uterine prolapse in displacement final.ppt
- 1. Uterine Displacement Submitted to: Resp. Ms. Vibha Associate professor SINPMS,Badal. Submitted by: Sonia M.Sc Nursing 2nd year SINPMS, Badal.
- 3. The uterus is normally anteverted,anteflexed Version: is the angle between the longitudinal axis of cervix, and that of the vagina. Flexion: is the angle between the longitudinal axis of the uterus, and that of the cervix.
- 4. Prolapse of the Uterus • Prolapse : is a type of hernia and refers to the downward displacement of the vagina and uterus from the cavity that normally contain them.
- 5. Prolapse Definition Prolapse literally means "to fall out of place." In medicine, prolapse is a condition where organs, such as the uterus, fall down or slip out of place. It is generally reserved for organs protruding through the vagina, or for the misalignment of the valves of the heart. Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.
- 6. Displacement of the uterus within the pelvic cavity is classified according to the direction of the displacement which are: 1. Retroversion - backward tilting of the uterus toward the rectum. 2. Retroflexion - bending of the uterine corpus in a back manner toward the rectum. 3. Anterversion - axaggerated forward tilting of the uterus. 4. Anterflexion - flexing or folding of the uterine corpus upon itself.
- 7. The direction of the displacement normal normal normal Retroflexion Retroversion Anterflexion
- 8. Downwards Displacement (Genital Prolapse) Genital prolapse is the descent of one or more of the genital organ (urethra, bladder, uterus, rectum or Douglas pouch or rectouterine pouch”) through the fasciomuscular pelvic floor below their normal level. Vaginal prolapse can occur without uterine prolapse but the uterus cannot desent without carrying the vagina with it.
- 9. Varieties of prolapse: Vaginal Prolapse: 1) Anterior vaginal wall prolapse: a. Prolapse of the upper part of the anterior vaginal wall with the base of the bladder is called cystocele b. Prolapse of the lower part of the anterior vaginal wall with the urethra is called urethrocele. c) Complete anterior vaginal wall prolapse is called cysto-urethrocele.
- 11. 2) Posterior vaginal wall prolapse: a) It is called rectocele if the anterior wall of the rectum is also prolapsed with the middle third of the posterior vaginal wall. b) It is called entrocele (hernia of the pouch of Douglas) if the upper third of the posterior vaginal wall descends lined by the peritoneum of the Douglas pouch and containing loops of the intestine
- 13. 3) Vault prolapse: descent of the vaginal vault, where the top of the vagina descends or inversion of the vagina after hysterectomy. * Vault prolapse is more likely to occur after subtotal than after total hysterectomy.
- 16. Uterine prolapse ("dropped uterus") is a condition in which a woman's uterus (womb) sags or slips out of its normal position. The uterus may slip enough that it drops partially into the vagina (the birth canal), creating a perceptible lump or bulge. This is called incomplete prolapse. In a more severe case— known as complete prolapse—the uterus slips to such a degree that some of the tissue drops outside of the vagina. Uterus and the cervix lie at right angle of the long axis of the vagina .As the uterus descends, it may pull the vaginal canal and even the bladder and rectum with it. It is the second most common after cystourethrocele (bladder and urethral prolapse). Uterine Prolapse
- 17. II) Uterine prolapse: 1)Utero-vaginal (the uterus descends first followed by the vagina): This usually occurs in cases of virginal and nulliparous prolapse due to congenital weakness of the cervical ligaments. 2) Vagino-uterine (the vagina descends first followed by the uterus):This usually occurs in cases of prolapse resulting from obstetric trauma.
