INTRODUCTION

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.

Prolapse Retroversion is usually implicated in the pathophysiology of prolapse which is

mechanically caused by traction following cystocele.

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.

PREGNANCY IN RETROVERTED UTERUS

Retroversion 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, 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 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.

PELVIC ORGAN PROLAPSE

INTRODUCTION
Uterus (womb in which a fetus develops) is normally held in place inside pelvis with various
muscles, tissue, and ligaments. Sometimes-because of childbirth or difficult labor and delivery-these
muscles weaken. As a woman ages and with a natural loss of the hormone estrogen, her uterus can
collapse into the vaginal canal, causing the condition known as a prolapsed uterus.

DEFINITION
It is a clinical entity which includes the descent of vaginal wall and or the uterus. It is infact a form
of hernia

ETHIOLOGY OF PELVIC ORGAN PROLAPSE

The genital prolapsed occur due to the weakness of the structure supporting the organs in position.
These factors may be anatomical or clinical.
The clinical factors are
 Predisposing
 Aggravating
Predisposing factors
 Acquired
 Congenital
Acquired
Vaginal delivery with consequent injury to the supporting structure is the single most acquired
predisposing factor in producing prolapsed.The prolapse is unusual in cases delivered by caesarean
section. The injury is caused by :
1. Overstretching of the Mackenrodt's and uterosacral ligaments
 Premature bear down efforts prior to full dilatation of the cervix.
  Delivery with forceps or ventouse with forceful traction.
 Prolonged second stage of labour.
 Downward pressure on the uterine fundus in an attempt to deliver the placenta.
 Precipitate labour.
In all these conditions the uterus tends to be pushed down into the flabby distended vagina.
2. Overstretching and breaks in the endopelvic fascial sheath.
3. Overstretching of the perineum.
4. Imperfect repair of the perineal injuries. Poor repair of collagen tissue.
5. Loss of levator function.
6. Neuromuscular damage of levator ani during childbirth.
7. Subinvolution of the supporting structures. This is particularly noticeable in
 Ill-nourished and asthenic women.
 Early resumption of activities which greatly increase intra-abdominal pressure before
the tissues regain their tone.
 Repeated childbirths at frequent intervals.
Congenital
Congenital weakness of the supporting structures is responsible for nulliparous prolapse or prolapse
following an easy vaginal delivery. One should be on the look out for an occult spina bifida and
associated neurological abnormalities.

CLINICAL TYPES OF PELVIC ORGAN PROLAPSE

The genital prolapse is broadly grouped into :
 Vaginal prolapse
 Uterine prolapse
While vaginal prolapse can occur independently without uterine descent, the uterine prolapse is
usually associated with variable degrees of vaginal descent.

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

Anterior Wall Posterior Wall

Uterovaginal Congenital

Cystocele Urethrocele Cystouretrocele

(upper 2/3) ( Lower 1/3) (combined)

Relaxed Perineum Rectocele Valt prolapse

Primary Secondary

Enterocele Following

Vaginal Abdominal
Hysterectomy hysterectomy
 PELVIC ORGAN PROLAPSE ACCORDING TO COMPARTMENTS

Anterior Middle Posterior

Bladder Uterus Pouch of Douglas
Urethra Vaginal Vault Rectum, Perineum

DEGREE OF UTERINE PROLAPSE (CLINICAL)

Three degrees are described
First degree
 The uterus descend down from its normal anatomical position but external os still remain
insde the vagina
Second degree
 The external os protrudes outside the vaginal interoitus but uterine body still remains inside
the vagina
Third degree
 The uterine body descends to the outside of the interoitus
Procidentia
 Invoves prolapsed of the uterus with eversion of the entire vagina
Complex prolapsed
 Is one when prolapsed is associated with some other specific defects.

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.

CLINICAL EXAMINATION AND DIAGNOSIS OF PELVIC ORGAN PROLAPSE

1. A composite examination — inspection and palpation : Vaginal, rectal, rectovaginal or even
under anaesthesia may be required to arrive at a correct diagnosis.
2. Pelvic Organ Prolapse (POP) is evaluated by pelvic examination in both dorsal and standing
positions. The patient is asked to strain as to perform a Valsalva maneuver during
examination. This often helps to demonstrate a pro-lapse which may not be seen at rest.
3. A negative finding on inspection in dorsal position should be reconfirmed by asking the
patient to strain on squatting position.
4. Prolapse of one organ (uterus) is usually asso-ciated with prolapse of the adjacent organs
(bladder, rectum).
5. Aetiological aspect of prolapse should be evaluated.
Cystocele : There is a bulge of varying degree of the anterior vaginal wall which increases when the
patient is asked to strain. This may be seen on inspection. In others, to elicit this, one may have to
separate the labia or depress the posterior vaginal wall with fingers or using Sims' speculum, placing
the patient in lateral position. The mucosa over the bulge has got transverse rugosities.The bulge has
got impulse on coughing, with diffuse margins and is reducible
Cystourethrocele : The bulging of the anterior vaginal wall involves the lower-third also.One may
find the urine escape out through the urethral meatus when the patient is asked to cough. To elicit
this test bladder should be full
Relaxed perineum: There is gaping interoitus with old scar of incomplete perineal tear. The lower
part of the posterior vaginal wall is visible with or without straining.
Rectocele and enterocele : when the two condition exists together there is bulging of the posterior
vaginal wall with a transverse sulcuss between the two ultimate differtiation of tee two entities is by
rectal or rectovaginal examination.
Uterine prolapsed : In second or third degree of prolpse inspection can reveal a mass protruding out
through the nteroitus, the leading part of which is the external os. In first degree uterine prolapsed the
diagnosis is made through speculum examination when one finds the cervical descend below the
level of ischeal spine on straining.
To diagnose the third degree prolapsed palpation is essential. If thumb iss placed anteriorly and
fingers posteriorly above the mass outside the interoitus are opposed.

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.

Types of prolapse and the common surgical repair procedure

VAGINAL WALL
Anterior (upper 2/3rd or whole) Anterior colporrhaphy
Paravaginal repair
Posterior ( loer 2/3) Colpoperineorrhaphy
Posterior Vaginal repair of enterocele with PFR
McCall culdoplasty
Combined anterior and posterior Pelvic floor repair

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. .
5) Lynna Y.Littileton. Maternity nursing care. 1st edition. Delmar lerning pubishers. .
6) Fraser Cooper. Myles text book for midwives. 14th edition. Churchill Livinstone
Publishers.