1. Prepared By Miss: Raheegeh Awni
UTERINE PROLAPSE
Prepared By Miss: Raheegeh Awni

2. Uterine prolapse
Although vaginal prolapse can occur without uterine prolapse, the uterus cant descend without carrying the vagina with it.
Complete procidentia procdentia represents failure of all genital supports.
Hypertrophy, elongation, congestion and edema of the cervix may cause large protrusion of tissue beyond the introitus, which may be mistaken from procidentia.

3. Uterine prolapse occurs when pelvic floor muscles and ligaments stretch and weaken, providing inadequate support for the uterus. The uterus then descends into the vaginal canal.

4. Uterine prolapse often affects postmenopausal women who've had one or more vaginal deliveries.
Damage to supportive tissues during pregnancy and childbirth, effects of gravity, loss of estrogen, and repeated straining over the years all can weaken your pelvic floor and lead to uterine prolapse.

5. Classification of uterine prolapse
Classified according to severity:
First degree-the fundus reaches the internal os.
Second degree-the body or corpus of the uterus inverted to the internal os.
Third degree-the uterus, cervix and vagina
are inverted and visible.

6. Causes Pregnancy and trauma during childbirth,
after a difficult labor and delivery,
aging
reduced amounts of circulating estrogen after menopause
tumor in the pelvic cavity.
Genetics also may play a role in strength of supporting tissues.
Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent

7. Risk factors One or more pregnancies and vaginal births
Giving birth to a large baby
Increasing age
Frequent heavy lifting
Chronic coughing
Frequent straining during bowel movements
Genetic predisposition to weakness in connective tissue

8. Some conditions, such as obesity,
chronic constipation
chronic obstructive pulmonary disorder (COPD), can place a strain on the muscles and connective tissue in pelvis

9. Symptoms Uterine prolapse varies in severity.
Sensation of heaviness or pulling in pelvis
Tissue protruding from vagina
Urinary difficulties, such as urine leakage or urine retention
Trouble having a bowel movement
Low back pain
Feeling as if a woman is sitting on a small ball
Sexual concerns

10. Complications Possible complications of uterine prolapse include:
Ulcers. The friction may lead to vaginal sores (ulcers). In rare cases, the sores could become infected.
Prolapse of other pelvic organs. If a woman has uterine prolapse, she also might have prolapse of other pelvic organs, including bladder and rectum.

11. A prolapsed bladder (cystocele) bulges into the front part of vagina, which can lead to difficulty in urinating and increased risk of urinary tract infections.
Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele), which may lead to difficulty having bowel movements.

12. Tests and diagnosis
Pelvic exam. a complete pelvic exam to check for signs of uterine prolapse.
A woman is asked to bear down as if having a bowel movement to see how much that affects the degree of prolapse.
To check the strength of pelvic muscles, a woman is instructed to contract them, asif stopping the stream of urine.
Imaging tests. Imaging tests aren't generally needed for uterine prolapse, but they're sometimes helpful in assessing the degree of prolapse.
Ultrasound or magnetic resonance imaging (MRI) to further evaluate your condition

13. Prevention 1- Maintain a healthy weight
2- Kegel exercises Practice— special exercises in which a repeated squeezing and relaxing the muscles of pelvic floor — during pregnancy and afterward.
To perform these exercises, tighteness of pelvic muscles as if one is stopping stream of urine.
Hold for a count of five, relax and repeat. Do these exercises several times a day.
3- Controlling of coughing

14. Treatments and drugs
Losing weight, stopping smoking and getting proper treatment for contributing medical problems, such as lung disease with coughing, may slow the progression of uterine prolapse.
In very mild uterine prolapse, either without symptoms or with symptoms that aren't terribly bothersome, no treatment is necessary. However,pelvic floor may continue to lose tone, making the uterine prolapse more severe.

15. Lifestyle changes
Lifestyle changes may be the first step to ease symptoms of uterine prolapse:
1- Achieve and maintain a healthy weight, to minimize the effects of being overweight on supportive pelvic structures.
2- Perform Kegel exercises, to strengthen pelvic floor muscles.
3- Avoid heavy lifting and straining, to reduce abdominal pressure on supportive pelvic structures

16. Vaginal pessary
A vaginal pessary fits inside the vagina and is designed to hold the uterus in place.
The pessary can be a temporary or permanent form of treatment.
Vaginal pessaries come in many shapes and sizes.
Once the pessary is in place, it should be dislodged and feels reasonably comfortable.
A woman is advised to remove the device and clean it with soap and water frequently.
leave the pessary out overnight and reinsert it each day to use only during waking hours.

17. Surgery to repair uterine prolapse
surgical repair is an option.
Surgical repair of uterine prolapse usually requires vaginal hysterectomy to remove uterus and excess vaginal tissue.
Surgical repair may be possible through a graft of your own tissue, donor tissue or some synthetic material onto weakened pelvic floor structures to support your pelvic organs.