- 18. Degree of Uterine Prolapse First degree (mild) of uterine prolapse is defined as descent of the uterus to any point in the vagina above the hymen Second degree (moderate) uterine prolapse is defined as descent to the hymen Third degree (severe) - uterine prolapse is defined as descent beyond the hymen
- 20. Degree of Uterine Prolapse 3rd degree 2nd degree 1st degree normal
- 21. ASSESSMENT History Patient may complain of one or more of the following: A feeling of heaviness or pressure in the pelvis Feeling as if sitting on a small ball or as if something is falling out of the vagina Pain in the pelvis, abdomen, or lower back Pain during intercourse A protrusion of tissue from the vagina Recurrent urinary tract infections (UTIs) Unusual or excessive discharge from the vagina Difficulty with urination, including involuntary loss of urine (incontinence), or urinary frequency or urgency
- 22. Physical Examination Performed to exclude the presence of an abdominal or pelvic tumor that may be responsible for the prolapse. Pelvic examination to assess the degree of prolapse is usually performed with the woman either in the left lateral position using a Sims speculum or in a semirecumbent position in the examination chair. Physical findings may be enhanced by having the patient strain during the examination or by having her stand or walk.
- 23. Examination in a standing position allows an accurate assessment of the degree of the prolapse. Stages : Stage I - Descent of the uterus to any point in the vagina above the level of the hymen Stage II - Descent to the level of the hymen Stage III - Descent beyond the hymen Stage IV - Total eversion or procidentia
- 24. ETIOLOGY
- 25. Normal aging and lack of estrogen hormone after menopause may also cause uterine prolapse. Chronic cough and obesity increase the pressure on the pelvic floor and may contribute to the prolapse. Uterine prolapse can also be caused by a pelvic tumor, although this is rare. Chronic constipation and the pushing associated with it can worsen uterine prolapse. ETIOLOGY cont.
- 26. It is occurs due to failure of one or more of the supportive ligaments may be for the following factors 1. Congenital : imperfect development of supporting tissue ( at birth , before marriage). 2. Acquired a. Labor : 1-Bearing down without contraction 2- Forceps delivery 3- extraction of placenta by extreme fundus pressure 4- large head baby without episiotomy 5-prolonged of the second stage of labor, specially when the baby is large b. During puerperium: -No kegle’s exercise -No sim’s sitting position -lack of exercise and bodily weakness - lack of proper rest and diet in post- natal periods, repeated deliveries.
- 27. 4. fibroid , sub involution 5. Lax ligament ; pregnancy 6. Atrophy of the supporting tissue at menopause. 7. Increase in intra abdominal pressure as Abdominal mass, Chronic cough, Chronic constipation 8. Obesity **Note most of prolapse occur in a obese women, multiparous, and menopause
- 28. Predisposing Factors: 1. Weakness of the pelvic cellular tissue: The cervical ligaments which act as the main support for the uterus may become weakened by the following: a) Obstetric trauma b) Congenital weakness c) Postmenopausal atrophy 2)Injury of the pelvic floor
- 29. PATHOPHYSIOLOGY Displacement or prolapsed of the uterus, bladder, or rectum can be a congenital or an acquired condition. Congenital tilting or flexion of the uterus is rare. More commonly, tilting or flexion disorders in which the uterus remains within the pelvic cavity are related to the: i. Scarring and inflammation of pelvic inflammatory disease. ii. Endometriosis iii. Pregnancy iv. tumors
- 30. Downward displacement of the pelvic organs into the vagina result from: PATHOPHYSIOLOGY cont.
- 31. Signs & Symptoms -Women with mild cases of uterine prolapse may have no obvious symptoms. However, as the slipped uterus falls further out of position, it can place pressure on other pelvic organs—such as the bladder or bowel— causing a variety of symptoms, including: Before actual prolapse. the patient feels a sensation of weakness in the perineum. particularly towards the end of the day. Later the patient notices a mass which appears on straining. and disappears when she lies down. Urinary symptoms are common and trouble some even with slight prolapse: a)Urgency and frequency by day. b) Stress incontinence. c) Inability to micturate unless the anterior vaginal wall is pushed upwards by the patient's fingers. d) Frequency and scalding day and night when cystitis develops .
