uterine prolapse

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2 : introduction a descent or herniation of the uterus into or beyond the vagina considered under the broader heading of "pelvic organ prolapse" which also includes cystocele, urethrocele, enterocele, and rectocele. anatomically, the vaginal vault has 3 compartments: - an anterior compartment (consisting of the anterior vaginal wall) - a middle compartment (cervix) - posterior compartment (posterior vaginal wall). UP involves the middle compartment
3 : Supports of uterus Apart from the normal position-anteverted anteflexed there is a three tier system consisting of the following: Upper Middle (strongest and important) lower
4 : Upper tier – The upper most supports of the uterus is comparitively WEAK, Mostly by maintaining the uterus in anteverted position, Endopelvic fascia, Round ligaments, Broad ligaments with intervening pelvic cellular tissue. The last two act as a guyrope with steadying effect on the uterus,they have no action in preventing descent of the uterus.
5 : Middle tier – This constitutes the strongest support of the uterus, Cervico-vaginal junction : anatomicaly,the fibro-muscular tissue of the cervix is continuous with that of vagina. Pelvic cellular tissue : consists of connective tissues and smooth muscles.These tissues are condensed and reinforced by plain muscles to form ligament - Mackenrodt’s,uterosacral,pubocervical.This hammock like arrangement is the cardinal support of uterus.
6 : Inferior tier – Indirect support to uterus Principally given by the musculofascial tone of the hollow vagina which is amply supported by the fascial condensation at the vault and by the pelvic floor at the lower end.
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8 : three stages of uterine prolapse First stage Second stage Third stage
9 : Aetiology of uterine prolapse Predisposing Aggravating Acquired congenital Acquired predisposing factors: Vaginal delivery with consequent injury to the supporting strutures, injury caused by: 1. overstrecthing of mackenrodt’s and uterosacral ligaments, 2. overstrecthing of endopelvic facial sheeth of the vagina, 3. overstrecthing of the perineum, 4. subinvolution of the supporting structures.
10 : Congenital predisposing factors: Congenital weakness of supporting structures, in such cases anatomic or functional abnormalities may be observed .
11 : types Uterovaginal prolapse Congenital uterine prolapse
12 : Feeling of something is coming down specialy when she is moving about. Dragging pain in pelvis Sexual dysfunction, including dyspareunia, decreased libido, and difficulty achieving orgasm Lower back pain Constipation Difficulty walking Difficulty in passing stool Difficulty urinating Urinary frequency Urinary urgency Urinary incontinence Purulent discharge or blood stained p/v discharge Ulceration Signs and Symptoms
13 : Assessment In first degree of uterine descent,the diagnosis is made through speculum examination when one finds the cervical descent below the ischial spines on straining. In second or third degree of prolapse,inspection can reveal a mass protruding out through the introitus ,the external os is visible on seperating the labia. To diagnose a third degree prolapse, palpation is essential.If the thumb is placed anteriorly and the fingers posteriorly above the mass outside the introitus are apposed . BIMANUAL EXAMINATION : shallow vaginal fornix and normal length of the vaginal cervix with normal size uterine body. SOUND TEST : marked increase in length of the uterine cavity,this signifies elongation of the supravaginal part of the cervix. Signs of decreased estrogens Loss of rugae in the vaginal mucosa Decreased secretions Thin perineal skin Easy perineal tearing
14 : Lab Studies Imaging Studies Laboratory studies are unnecessary in uncomplicated cases…. Cervical cultures - cases complicated by ulceration or purulent discharge (Pap smear cytology) or biopsy - in rare cases of suspected carcinoma Ultrasonography MRI - to grade pelvic organ prolapse
15 : Differential diagnosis Congenital elongation of cervix Chronic inversion Fibroid polyp
16 : treatment Preventive - a) general measures, b) Pelvic floor exercises and yogas, Conservative – a) pessaries, b) oestrogen therapy, Surgery
17 : Preventive measures GENERAL MEASURES – Intra natal care – To prevent premature bearing down efforts, To prevent premature apllication of forceps before the cervix is fully dialated, To avoid prolonged second stage, To avoid too much fundal pushing in an ettempt to expel the placenta, To perform timely and adequate episiotomy, To repair any perineal injuries immediately and accurately.