18. Doctors generally prefer to perform uterine prolapse repair vaginally vaginal procedures are associated with less pain after surgery, faster healing and a better cosmetic result.
Abdominal surgery and Laparoscopic techniques — using smaller abdominal incisions, a lighted camera-type device (laparoscope) to guide the surgeon and specialized surgical instruments — offer a minimally invasive approach to abdominal surgery.

19. scenario
History
An 83-year-old woman complains of a dragging sensation in the lower abdomen and
lower back pain when standing or walking. It has been present for some years but she can now only stand for a short time before feeling uncomfortable. It is not noticeable at night.
She has had four vaginal deliveries. She had her menopause at 52 years and took hormone-replacement therapy for several years for vasomotor symptoms.
She has not had any postmenopausal bleeding and has not had a smear for several years.

20. She is generally constipated and sometimes finds she can only defecate by placing her fingers into the vagina and compressing a ‘bulge’ she can feel.
She has mild frequency and gets up twice most nights to pass urine.
There is no dysuria or haematuria.
Occasionally she does not get to the toilet in time and leaks a small amount of urine, but this does not worry her unduly.
Medically she is very well and does not take any medications regularly. She lives alone and does her own shopping and housework.

21. Examination
On examination she appears well. Blood pressure and heart rate are normal. She is of average build.
The abdomen is soft and non-tender.
There is a loss of vulval anatomy consistent with atrophic changes.
On examination in the supine position there is a mild prolapse.
On standing, the cervix is felt at the level of the introitus. There is a large posterior wall prolapse and a minimal anterior wall prolapse.

22. Questions
• What is the diagnosis for her discomfort and pain?
• How would you manage this patient?

23. ANSWER
The diagnosis is of second-degree uterovaginal prolapse with rectocoele.
Prolapse is traditionally categorized according to the level of descent of the cervix in relation to the introitus:
• first degree: descent within the vagina
• second degree: descent to the introitus
• third degree: descent of the cervix outside the vagina
• procidentia: complete eversion of the vagina outside the introitus.

24. More complex grading systems are used by some specialists that involve specific measurements
using the hymen as a reference point.
Common presenting symptoms are of ‘something coming down’, a ‘lump’ or a dragging sensation. Symptoms are always worse on standing or walking because of the effect of gravity.
Prolapse is more common in women who are parous, have had long or traumatic deliveries, have a chronic cough or constipation.
However it may occur in any woman, even if she is nulliparous, as it relates to collagen strength.

25. Management
Initial management involves treating the constipation with dietary manipulation and laxatives.
This may relieve some of the symptoms and is also important to prevent recurrence if surgery is to be performed.
Pelvic floor exercises are helpful for mild prolapse and to preserve the integrity of repair postoperatively, though in this case they are unlikely to make any significant difference to the presenting symptoms.
If surgery is not wanted then she can try a ring pessary to
hold up the prolapse, which can work extremely well and only needs replacing every 6 months.

26. Although she is 83 this woman has no medical problems and should be offered definitive
prolapse surgery which for her involves vaginal hysterectomy and posterior vaginal wall
repair (colporrhaphy).
As there is no abdominal incision involved, recovery is quick and she would expect to be in hospital for around 3 days.

27. hystrectomy

28. Hysterectomy
Is the term used to describe an operation involving the removal of the uterus Surgical removal of the uterus, either completely (total hysterectomy) or leaving the cervix (subtotal hysterectomy).
It is performed in the presence of cancer or a benign fibroid tumour if the fibroid is large or rapidly growing, causes excessive bleeding or discomfort, or seems to be breaking down.
Hysterectomy may also be performed after cesarean section in cases of complications such as uncontrolled bleeding, gross infection, or pelvic cancer

29. The ovaries and Fallopian tubes may also be removed during a hysterectomy (total hysterectomy with bilateral salpingoopherectomy
Today the most common form of abdominal hysterectomy is performed through a transverse cut in the lower abdominal wall (bikini line incision).
This approach allows easy removal of the ovaries, which is not always possible vaginally.

30. Vaginal hysterectomy is still used in around 1 in 5 hysterectomies in the UK, and allows a quicker recovery.
This operation is usually preferred for prolapse or heavy periods where removal of the ovaries is not essential and the uterus is of normal size (although some surgeons will remove some enlarged wombs vaginally).

31. indications
Hysterectomies are performed for a variety of benign (non-cancerous) conditions, most commonly including heavy, painful periods and prolapse of the uterus.
The painful, heavy periods can be caused by a variety of conditions including endometriosis, fibroids, chronic pelvic infections, and adhesions.
ovarian cyst
changes to the cervix that have not resolved with simple treatments.

32. Complications of hysterectomy
There can be a requirement for blood transfusion – 2–12 per cent for
abdominal hysterectomy and 2–8 per cent for vaginal hysterectomy,
1 per cent for laparoscopic surgery.