- 32. Pelvic pressure: a feeling of heaviness or pressure in the pelvis Pelvic pain: discomfort in the pelvis, abdomen or lower back Pain during intercourse A protrusion of tissue from the opening of the vagina Recurrent bladder infections Unusual or excessive discharge from the vagina Constipation Rectal symptoms are not so marked. The patient always feels heaviness in the rectum and a constant desire to defoecate. Piles develop from straining. Backache, congestive dysmenorrhoea and menorrhagia are common. Leucorrhoea is caused by the congestion and associated by chronic cervicitis.
- 33. 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
- 34. Causes of Uterine Prolapse -Trauma incurred during the birthing process, particularly with large babies or after a difficult labor and delivery, is one of the main causes of the muscle weakness that leads to uterine prolapse. -Reduced muscle tone from aging, as well as lowered amounts of circulating estrogen after menopause, may also form contributing factors in pelvic organ prolapses. - In rare circumstances, uterine prolapse may be caused by a tumor in the pelvic cavity. -Genetics also may play a role; women of Northern European descent experience a higher incidence of uterine prolapse than do women of Asian and African heritage. - Finally, increased intra-abdominal pressure, stemming from such diverse conditions as obesity, chronic lung disease and asthma, can be contributing factors in uterine prolapse.
- 35. Screening & Diagnosis -Diagnosing uterine prolapse requires a pelvic examination. You may be referred to a doctor who specializes in conditions affecting the female reproductive tract (gynecologist). -The doctor will ask about your medical history, including how many pregnancies and vaginal deliveries you've had. -She will perform a complete pelvic examination to check for signs of uterine prolapse. You may be examined while lying down and also while standing. -Sometimes imaging tests, such as ultrasound or magnetic resonance imaging (MRI)- Distinguish facial and muscular layers of pelvic support, might be performed to further evaluate the uterine prolapse.
- 36. Diagnostic tests
- 37. Treatment • A.Prevention • although inherent development defects can not be prevented, damage and stretching of the tissue can be minimized in childbirth if certain prophylactic measure are undertaken as • 1. Avoidance of pushing ( bearing down) before full dilatation of the cervix • 2. avoidance of prolongation of the second stage of labor
- 38. • 3. Avoidance of fundal pushing in attempt to expel the placenta • 4. Avoidance of perineal tears during childbirth • 5. Careful repair in the accurate layers of the vaginal wall and perineal tears and incision ( colpoperineorrhy) • 6.Early ambulation after childbirth
- 39. • 7. pelvic floor exercises( Kegel exercise) • 8. avoid chronic constipation and straining • 9. estrogen therapy • 10. good antenatal care in pregnancy • 11. good postnatal care with proper rest, correct diet, and sleeping in semisetting position.
- 41. conservative Treatment: • laxatives and stool softeners • vaginal pessary, Prolonged use of the pessary may lead • to necrosis and ulceration Should be removed and cleaned every 1 to 2 months. • Kegel exercises
- 42. A) Prophylactic treatment for Obstetric prolapse: 1. Proper ante-natal care (before delivery):The pelvic floor should be both strong and elastic. It is strong to help internal rotation of the fetal head in the second stage of labour (Gutter like action) and is elastic, so that the baby can pass through painlessly causing the least amount of trauma to the pelvic floor.
- 43. 2. Proper intra-natal care (during delivery):Avoid etiological factors as straining during the first stage(before full cervical dilatation); avoid the application of forceps before full cervical dilatation; episiotomy should be done when indicated to avoid hidden perineal lacerations; and avoid fundal pressure to deliver the placenta.
