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Prolapse of uterus

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 The  internal genitalia consists of the:
 Vagina
 Cervix
 Uterus
 Fallopian Tubes
 Ovaries




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 The vagina connects the cervix to the external
  genitals
 It is located between the bladder and rectum
 It functions :
 As a passageway for the menstrual flow
 For uterine secretions to pass down through the
  introitus
 As the birth canal during labor
 With the help of two Bartholin’s glands becomes
  lubricated during SI


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 The  cervix connects the uterus to the vagina
 The cervical opening to the vagina is small
 This acts as a safety precaution against
  foreign bodies entering the uterus
 During childbirth, the cervix dilates to
  accommodate the passage of the fetus
 This dilation is a sign that labor has begun




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 The  muscle and tissue located between
  the vaginal opening and anal canal
 It supports and surrounds the lower parts
  of the urinary and digestive tracts
 The perinium contains an abundance of
  nerve endings that make it sensitive to
  touch




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 A pear shaped organ about the size of a clenched
  fist
 It is made up of the endometrium, myometrium
  and perimetrium
 Consists of blood-enriched tissue that sloughs off
  each month during menstrual cycle
 The powerful muscles of the uterus expand to
  accommodate a growing fetus and push it
  through the birth canal




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 Supports
 Theuterus is primarily supported by the
 pelvic diaphragm, perineal body and the
 urogenital diaphragm. Secondarily, it is
 supported by ligaments and the peritoneum
 (broad ligament of uterus)




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 Major  ligaments
 Uterus is held in place by several peritoneal
  ligaments, of which the following are the
  most important (there are two of each):
 uterosacral ligament from the posterior
  cervix to the sacrum of pelvis
 cardinal ligaments from the side of the
  cervix to the ischial spines
 pubocervical ligaments from the side of the
  cervix to the pubic symphysis

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Prolapse of uterus




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   In prolapse straining causes protrusion of vaginal
    walls at vaginal orifice
   In severe cases cervix of uterus may be pushed
    down to the level of vulva
   Mostly in postmenopausal and multiparous women




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 Pathophysiology

Uterine prolapse is predominantly a disorder of
 parous women whereby there is damage to
 the musculature, ligaments, and nerves




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 Pelvic floor muscles are contracted at rest
  and act to close the genital hiatus and
  provide a stable platform for the pelvic
  viscera.
 Levator ani tone is essential for maintaining
  the pelvic organs in place. Decline of normal
  levator ani tone by direct muscle trauma or a
  denervation injury may occur during vaginal
  delivery. This results in an open urogenital
  hiatus and changes to the horizontal
  orientation of the levator plate, which
  causes a prolapse.

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 Patients with prolapse may have altered
  collagen metabolism, and this can lead to
  prolapse.
 Women with joint hypermobility and rare
  connective-tissue disorders such as Ehlers-
  Danlos or Marfan syndromes have a higher
  prevalence of prolapse.




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 In a case control study, MRI demonstrated
  that women with prolapse were more likely
  to have anatomical defects in the levator
  ani. Consequently, in these women the
  levator ani generated less vaginal closure
  force during maximal contraction




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Aeitiology
   Atonicity and atony after menopause

   Birth injury,excessive stretching of pelvic
    floor muscles and ligaments that occurs
    during child birth

   Peripheral nerve injury such as pudendal
    nerve injury during child birth


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 In  India a higher incidence and more severe
   degree of prolapse occurs in women who are
   deliverd at home by dais.This is because
a) Patients are made to bear down before
   fulldialatation of the cervix
b) The second stage of labour is also prolonged
   with undue stretching of pelvic floor muscle
   as episiotomy is not employed




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 In unmarried or nulliparous women
1. Spina bifida
2. Congenital weakness of pelic floor muscle




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 Ventouse   extraction of foetus before cervix
 is fully dialated




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 Prolonged  bearing down in second stage of
  labor and Crede’s method of downward
  vigourous push on the uterus to expel
  placenta may weaken ligamentory supports
  of genital tract
 Delivery of big baby
 Rapid succesion of pregnancies




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 Raised intra abdominal pressure
 In rare cases pelvic tumor could be the
 cause.


 Obese women are more likely to develop this
 condition as obesity causes additional strain
 on the pelvic muscles.


          coughing due to chronic bronchitis
 Extensive
 and asthma can lead to uterine prolapse.

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 Surgical procedures
 Abdomino peritoneal excision of rectum and
  radical vulvectomy




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   Excessive straining and pushing during bowel
    movements due to constipation can be a
    cause.
   Women with retroverted uterus are at
    higher risk for uterine prolapse




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 Inrecent years,the incidence of prolapse is
  greatly reduced. The more liberal use of
  caesarean section and the elimination of
  labours are probably the two most
  important factors




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CLASSIFICATION OF PROLAPSE
 Anterior vaginal wall
o Upper two thirds-   cystocoele
o Lower one third -    urethrocoele
 posterior vaginal wall
o Upper one third-   entercoele
o Lower two thirds -rectocoele




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 Uterine  descent
 Primary - descent of cervix in to vagina
 Secondary- descent of cervix up to introitus
 Teritiary - descent of cervix outside the
  introitus
 Procidentia : all of the uterus outside the
  introitus




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                        Cystocoele
  In prolapse of anterior vaginal wall,the upperpart
  of anterior vaginal wall descends and in advanced
  cases protrude outside vaginal orifice.
 In these cases vesical and vaginal fasciae are
  thinned out and fail to support the bladder,sothat
  bladder prolapses with anterior vaginalwall .This
  condition is called cystocele




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 The weakening of the muscular wall in this
condition can cause urine to leak from the
bladder when there is an increase in internal
abdominal pressure such as in sneezing or
coughing