33. Morbidity of vaginal hystrectomy (1–2 per 1000)
Haemorrhage
Damage to bowel
Bladder
Ureter
Cerebral mortality
Life-threatening events
Urinary retention
Other

34. Morbidity from total abdominal hysterectomy.
Wound infection %
Urinary tract infection (UTI)
Other infections
Bleeding
Deep vein thrombosis/pulmonary embolism (DVT/PE)
At 3 months cumulative wound infection or UTI
40.0

35. Hysterosalpingography

36. Hysterosalpingography
Hysterosalpingography, also called uterosalpingography, is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called fluoroscopy and a contrast material.

37. Fluoroscopy is a special x-ray technique that makes it possible to see internal organs in motion.
When the uterus and fallopian tubes are filled with a water-soluble contrast material, the radiologist is able to view and assess their anatomy and function.

38. Hysterosalpingography

39. Hysterosalpingography

40. Benefits
Hysterosalpingography is a minimally invasive procedure with rare complications.
Hysterosalpingography is a relatively short procedure that can provide valuable information on a variety of abnormalities that cause infertility or problems carrying a fetus to term.

41. Hysterosalpingography can occasionally open fallopian tubes that are blocked allowing the patient to become pregnant afterwards.
No radiation remains in a patient's body after procedure.

42. Risks A slight chance of cancer from excessive exposure to radiation.
It worsen chronic inflammatory condition, pelvic infection or untreated sexually transmitted disease.
Notify the physician or technologist before the procedure to avoid infection.

43. Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant.

44. uses of the procedure
1- Is primarily used to examine women who have difficulty becoming pregnant by allowing the radiologist to evaluate the shape and structure of the uterus, the openness of the fallopian tubes, and any scarring within the peritoneal cavity.

45. 2- The procedure can be used to investigate repeated miscarriages that result from congenital abnormalities of the uterus and to determine the presence and severity of these abnormalities, including:
tumor masses
adhesions
uterine fibroids
Abnormal structure

46. 3- Hysterosalpingography is also used to evaluate the openness of the fallopian tubes, and to monitor the effects of tubal surgery, including:
blockage of the fallopian tubes due to
infection or
scarring
tubal ligation

47. 4- the closure of the fallopian tubes in a sterilization procedure and a sterilization reversal
5. the re-opening of the fallopian tubes following a sterilization or disease-related blockage

48. Preparation
This procedure is generally done in the x-ray department of a hospital or large clinic.
General anesthesia is not needed.
A pain reliever may be taken prior to the procedure to lessen the severity of cramping.

49. Aftercare
Observed for some period after the procedure to ensure that she does not have any allergic reactions to the dye.
A sanitary napkin may be worn after the procedure to absorb dye that will flow out through the vaginal opening.
If a blockage is seen in a tube, the patient may be given an antibiotic.

50. Notify physcian if she experiences excessive bleeding, extensive pelvic pain, fever, or an unpleasant vaginal odor after the procedure.
These symptoms may indicate a pelvic infection.
Counseling to interpret the results of the x rays, and to discuss any additional procedures to treat tubal blockages or uterine abnormalities found.

51. Risks Cramps abdominal pain, pelvic infection, and allergic reactions.
It is also possible that abnormalities of the fallopian tubes and uterus will not be detected by this procedure

52. Normal results
A normal hysterosalpingography will show a healthy, normally shaped uterus and unblocked fallopian tubes.

53. Abnormal results
Blockage of one or both of the fallopian tubes or abnormalities of the uterus may be detected.

54. Dilation (or dilatation) and curettage

55. Dilation (or dilatation) and curettage
(D&C) refers to the dilation (widening/opening) of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping (curettage).
It is a therapeutic gynecological procedure as well as used method of first trimester abortion.

56. Clinical uses
to remove tissue in the uterus that may be causing abnormal vaginal bleeding including postpartum retained placenta; to remove retained tissue retained POC or retained products of conception.
missed or incomplete miscarriage

57. Complications uterine perforation. Infection
Heamorrhage: heavy bleeding is rare
Asherman syndrome: This complication is rare and involves the formation of scar tissue in the uterus, caused by aggressive scraping or abnormal reaction to the scraping.

58. Dilation and Curettage Preparation
A few days before D&C, woman should stop taking drugs such as aspirin, which can cause increased risk of bleeding, and any over-the-counter medications, such as cold tablets and laxatives.
Avoid alcohol and tobacco use.

59. If woman has uncontrolled high blood pressure, a strict treatment plan in or out of the hospital to improve blood pressure.
Control DM
instruct woman not to eat or drink for 12 hours before D&C if it is done under general anesthesia.
Obtain routine blood, urine, and other tests.

60. After the Procedure Cramps, like menstrual cramps after a D&C.
Although most women experience cramps for less than an hour, some women may have cramps for a day or longer.
Some light bleeding for several days may be present.
keep you for an hour or until you become fully awake.

61. Naproxen or ibuprofen are usually given for relief from cramping.
Narcotics are seldom, if ever, needed for the pain following the D&C.

62. Thank you