- 44. 3. Proper post-natal care (after delivery): Accurate repair of perineal tears or episiotomies, avoidance of occurrence of R.V.F. by postural treatment (daily time rest, relaxation on face, knee chest position) correction of retroversion during the puerperium with the use of knee chest position or pessaries, encourage pelvic floor exercises and other postnatal ex's, prevent puerperal constipation in order to avoid strong bearing down efforts while the supporting ligaments of the uterus are slack, and care of general health to prevent debility and bad general health.
- 45. B) Palliative treatment: palliative treatment by wearing a pessary is indicated in the following conditions: 1)Slight degrees of prolapse in young patients. Operation should be postponed until the woman has had a sufficient number of children as long as the symptoms are mild. 2) Prolapse of the uterus in early pregnancy. The pessary is worn until the end of the fourth month until size of the uterus will be sufficient to prevent its descent. 3) Contraindications to operations as lactation, severe cough , or patients refusing surgical repair. 4) Bad surgical risks as old patient with advanced diabetes or severe hypertension.
- 46. Pessaries used in prolapse Ring pessaries: A pessary of suitable size is introduced in the vagina above the level of the levator ani muscles. It stretches the redundant vaginal wall and prevents descent of the uterus. The "cup and stem" pessary : Is used if the patient's pelvic floor are so weak or lacerated that a ring pessary cannot be retained in the vagina. Whatever type of pessary is used, this method of treatment is at its best only a temporary method to give relief of symptoms. There is always the drawback of a foreign body in the vagina, which is liable to cause leucorrhoea and if neglected may even ulcerate into the wall of the vagina.
- 47. A pessary is a device which is inserted into the upper part of the vagina to provide support to the pelvic structures. The majority of pessaries are made of silicone and come in a number of shapes and sizes. A pessary needs to be inserted by a medical professional and can be kept in place for 3-4 months, after which it will require changing. When inserted properly, a woman should not be able to feel a pessary. Pessaries provide a temporary solution to prolapse symptoms for pregnant women, women who have recently given birth or for women who are awaiting surgery. Pessaries can also be used permanently by women who do not wish to have surgery or who are unsuitable candidates
- 48. Precautions during wearing a pessary: The patient is instructed to have a daily vaginal douche, and every month the pessary is removed, cleaned, the vagina examined for any signs of pressure and the pessary then reintroduced. If the pessary is made of rubber it should be changed every three months.
- 49. c)Actual treatment: Physiotherapeutic lines: indicated in: 1. Early and mild cases. 2. As a prophylactic measure after delivery. 3. Alleviation in more severe cases (pre-and post operative treatment). Aims out of P.T. treatment • To establish the awareness of the function pubococcygeus and pelvic supports & To strength the pubococcygeus muscle.
- 50. Physical therapy treatment: Is divided into two phases: Muscle re-education: Is important as the patient lack awareness of the function of the pubococcygeus muscle, it includes: • Muscle re-education for pubococcygeus muscle • Biofeedback [Kegel perineometer and EMG biofeedback .Mid-stream urine flow (stop test) .Cyriax method Resistive exercises for pubococcygeus muscle: • An inflated cuffed catheter • Vaginal cones
- 51. a)Muscle re-education of pubococcygeus muscle: Pelvic floor exercises b)Biofeedback (Kegel perineometer and EMG biofeedback): Kegel perineometer provides the patient by powerful sensory and visible biofeedback, is able to measure pubococcygeus muscle up to 100 mmhg so that changes in pelvic floor strength can be measured.,
- 52. EMG biofeedback Provides the patient by sensory, visible and auditory biofeedback EMG biofeedback is useful in both increase the level of pubococcygeal muscle activity and improving the ability of the muscle to relax on volition ,EMG devices and perineometers appears to be useful tools for evaluation,& treatment) of pelvic floor dysfunction.
- 53. * Cyriax method Cyriax method of treatment for stress incontinence is also suitable for early cases of genital prolapse. This method aims to strength: pubococcygeus, gluteal, anal, and abdominal muscles. The patient is asked to lie in crock-lying position, to breathe in deeply from her nose, and at the same time contract pubococcygeus, gluteal, anal and abdominal muscles, this is associated with drawing all internal viscera up towards the diaphragm, then she will asked to relax and expire air from her mouth.