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Enterocoele  can be defined as
 the herniation of the pouch of
 Douglas into the upper ⅓ of
 posterior vaginal wall. The
 peritoneal sac may contain loops
 of bowel. Standing leads to a
 pulling sensation and backache
 is relieved by lying down.
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Rectocoele  : The herniation of
 the lower ⅔ of posterior vaginal
 wall where the rectum bulges
 into the vagina. This makes
 bowel movements difficult to
 the point that it may need to
 push on the inside of vagina to
 empty bowel.
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In  most cases of prolapse of uterus
 the vaginal portion of cervix is
 hypertrophied
In third degree prolapse epithelium
 covering cervix is thickened trophic
 ulcercs may be seen
In prolapse of uterus supra vaginal
 portion cervix is sometimes
 elongated
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Ulceration  of dependent
  portion of prolapsed tisse is
  caused by
o Friction
o Congestion
o Circulatory changes


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Something   protruding either at vulva
 or outside < straining >lying down
A ‘bearing down’ sensation
Backache >rest
Vaginal discharge
Increased frequency of micturition
Stress incontinence
Difficulty in voiding urine
 Coital problems

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She is made to strain and degree of
 prolapse should be noted
Stress incontinence should be looked for
 by asking the patient to cough
Palpation of levator ani to determine
 muscle tone
Speculum examination to determine
 degree of prolapse
Cervical cytolgy

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 Vaginal examination to determine
o Length of cervix
o Positon
o mobility




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Hemoglobin
Urine examination
Bloodurea
Blood sugar
X ray
ECG
High vaginal swab
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Vulval cyst
Cyst of ant vag wall
Urethral diverticula
Congenital elongation of cervix
Cervical fibroid polyp
Chronic invertion
Rectal prolapse

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Antenatal  physiotherapy
Proper management of
 second stage of labour
a)Generous episiotomy
b)Low forceps delivery
c)Suturing of perenieal tear


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Post  natal exercises
Early postnatal ambulation
Provision of adequate rest for
 first six months after delivery
Reasonable interval between
 pregnancies
Prophylactic hormone
 replacement therapy
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Pessary treatment.
Operative Treatment




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Depends on
Age
Desire to retain uterus
Menstrual history
General condition
 degree of uterine prolapse



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 Anterior colporrhaphy _ This operation is
  performed to repair a cystocele and
  urethrocele.
 Posterior colporrhaphy _ This operation is
  performed to repair a rectocele.
 Fothergill’s Repair(Manchester
  Operation)_Anterior colporrhaphy with
  amputation of cervix.This operation reserves
  menstrual and child bearing functions.This is
  suitable for women under40 years who have
  completed their families but are desirous of
  retaining menstrual function.

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 Shirodkar’s  Procedure
       _To avoid obstetrical complications of
  fothergill operation,Shirodkar modified this
  procedure. cervix is not amputated and
  pregnancy complications avoided.
 Vaginal Hysterectmy with pelvic floor repair
  suitable for women over 40 who have
  completed their families .
 Le-Fort’s Repair- Reserved for very elderly
  women who are unfit for major surgical
  procedures.

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 Colpocleisis-elderly women who suffer from
  vault prolapse after previos hysterectomy
 Abdominal Sling Operations_ Designed for
  young women who are suffering from second
  or third degree prolapse




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 Pessary treatment
  Indications
:Patient prefers a pessary.
        Pelvic surgery unaviodable risks
        Prolapse amenable to pessary
        The patient is not fit for surgery
        Patient wishes to delay operation



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GENITALIA- FEMALE PROLAPSES uterus,
 ARG MET,ARG NIT,AUR MET,LIL TIG, NAT H
  ,PALL,PLATINA,PULS,RHUTOX,SEPIA
 GENITALIA- FEMALE bearing down,uterus
   agar,bell,cham,lil tig,murex,nat h,nat
 mur,platina,sabina,sec,sep,stann




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           FEMALE PROLAPSES uterus,
 GENITALIA-

     ARG MET,ARG NIT,AUR MET,LIL TIG, NAT
 H PALL,PLATINA,PULS,RHUTOX,SEPIA
    CONFINEMENT AFTER SEPIA

 GENITALIA   FEMALE PROLAPSES vagina ,SEPIA




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FEMALE PROLAPSED UTERUS
   ARG MET,ARG NIT,BORAX,CALC,LIL TIG, NAT
  H,NAT PHOS, PALL,PLATINA,PULS, SEPIA
 FEMALE   BEARING DOWN PAIN genitalia and
  uterus
    AGAR,BELL,CHAM,LILI TIG,MUREX,NAT
  H,NAT M,PLAT,SAB,SEC,SEPIA,SATNNUM




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 Prolapse falling
   bell,calc,ign, merc, mur
  acid,puls,rhus tox,sulph
 Uterus prolapse       pall,platina
 Female organs in general

  Labour like bearing down pain
Bell,cham,gels,nux vom,puls, sepia


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Uterus   prolapse(falling,procidentia)

 argmet,aurmet,benacid,bry,calc,hel
 on,lyss,palla,plat, rhustox,sepia




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 Female
  sexualsystem,displacements,prolapsus
 Alertis,aur mur nat,bell,calc,collin,ferr
  iod,frax,helon,lil tig,mel cum
  sale,murex,nux vom,podo,puls,rhus
  tox,sep,stann




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Genitalia female organs
 prolapsus uterus
   ARN ,BELL,LIL TIG,NUX
 VOM,RHUS TOX,SEPIA
Genitalia female organs
 prolapsus vagina
 SEP


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FEMALE  PROLAPSUS
Arg,arg nit,aur,aur
 sulph,borax,calc, liltig,nat
 hp,nat p,pall,plat,puls,sep




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posted:8/27/2011
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