18 : B) Post natal care – To prevent undue distension of the bladder so as to facilitate involution of the pubocervical fascia, To encourage early ambulance, To avoid strenuous activities for atleast 6 months following delivery, To avoid future pregnancy too soon and too many by contraceptive practice.
19 : PELVIC FLOOR EXERCISES Kegel exercises are simple to do and can be done anywhere. You can do them after a uterine prolapse to tighten your pelvic muscles. Kegel exercises are done by constricting the pelvic muscles, as if you were trying to stop your urine flow, by clenching and holding these muscles tightly for a few seconds, then releasing them gradually. Contract your pelvic muscles 10 times, each time holding the muscles tightly and releasing them slowly. Do Kegel exercises four times a day. If you do this exercise correctly, you should feel your pelvic muscles move upward, and when you relax they will move back down. The more often you do Kegel exercises, the stronger will be the feeling of upward and downward movement. Its main aim is to improve muscle control by strengthening the pubococcygeus muscles of the pelvic floor and helps to prevent uterine prolapse .
20 : YOGAS
21 : Conservative treatment PESSARIES FIGURE 1. Various types of pessaries: (A) Ring, (B) Shaatz, (C) Gellhorn, (D) Gellhorn, (E) Ring with support, (F) Gellhorn, (G) Risser, (H) Smith, (I) Tandem cube, (J) Cube, (K) Hodge with knob, (L) Hodge, (M) Gehrung, (N) Incontinence dish with support, (O) Donut, (P) Incontinence ring, (Q) Incontinence dish, (R) Hodge with support, (S) Inflatoball (latex).
22 : Role of pessary The pessary is most commonly used in the management of pelvic support defects such as cystocele, rectocele and uterine prolapse. Pessaries can also be used in the treatment as a useful device for the nonsurgical management of a number of gynecologic conditions.
23 : Type Uses Most common sizes Ring* Mild uterine prolapse, 3 to 5, Incontinence ring* Stress urinary incontinence , 2 to 7 Ring with support* Mild uterine prolapse Mild cystocele, 3 to 5, Incontinence dish* Stress urinary incontinence Mild uterine prolapse,3 -5, Dish with support* Mild cystocele Stress urinary incontinence Mild uterine prolapse ,3 to 5 Donut* Moderate uterine prolapse Mild cystocele, 2 1/2 to 3 inches, Gellhorn* Moderate uterine prolapse Mild cystocele, 2 1/4 to 2 3/4inches, Inflatable* Moderate uterine prolapse Medium and large Cube* Moderate to severe uterine prolapse, Mild cystocele,Mild rectoceleOther vaginal vault prolapse ,2 to 4, Gehrung* Moderate to severe cystocele Mild rectocele Moderate to severe uterine prolapse, 3 to 5, Gehrung with knob* Same uses as Gehrung Stress urinary incontinence, 3 to 5, Hodge* Mild cystocele, 2 to 4,. Hodge with support* Mild cystocele Stress urinary incontinence, 2 to 4, Smith, Risser* Mild cystocele Stress urinary incontinence, 2 to 4, Introl† Stress urinary incontinence Call manufacturer,
24 : How to use Pessaries are fit by trial and error. After a complete pelvic examination has been performed, the physician should start with an average-sized pessary in the simplest style. When the pessary has been put into place, the fit and effectiveness should be checked. The largest pessary that the patient can wear comfortably is generally the most effective. The examiner's finger should pass easily between the pessary and the vaginal wall. The physician should check the pessary to be sure that the intended function is met. When the indication of the pessary is for stress urinary incontinence, the patient should cough to test for any leakage of urine. Finally, the examiner should ask the patient to stand, sit, squat .The patient should be instructed to immediately report any discomfort or difficulty with urination or defecation while wearing the pessary.
