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UTERINE PROLAPSE

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Uterine Prolapse/Pelvic relaxation/Pelvic floor hernia


a descent or herniation of the uterus into or beyond the vagina considered under the broader heading of "pelvic organ prolapse" which also includes cystocele, urethrocele, enterocele, and rectocele. anatomically, the vaginal vault has 3 compartments: - an anterior compartment (consisting of the anterior vaginal wall) - a middle compartment (cervix) - posterior compartment (posterior vaginal wall). UP involves the middle compartment

Four stages of uterine prolapse are defined:


stage I - descent of the uterus to any point in the

vagina above the hymen stage II - as descent to the hymen stage III - as descent beyond the hymen stage IV - as total eversion or procidentia
Uterine prolapse always is accompanied by some degree of vaginal wall prolapse..

Assessment
A complete pelvic examination is required, including a

rectovaginal examination to assess sphincter tone. A Sims speculum or a standard bivalve speculum with the anterior blade removed may facilitate diagnosis. Physical findings may be enhanced by having the patient strain during the examination or by having her stand or walk prior to examination. Standing with an empty bladder may result in a 1-2 stage difference in the degree of prolapse noted on examination when compared to a supine position with a full bladder. Mild uterine prolapse may be recognized only when the patient strains during the bimanual examination.

Evaluate all patients for estrogen status.


Signs of decreased estrogens

Loss of rugae in the vaginal mucosa Decreased secretions Thin perineal skin Easy perineal tearing Physical examination should also be directed toward ruling out serious conditions that may rarely be associated with uterine prolapse, such as infection, urinary outflow obstruction with renal failure, and hemorrhage. If urinary obstruction is present, the patient may exhibit suprapubic tenderness or a tympanitic bladder. If infection is present, purulent cervical discharge may be noted.

Lab Studies
Laboratory studies are

Imaging Studies

unnecessary in uncomplicated cases. Cervical cultures - cases complicated by ulceration or purulent discharge Papanicolaou test (Pap smear cytology) or biopsy - in rare cases of suspected carcinoma BUN and creatinine measurement - if PE findings suggest urinary obstruction

Pelvic ultrasound

examination Ultrasonography MRI - to grade pelvic organ prolapse

Pelvic heaviness or pressure Protrusion of tissue: A patient who reports of a "bulge" has been

found to be a valuable screening tool for the detection of pelvic organ prolapse (81% PPV, 76% NPV). Pelvic pain Sexual dysfunction, including dyspareunia, decreased libido, and difficulty achieving orgasm Lower back pain Constipation Difficulty walking Difficulty urinating Urinary frequency Urinary urgency Urinary incontinence Nausea Purulent discharge (rare) Bleeding (rare) Ulceration (rare)

Signs and Symptoms

Pathophysiology
Age Race (Hispanic) Pelvic structure (Anthropoid) Uterine structure Lifestyle (occupation) Multiparus Menopause

Decreased estrogen level

Obstetrical trauma

Weakening of the pelvic tissues, muscles, ligaments

Uterine prolapse
GI: Dysuria Constipation Urinary frequency Nausea & vomiting Urinary incontinence Urinary urgency Integumentary: Protrusion of tissue ulceration

Stage I (descent to any point of the vagina above the hymenal remnants)

Musculoskeletal: Pelvic heaviness Pelvic pain Low back pain

Stage II (descent to the hymen)

Reproductive: Sexual dysfunction Decreased libido

Stage III (descent beyond the hymen) Circulatory: Bleeding Stage IV (total eversion or procidentia)

Complications:

Urinary retention Constipation Hemmorhoids Cervical ulceration Infection (possible) Cystitis

Treatment/Medical Mngt:
Pessaries
+ fitted into the vagina to hold the uterus in place + temporary or permanent form + fitted individually for each woman + attaining and maintaining optimal weight is recommended

Surgery
+ uterus sutured back into place &

+ colpopexy - involves the use of surgical mesh for supporting the uterus
+ hysterectomy removal of uterus

Nursing management:
preventive measures:
Early visits to HC provider = early detection Teach Kegels exercises during PP period

preoperative nursing care:


Thorough explanation of procedure, expectation and effect

on future sexual f(x) Laxative and cleansing edema (rectocele) independently, at home a day prior procedure Perineal shave prescribed also Lithotomy position for surgery

postop nursing care:


Pt. is to void few hours after surgery; catheter if

unable (after 6 hrs)

NURSING

Pain

Administer analgesic as

prescribed. Provide comfort measures such as backrub. Provide diversional activities such as guided imagery and

Constipation
Administer stool

softeners/laxatives as prescribed. Encourage increase in fluid and fiber intake. Encourage early ambulation.

Urinary Incontinence
Determine if client is aware of

incontinence. Developmental issues/ medical conditions that can impair patients awareness and sensory perception of voiding. Determine patients particular symptoms (e.g. continuous dribbling). Implement bladder training for incontinence management by providing ready acces to bathroom or commode, encouraging adequate fluid intake, and establishing voiding/bladder emptying.

Sexual dysfunction
o Provide factual information about

individual condition involved to promote informed decision making. o Provide for ways to obtain privacy to allow for sexual expression for individual and/or between partners with out embarrassment and/or objection of others. o Establish therapeutic nurse-client relationship to promote treatment and facilitate sharing of sensitive information.

Risk for Infection

Observe for localized signs of

infection. Note for signs and symptoms for sepsis. Stress proper hand hygiene.