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Genital Organ Displacement
Practical Lesson
Vaginal Wall Prolapse
• Anterior vaginal wall prolapse:
1- Cystocele: It is the commonest type of prolapse. It is a bulging of urinary
bladder base in upper ¾ of anterior vaginal wall between bladder sulcus and
transverse vaginal sulcus.
2- Urethrocele: Bulging of urethra in lower ¼ of anterior vaginal wall between
transverse vaginal sulcus and submeatal sulcus. It is very rare to be present
alone.
3- Cysto-urethrocele: Total (complete) anterior vaginal wall prolapse. The
prolapsed tissues lies between bladder sulcus and submeatal sulcus.
• Posterior vaginal wall prolapse:
1- Enterocele: It is the descent of the upper part of posterior vaginal wall, lined
by peritoneum of Douglas pouch, containing intestine. It has a hernial sac
that has an orifice.
2- Rectocele: It is the descent of the lower part of posterior vaginal wall, it
occurs usually with perineal tears.
• Vaginal vault prolapse
Sometimes occurs after total hysterectomy.
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Sulci
Bladder
Ts Vag
SubM.
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Uterine Prolapse
• First degree uterine prolapse:
– Cervix lies below the ischial spines, but it does not
appear through the vulva.
• Second degree uterine prolapse:
– Cervix and part of the uterine body appear through the
vulva.
• Third degree uterine prolapse (procedentia):
– The uterus (cervix and body) lies outside the vulva and
fingers can be approximated above the fundus.
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Combined Prolapse
• Utero-vaginal prolapse:
– Uterine prolapse starts first followed by the vaginal
prolapse.
– It occurs in young age and it is associated with
congenital predisposing factors.
– The vagina is inverted with no cystocele.
• Vagino-uterine prolapse:
– Vaginal prolapse starts first followed by the uterine
one.
– It occurs in old age and it is associated with
acquired predisposing factors.
– The vagina is inverted with large cystocele.
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Clinical Picture
• Symptoms:
– Mass (due to descent):
• A lump in the vagina in case of vaginal wall prolapse.
• A patient with uterine prolapse may complain of a mass (cervix)
protruding from the vulva on straining and it disappears on lying down
(2nd degree), or the cervix may not disappear unless the patient pushes
it upward [Procedentia “3rd degree”].
– Pain (due to stretch of ligaments):
• Low backache (most dominant) which is relieved by lying flat or
temporarily using ring pessary to support the prolapse.
• Dragging suprapubic and inguinal pain or disomfort
– Vaginal and sexual symptoms:
• Blood-stained, sometimes purulent vaginal discharge.
– Vaginal discharge due to pelvic congestion or 2ry infection of trophic ulcer
• Patulous vagina and lack of sexual satisfaction for the patient and the
husband
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• Examination:
– General and Abdominal Examination
• predisposing factors, precipitating factors and complications of prolapse
• prepare patients for surgery.
– Local Examination:
Two separate evaluations must be made, first with the patient at rest, and then, under
conditions of maximal straining (Valsalva maneuver).
– Inspection:
• Stress incontinence is most likely to be demonstrated if the bladder is full
• Type and degree of prolapse:
– Vaginal prolapseanterior and posterior vaginal wall prolapse.
– Uterine prolapse: the cervix is apparent in 2nd and 3rd degrees
• If the cervix protrudes outside the vagina,
– may be ulcerated and hypertrophied, with thickening of the epithelium and
keratinization.
– A full pelvic examination:
• Exclude pelvic mass that may have caused the prolapse.
• Palpation:
– Clinical tests for stress urinary incontinence.
– Type and degree of prolapse:
» Vaginal Prolapse: differentiate cystocele from urethrocele and differentiate
rectocele from enterocele.
» Uterine diagnose 1st degree and differentiate 2nd from 3rd degree.
– Testing the Levator Muscles Tone:
» All prolapsed parts are replaced within the pelvis.
» Two fingers are inserted into the vagina and the patient is asked to close off her
vagina against the examining fingers.
» The levatores are palpated
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– Bimanual examination for the uterus, ovaries, adnexa, and Douglas pouch.
– Urinary tract symptoms:
•
Stress incontinence (SI) is the commonest.