- 54. Surgical Management: • Vaginal repair ( colporrhaphy) operation aim to restore strength and support to vaginal walls. The wall is opened , the fascia tightened and reinforced by suturing and redundant tissue from the vagina wall is excised.
- 55. • 1 . cystocele : is repaired by anterior colporrhaphy • 2. urethrocele : is repaired by anterior colporrhaphy with special attention to elevation of bladder neck • 3.rectocele: is repaired by posterior colpoperineorrhaphy • Which include repair of the perineum by bringing together the levator ani muscle adjacement to the perineal body • 4. Usually repair as a part of a Manchester repair operation or during an extended posterior colpoperineorrhaphy •
- 56. Treatment of Uterine Prolapse • 1.Manchester operation or repair • Done when there is a vaginal wall prolapse and slight descent of the uterus . Cervix dilated and its vaginal portion is a amputated &the transverse cervical ligament are shortened • The uterus is thus elevated and vaginal vault strengthens. The operation is follow by anterior and posterior repair operation • Vaginal hysterectomy and repair is performed for procidentia .
- 58. Nursing care Preoperative care: • beside the general measurement • Stopped taking ant contraceptive pills for 6 weeks before operation to minimize risk for thrombosis. • Assure from women finished menstrual period to avoid a menstrual flow during or shortly after operation
- 59. • Assure from absent of any vaginal infection through a vaginal examination .swab andor pap smear • Shave the vulva and prepare the skin • Bowel preparation: 1200ml tap water enema is usually given on the evening of the surgery
- 60. • In procidentia there is always ulceration of the vagina and cervix so women will stay in the hospital for 1 week before the operation to treat the ulceration by : a.bed rest with foot of the bed elevated to reduce edema b. vaginal packing with gauze soaked with antiseptic solution and glycerin apply 2 day c. estrogen cream to aid healing
- 61. • Vaginal preparation : douche no longer performed in many hospital in order not upset the natural defense mechanism . While another hospital do it to remove excessive or infective discharge in certain cases.
- 62. Postoperative care : • 1.Vaginal pack: it is to provide firm pressure to stop bleeding and to prevent adhesions across the vagina. The pack should be observed carefully for any soiling with discharge, since there should be almost no loss draining through the pack. • Pack is removed after 24hrs or as order. Following removal , some vaginal discharge is observed for amount, color, and consistency on regular basis 25.
- 63. • 2. Bladder management • Catheter is left 2-3 days for continuous draining . The 4 hrs clip and release program for 24 to 48 hers before removed • 3. Bowel management • A. Avoid constipation to prevent strain on the suture line • B. On the 3 night after surgery . Medication given to assist bowel movement , this medication should only soften the stool without causing active peristaltic stimulation.
- 64. • C.If bowel movement not start until 5 day postoperative 2 glycerin suppository are used, if this failed an olive oil enema is given , yet the enema should carefully applied in colpoperineorrhaphy.
- 65. 4. Vulva Care: i. apply water with mild antiseptic is poured over the vulva and it is swabbed from front to back , this procedure is repeated twice day untill she allowed to bath or shower daily. ii. a clean vulva pack is held in place all the time and is changed frequently to avoid accumulation of discharge which encourage growth of microorganizm thus increase incidance of infection.
- 66. iii. when woman becomes able to change the pad by herselfs, should instruct her to: a. wash hands before and after change the pad. b. Apply the pad from front to back c. Wipe the area from front to the back after using toilet
- 67. • 5. Perineal care: • Perineal dressing are done 3 day using week antiseptic solution • Air cushions should be provided • A lamp ( day head) is used after the 5th postoperative day to aid healing ,applied for 10 minute 2 day followed by the application of a drying panty .