Uterine prolapse main causes,serious condition and best treatment of uterine prolapse 2023 | by Dr.lalit b.

                Uterine prolapse 

The uterus is not a fixed organ. Minor variations

in position in any direction occur constantly with

changes in posture, with straining, with full bladder or

loaded rectum. Only when the uterus rests habitually

in a position beyond the limit of normal variation,

should it be called displacement.

                 Uterine prolapse 

Degrees of uterine prolapse 

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 of Uterine prolapse 

 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.

 

           Stages of uterine prolapse 

Acquired

Puerperal: The stretched ligaments caused by

childbirth fail to keep the uterus in its normal position.

A subinvoluted bulky uterus aggravates the condition.

Prolapse: Retroversion is usually implicated in the

pathophysiology of prolapse which is mechanically

caused by traction following cystocele.

Tumor: 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.

Clinical Presentation of uterine prolapse 

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 — It is due to

varicosities in broad ligament produced by the

kinks. The manifestations are those of ‘pelvic

congestion syndrome’ 

 Backache.

 Dyspareunia — Deep dyspareunia may be due

to direct thrust by the penis against the retro-

flexed uterus or the prolapsed ovaries lying in the

pouch of Douglas. Similar pain, if reproduced by

pressing with examining fingers, may confirm its

reality.

 Infertility — In third degree retroversion, the

external os is away from the seminal pool at

the posterior fornix during coitus or it may be

occluded by the anterior vaginal wall. Associated

underdevelopment of the uterus may also be a

contributing factor.

The physician should however, think twice before

declaring to the patient the fact that the particular

symptomatology is related to the backward position

of the womb. This applies especially to backache,

chronic pelvic pain, or dyspareunia. In such cases, a

Hodge-Smith pessary may be placed inside for about

3 months after correcting the uterine position to

anteversion. If the symptoms are in abeyance during

this period and recur back after its removal, it may be

concluded that the symptoms are due to retroverted

uterus. This is known as ‘pessary test’.

Signs

Bimanual examination reveals — (a) The cervix is

directed upwards and forwards. (b) 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 reveals — the cervix

comes in view much easily and the external os points

forwards.

Rectal examination is of help to confirm the

diagnosis.

Differential Diagnosis

The retrodisplacement 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.

Pregnancy in Retroverted Uterus

Retroversion per se has got practically no adverse

effect either on fertility or on early pregnancy

wastage. In pregnancy, spontaneous correction usually

occurs by 12–14 weeks. While the cause of infertility

is mainly mechanical as mentioned earlier, repeated

pregnancy wastage may be due to disturbance in

uterine vascularity or due to thrust during intercourse

especially in abortion prone women.

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 and 4

weeks postpartum.

Corrective Treatment

 Pessary         Surgical

Pessary

Pessary is less commonly used in present day

gynecologic practice. However, it may be indicated:

(1) for pessary test, (2) in subinvolution of uterus (see

, (3) 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 retroverted 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 extraperitoneally to the

under surface of the anterior rectus sheath (). This will pull the uterus forwards and maintains

it permanently in the same position.

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