– descent of the urethrovesical junction or
– if delivery and repeated operations have produced scarring around the
urethra and bladder neck leading to inadequate urethral closure.
– Cystourethrocele is not the sole cause of SI and there presence is
sometimes is just a mere association.
•
Voiding difficulty can occur if a large cystocele is present and bladder
neck is anchored normally.
– This can lead to retention followed by overflow incontinence.
– It can be corrected temporarily by manually replacing the prolapse (the
patient needs to “splint” her vagina to micturate).
•
•
Frequency (during the daytime) and inadequate emptying (sense of
incomplete act) if sufficient urine is being voided but a chronic residual
urine remains.
A urinary tract infection may supervene.
– In case of infection (on top of stasis) and stone formation, there are
frequency day and night, dysuria, and urgency.
– Rectal symptoms:
•
•
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Incomplete bowel emptying,
Constant desire for defecation, increased frequency of defecation.
Dyschesia and piles may develop due to straining.
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• Investigations:
– To detect predisposing or precipitating factors:
e.g. x- ray chest, and abdominal U/S.
– Preoperative preparation: These are very
essential, CBC, urinary investigations (IVP, urine
analysis, urine culture and sensitivity, kidney
function tests).
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DD
•
Anterior Vaginal Wall Prolapse:
–
Differentiation of anterior vaginal wall prolapse from other
conditions:
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Congenital anterior vaginal wall cysts e.g. Gartner’s cyst.
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The gartner’s cyst appears lateral to the midline. It is not compressible
and irreducible.
On the other hand, a cystocele appears on standing or straining. It is
reducible and compressible. If a catheter is passed, it can be felt in
the mass.
Urethral diverticulum is compressible and urine comes out with
local pressure.
Inclusion dermoid cyst following trauma or surgery.
Recognition of the type of anterior vaginal wall prolapse,
whether cystocele or urethrocele
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•
Posterior Vaginal Wall Prolapse:
–
Rectocele Vs Implantation Dermoid /Vaginal cyst.
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•
–
Rectocele: appears on standing or straining. It is reducible and
compressible. If a finger is introduced in the rectum it can be felt in the
mass.
Posterior vaginal wall cysts: implantation dermoid (the commonest). It is
irreducible and incompressible. A finger in the rectum can not be
introduced in the mass.
Rectocele Vs Enterocele
•
•
Rectocele: it is the prolapse of the lower 2/3 of posterior vaginal wall.
On reduction, it is empty (no gurgling). It does not give impulse on
coughing. Per rectum exam, a finger gets inside the mass.
Enterocele: it is prolapse of upper 1/3 of posterior vaginal wall. Gurgling
sensation on palpation (because intestine contains air). Positive impulse
on coughing (may be seen or felt). Per rectum exam, the mass is out of
reach of the finger (the rectum is pushed backwards by the swelling and
is not forming a part of the mass).
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Uterine Prolapse
Uterine Prolapse
Old age and high parity.
External os appears outside the vulva
with shallow fornices.
Elongation of suprvaginal portion of
cervix
It yields on straining and in volsellum
test.
In 3rd degree prolapse
the thumb and fingers can meet
together above the fundus of uterus when
the uppermost portion of the prolapsed
mass is palpated (finger test or grip sign).
Congenital Elongation of the
Cervix
Young age and in nulligravida.
The fornices and the vaginal vault
are at the normal level (the level of
ischial spines).
The Portiovaginalis portion of
cervix is elongated
It does not yield on straining
and/or upon traction with a
volsellum.
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Differentiation between uterine prolapse and
masses protruding from the vulva
• Fibroid polyp:
– absence of external os.
– The cervix is at its normal position with the pedicle of the tumor coming
out through the cervix.
– A sound can be introduced for long distance inside the uterine cavity.
• Inversion of uterus:
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absence of external os.
the mass is covered by smooth endometrium.
the body of the uterus is not felt per abdomen.
A uterine sound can be introduced for a short distance or cannot be
introduced at all.
• A cauliflower carcinoma or sarcoma of cervix or vagina may
appear at the vulva.
– The mass is friable, necrotic, indurated at the base and bleeds on touch
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