourage early ambulance
Encourage pelvic floor exercise
General measures
Avoid strenuous activity
Avoid filure pregnancy too soon and too many by contraceptive practice
CONSERVATIVE
Improvement of general measures
Oesrtogen replacement therapy may improve minor degree prolapsed in post menopausal
women.
Pelvic floor exercise in an attempt to strengthen the muscles.
PESSARY TREATMENT
To relieve the symptoms by stretching the hiatus urogenitalis,thus preventing vaginal and uterine
descent.
Erly pregnancy- pressary should be placed inside up to 8 weeks when uterus becomes
sufficiently enlarged to sit on the brim of the pelvis
Puerperium- to facilitate involution
Patient absolutely unfit for surgery
Patent unwilling for operation
While waiting for operation
SURGICAL MANAGEMENT
Guideline for prolapsed surgery
1. Surgery is the treatment of choice where conservative treatment fails.
2. Surgical procedure may be
Restorative –
o Correcting her own support tissues
o Compensatory
Expirative
o Removing the uterus and correcting the support tissue
Obliterative – closing the vagina
3. Meticulous examination even under anesthesia is necessary to establish correct diagnosis
4. The procedure depends upon the anatomic alteration of the structures
5. Consideration should be given on age, reproductive and sexual function of the women
Types of operations
1) Anterior colporrhaphy
To correct cystocele and urethrocele. The underlying principle is to excise a portion of the
relaxed anterior vaginal wall to mobilize the bladder and push it upwards after cutting the
vesicocervical ligament.
2) Paravaginal defect repair
For recurrent cystocele following repair
3) Perineorrhaphy/colpoperineorrhaphy
It is an operation designed to repair the prolapsed of posterior vaginal wall.
4) Repair of enterocele and vault prolapsed
Along with the repair operation, enterocele is to be corrected transvaginally. The principle of
correction are to obliterate the neck of the enteocele sac as high as possible by purse string
suture
5) Pelvic floor repair
The prolapsed of the anterior vaginal wall is associated with any orm of posterior wall
prolapsed and relaxed perineum. Such corrective procedure is known ass pelvic floor repair
6) Fothergill’s or Manchester operation
The operation is designed to correct uterine descent associated with cystocele
7) Vaginal hysterectomy with pelvic floor repair
Removal of the uterus per vginum. It should be emphasized that hysterectomy is not the
surgery for prolapsed. It is associated with the repair of the pelvic floor.
8) Cervicopexy or sling operation
The operation is indicated in congenital or nulliparous prolapsed without cystocele where the
cervix is pulled up mechanically through abdominal route.
UTEROVAGINAL
Uterus along with vaginal wall Vaginal hysterectomy with PFR
Fothergill’s operation
VAGINAL WALL
Following hysterectomy Vaginal : repair of the vaginal vault along with
(vaginal or abdominal) PFR
Sacrospinous colpopexy
Colpoclesis
Abdominal sacral colpopexy
UTERUS (WITHOUT VAGINAL Cervicopexy or sling opeation
WALL)
COMPLCATION OF VAGINAL REPAIR OPERATION
Operative
Hemorrhage
Trauma
Postoperative
Urinary retension
Hemorrhage
Sepsis
Late
Dyspareunia
Recurrence of prolapsed
VVF following bladder injury
RVF following rectal injury
CHRONIC INVERSION
DEFINITION
Inversion is a condition where the uterus becomes turned inside out, the fundus prolapsed through
the cervix.
CAUSES
Incomplete obstetric inversion unnoticed or left uncared following failure to reduce for a
variable period of 4 weeks or more
Submucous myomatous polyp
Sarcomatous changes of fundal fibroma
Senile inversion following high amputation of the cervix
TYPES
Two types
Incomplete – fundus protrudes through the cervix and lying inside the vagina
Complete – whole of the uterus including the cervix are inverted
SYMPTOMS
Sensation of something coming down per vaginum
Irregular vaginal bleeding
Offensive vaginal discharge
SIGNS
Inspection
Protruding mass with following features
Globular
No opening in the leading pat
Shaggy look
Tumour may present at the bottom
Per vaginum
Cervical rim is felt high up in incomplete variety
Rectal examination
Rectoabdominal examination to note uterine cavity using uterine sound
Sound test
Demonstration of shortness or absence of uterine activity using uterine sound
TREATMENT
General measures
Correction of aanemia by bloo transfusion
Local sepsis is to be controlled
Definitive treatment
Rectification should be done by surgery
Preservation or removal of the utrus
Conservative
Retificaion
It is a sound policy to remove the tumor by shelling from its capsule raaather than dividing
the pedicle in such cases.
NURSING MANAGEMENT
1) Pain related to relaxation of pelvic support and elimination difficulties
Obtain a thorough pain history including ongoing pain experience, method of pain
control used.
Assess the onset, severity, duration, precipitating factor, an aggravating factor of pain
Encourage the client to increase fluid nd fiber in diet
Assist the client in setting regular toileting pattern
Urge the client to avoid the routine use of laxative to prevent compound constipation
2) Impaired Urinary Elimination related to Mechanical trauma, surgical manipulation, presence
of local tissue edema, hematoma
Note voiding pattern and monitor urinary output
Palpate bladder. Investigate reports of discomfort, fullness, inability to void.
Provide routine voiding measures, e.g., privacy, normal position, running water in
sink, pouring warm water over perineum.
Provide/encourage good perianal cleansing and catheter care (when present)
Check residual urine volume after voiding as indicated
3) Low Self-Esteem related to Concerns about inability to have children, changes in femininity,
effect on sexual relationship
Provide time to listen to concerns and fears of patient and SO. Discuss patient’s
perceptions of self related to anticipated changes and her specific lifestyle
Assess emotional stress patient is experiencing. Identify meaning of loss for patient.
Encourage patient to vent feelings appropriately
Provide accurate information, reinforcing information previously given
Ascertain individual strengths and identify previous positive coping behaviors.
Provide open environment for patient to discuss concerns about sexuality.
4) Knowledge deficit related to the cause of structural disorder and treatment option
Assess the clients understanding on pelvic organ prolapsed
Discuss the association between uterine, rectal and bladder prolapsed and symptoms
to help the client understand about the ethiology of her symptoms and pain.
Provide written material with picture to promote learning and understand the women
what had occurred to her body secondary to age, childbirth, weight gain and gravity
Document details of teaching and learning and allow for continuity of care and
further education if needed
CONCLUSION
While women have little control over some contributing factors to prolapse (eg., having a long labour
or giving birth to a large infant), there are a number of other steps they can take to reduce their risk.
Many women will have some kind of pelvic organ prolapse. It can be uncomfortable or painful. But it isn't
usually a big health problem. It doesn't always get worse. And in some women, it can get better with time.
BIBLIOGRAPHY
1) D C Dutta. Text book of gynecology including contraception. 5th edition. 2009. New central
book agency. Page no 193-219
2) Annamma Jacob.A comprehensive textbook on midwifery and gynaecological
nursing. 1st edition. 2005. Jaypee publishers. Page no 681
3) Sussan Scot. Maternity and pediatric Nursing. 1st edition. Lippincot publishers. Page
no 203
4) Lowdermilk,pery,cashion. Maternity nursing. 8th edition. Mosby Publishers. .
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