UTEROVAGINAL PROLAPSE WITH GROSS CERVICAL ELONGATION: An

UnusualPresentation

Dr Ayona Barthakur, MD, DNB. DrSangita Pandey,M.D

Barthakur Clinic and Hospital, Guwahati

Introduction:
Uterine Prolapse is a medical condition which has probably affected women for all of time as it has been documented in the oldest medical literature-the Egyptian Papyri ( KAHUN PAPYRUS 1835 B.C ). The Ebers Papyrus ( 1550 B.C ) recommends " to correct a displaced womb: with oil of earth [petroleum] with fedder [manure] and honey; rub the body of the patient". We , in 2011 A.D report an unusual presentation in pelvic organ prolapse.

Case Report:
A 29 year old primipara presented in the OPD of a private Hospital with the complaints of a:Something coming down P/V, b:- Urinary Frequency and Hesitancy, c:-episodic urinary retention and feeling of incomplete evacuation of the bladder, d:-Discharge P/V and e:- pain lower abdomen for the past 9 months. She was also planning for a second pregnancy. She was a primipara with a 5 year old child, the antenatal period was uneventful other than a history of discharge per vaginum: she had had PROM , was in labour for approximately 16 hours and had a difficult vaginal delivery with Urinary retention both intra and postpartum [ medical records of this particular period were unavailable.] Systemic Examination findings showed a normotensive patient of average height, weight and nutritional status, the positive findings were mild pallor and hypogastric tenderness. On local examination,There was an elongated , cylindrical mass approximately 4 inches long protruding from the introitus, with an unhealthy look: which conveyed the first impression of Procidentia. However on a closer look neither could the cervix be seen per se, nor was the aperture of the external os visible. After a short course of local and systemic antibiotics, she was taken up for surgery under S/A.

EUA

findings:

Image 2 Stage 4 pop image 1

stage 4 PELVIC ORGAN PROLAPSE { POPQ SYSTEM}

Diagram of image 2

Metal catheter in situ

Bulge of catheter tip

Tip of uterine sound

Predominant hypertrophy of 2/3 of the cervical walls on a longitudinal cross section with the os shifted towards the outermost edge[ image 2 and diagram of the same]

LEADING POINT OF PROLAPSE: Upper anterior vaginal wall Ap : + 9 HYPERTROPHIC CERVICAL ELONGATION : C -D = 10 cm

cm i.ecystocoele +++

Image 3

Bladder base

Diagram of image 3

Dissected edge of anterior vaginal wall

Cervical tissue Tip of hegars dilator

extremely pinpint os; initially only the tip of uterine sound the tip of the hegars dilator [ images 2 and 3]

could be inserted followed by

Operation executed:Modified Manchester Fothergill surgery

Image 4 end result

Discussion
Today, any vaginal surgery for POP is dictated by the need of individual patient problems. The procedure performed on this patient kept in mind her desire to preserve her fertility ,and studies have recommended the Manchester Fothergill surgery as a viable fertility sparing procedure[1]. In fact, comparitive studies have shown a good outcome with the MussetPoitout procedure for cases of isolated cervical elongation versus vaginal hysterectomy even for women who did not desire to conserve the uterus[2]. In our case , the post-operative period was uneventful, however, researchers analyzing the vascular morphology of the uterine cervix found that the stromal and vascular wall sclerosis , in the sinusoidal veins of the cervical mucosa and muscles which in turn are triggered off by the cervical hypertrophy and elongation; may all contribute to a distressed vascular capacity and can be considered a morphologic cause of operative complications.[3] A histochemical and histological evaluation of patients with hypertrophic cervical elongation has shown no differences in the amount of elastin, collagen and smooth muscle versus healthy women;but the oestrogen and progesterone levels are greater[4]. The significance of this phenomenon needs to be determined by further research. We thus conclude by stating that we have aimed for a successful site specific correction and can hope that the patients expectations be fully satisfied with a normal conception and uneventful outcome. 1.The Manchester-Fothergill Procedure as a Fertility Sparing Alternative for Pelvic Organ Prolapse in Young Women Christine C. et al Volume 19, Issue 2 , Pages 89-93, April 2006 Journal of Pediatric and Adolescent Gynecology, April 2006 2.. J GynecolObstetBiolReprod(Paris). 2002 Jun;31(4):343-51.[Great elongation of uterine cervix: retrospective study of 20 cases].[Article in French]Deval B, Heitz D, Dara E, Paniel B, Truc JB, Levardon M, PoitoutP.Service de GyncologieObsttrique, Universit Bichat-Beaujon, Hpital Beaujon,100, avenue du Gnral-Leclerc, 92110 Clichy, France. 3.ArkhPatol. 1988;50(2):43-9.[Changes in blood vessels of the cervix uteri in cervical deformities and hypertrophy][Article in Russian]Miagkova M 4.IntUrogynecol J. 2010 Aug;21(8):995-1000. Epub 2010 Mar 24.Hypertrophic cervical elongation: clinical and histological correlations.Ibeanu OA, Chesson RR, Sandquist D, Perez J, Santiago K, Nolan TE.Johns Hopkins University, Baltimore, MD, USA. 5.Bump RC, Mattiasson A, Bo K, Brubaker LP, DeLancey JO, Klarskov P, Shull BL, Smith AR. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. , Am J ObstetGynecol 1996 Jul, 175(1):10-7. 6.Bland DR, Earle BB, Vitolins MZ, et al. Use of the pelvic organ prolapse staging system of the International Continence Society, American Urogynecologic Society and Society of Gynecologic

Surgeons in perimenopausal women. Am J ObstretGynecol 1999, 181: 1324-1328