25 : Follow up After the initial fitting of the pessary, the patient should be followed-up within a few days,then within one to two weeks for another examination, after which time the examinations can be spaced to every two to three months so that the physician can recheck the fit. The pessary should be removed and cleaned with soap and water while the vagina is inspected for erosions, pressure necrosis or allergic reaction.
26 : complication Although the pessary is an extremely safe device, it is still a foreign body in the vagina. Because of this, the most common side effect of the pessary is increased vaginal discharge and odour. This side effect can be minimized with the use of an acidic vaginal gel such as Trimo-San, which also helps to relieve minor irritation and itching. Some physicians recommend that patients douche with dilute vinegar or hydrogen peroxide for relief. Postmenopausal women with thin vaginal mucosa are more susceptible to vaginal ulceration with use of a pessary. Treatment with estrogen cream can make the vaginal mucosa more resistant to erosion and should be used before or concurrently with the fitting of the pessary in such patients. A pessary that is neglected can become embedded in vaginal mucosa and may be difficult to remove. In some cases, the use of estrogen cream may enable easier removal of the pessary by decreasing inflammation and promoting epithelial maturation. In extreme and rare cases, the pessary must be removed surgically. Even with a neglected, embedded pessary, the development of a fistula is extremely rare. In the patient with an improperly fitted ring pessary, the cervix and lower uterus can herniate through the open center of the ring and become incarcerated. If not recognized, this incarceration could lead to strangulation and necrosis of the cervix and uterus.
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28 : Oestrogen therapy The principle hormone used in HRT is oestrogen. This is ideal for a woman who had her uterus removed already,but can also be to the woman intact with uterus. only oestrogen therapy leads to endomerial hyperplasia and even endometrial carcinoma. oestrogen and cyclic progestin, subdermal implants, percutaneous oestrogen gel, transdermal patch, vaginal cream,
29 : surgery Vaginal : – Vaginal hysterectomy + Pelvic Floor Repair – Manchester [Fothergill] Repair + PFR – Le Fort’s operation Abdominal : Total abdominal hysterectomy [usually will also require vaginal repair].
30 : Ayurvedic aspect Here prasramsini yoni vyapada can be correlated to second degree prolapse and maha yoni vyapada can be correlated to third degree prolapse.
31 : Prasramsini yonivyapada chikitsa Snehana with traivrta sneha,followed by swedana should be given.use of meat soup of gramya anupa,audaka animals.Basti of milk medicated with dashamula and its oral use.Anuvasan and uttarbasti should be done.(cha.sam.chi.20/110,111). Oral intake of meat soup of aquatic animals , swedana by milk ,oral use or anuvasana and uttar basti of sneha medicated with decoction and paste of dashamoola and trivrta is beneficial . (ash.sam.u.39/42) Anointing with ghrta and then apply sudation with milk ,now a ball of vesawara (minced meat or solid mixture of certain drugs like sunthi,maricha , krsna,dhanyaka,ajaji,dadima,and pippalimula should be inserted in canal and bandage is applied and is removed when the patient has desire of micturition.(bhav.pra.chi.70/39,40) anuvasana and uttar basti should be done with hundreds and thousands times cooked oil medicated with drugs capable of suppressing vata or sukumara,bala or sirisa taila which is effective on pain,roughness,stiffness,displacement of vagina. (ash.sam.u.39/37) Laghuphalaghrta is prescribed by sharangadara useful in yonivyapadas.
32 : Mahayoni yonivyapada chikitsa Snehana with traivrta sneha,followed by swedana should be given.use of meat soup of gramya anupa,audaka animals.Basti of milk medicated with dashamula and its oral use.Anuvasan and uttarbasti should bedone.(cha.sam.chi.20/110,111). Oral intake of meat soup of aquatic animals , swedana by milk ,oral use or anuvasana and uttar basti of sneha medicated with decoction and paste of dashamoola and trivrta is beneficial . (ash.sam.u.39/42) the yoni should be filled with fat of bear,crab,cock,pig medicated with madhura group of drugs and then a bandage of cloth should be applied.(cha.sam.chi.20/110-113).
33 : Thank you


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