Uterine Prolapse and Inversion, Vaginal Prolapse, Ureter injury😍

Uterine Supports

Type	Structures
Muscular	Levator ani, Perineal body, Urogenital diaphragm
Fibromuscular	Cardinal, Uterosacral, Pubocervical, Round ligaments
Peritoneal	Broad ligament

• Uterus is normally anteverted and anteflexed.

• Supported by muscular, fibromuscular, and peritoneal structures.

• Mechanical Support (Prevents Prolapse)
• Angle of Anteversion: 90° (Between Cervix and Vagina)
• Angle of Anteflexion: 130° (Between Uterus and Cervix)

• On P/V Examination
• Anteverted Uterus: Fundus > Anterior Lip of Cervix
• Retroverted Uterus: Posterior Lip of Cervix Felt First

Not a true support of the uterus

• Not a true support → does not prevent prolapse

• Round ligament → maintains anteversion
• Homologous to: gubernaculum testis (scrotal ligament).
• Uterine retroversion: results when round ligament laxity occurs.
• From uterine cornu (anterolateral to tube) → through inguinal canal → labia majora.
• Maintains anteverted position of uterus.
• Pain in stretching during pregnancy = round ligament pain.
• Remnant of gubernaculum (female).

• Broad ligament
• Keeps uterus centrally placed
• Double layer of peritoneum from uterus to lateral pelvic wall.
• Contains:
• Uterine tubes
• Round ligament
• Ovarian ligament
• Uterine and ovarian vessels

Clinical Correlation

• Prolapse:
• due to weakness of levator ani and cardinal + uterosacral ligaments.

• Round ligament pain: due to stretch during pregnancy.

• Uterine retroversion: results when round ligament laxity occurs.

1. Muscular Supports

• a. Pelvic Diaphragm
• Levator Ani (Most Important Support)
• especially pubococcygeus
• Failure → uterine prolapse.

• b. Perineal Body
• Superficial & Deep Transverse Perinei
• Bulbospongiosis

• c. Urogenital Diaphragm

2. Fibromuscular (Ligamentous) = Triadiate Ligament

• a. Transverse Cervical (Cardinal / Mackenrodt’s) Ligament
• Main mechanical support of uterus.
• From cervix and upper vagina → lateral pelvic wall.
• Contains uterine vessels.

• b. Uterosacral Ligaments
• Pulls cervix upward and backward.

• c. Pubocervical Ligaments
• Keeps cervix forward.

DeLancey

• three-level systems of genital tract supports:

Level	Structures	Defect Leads To
I	Uterosacral & cardinal ligaments	Uterine descent, enterocele, vault prolapse
II	Pelvic fascia, paracolpos, arcus tendineus, pubocervical fascia, rectovaginal fascia	Cystocele, rectocele
III	Levator ani muscle	Urethrocele, gaping introitus, deficient perineum

Important Questions

Feature	Details
First Step for Prolapse	Retroversion of Uterus (Manually Correctable)
Fixed Retroverted Uterus Seen In	Endometriosis
Ligament Keeping Uterus in Anteverted Position	Round Ligament (RL) > Uterosacral (US) Ligament
Ligament Preventing Retroversion	US Ligament > RL
Secondary Support Ligament	RL
Ligament Without Support Function	Broad Ligament
Part of Levator Ani Damaged Causes Maximum Prolapse Risk	Puborectalis > Pubococcygeus

• Mnemonic: RTO
• Round ligament → Samson artery (Branch of Inferior Epigastric art)
• Fallopian tube
• Ovarian ligament → Utero ovarian anastomosis

• Suspensory ligament (Infundibulopelvic) → Ovarian artery

• Transverse cervical ligament → Uterine artery, Ureter

Uterine Prolapse

Decubitus Ulcer

• Cause
• Venous Congestion

• Management
• Packing with Acriflavine (Antiseptic) and Glycerine

• Mnemonic: Akriyum glue um vach ottikkum

Classification of Prolapse (POP-Q Classification)

• Reference Point
• Hymen

Risk Factors

• Menopause

• Birth Trauma

• Multi Gravida

• Instrumental Delivery

• Injury to pudendal nerve

• ↑↑↑ Intra-abdominal Pressure
• Chronic bronchitis
• Constipation
• Obesity

Uterine Prolapse Grading

Management

• Depends on age and parity of female.

• Done for second and third degree prolapse.

Uterine Inversion

Definition: 

• Prolapse of the uterine fundus into the uterine cavity

• obstetric emergency

Causes of Postpartum collapse:

1. PPH

2. Inversion

3. AFE

Notes

• M/C cause (Immediate postpartum uterine inversion): 
• Mismanaged 3rd stage of labour.

• Shock in Uterine Inversion: 
• Immediate shock after delivery.

• Initial Shock Classification: 
• Neurogenic → Hemorrhagic shock (Cause of death).

• O/E:
• P/A: Cup-like depression below umbilicus (Fundus is depressed).
• P/V: bleeding and globular mass in vagina.

Note:

• Water Under bridge:
• Uterine artery crosses ureter 2 cm lateral to internal OS.
• M/C site of ureteric injury during hysterectomy.

ㅤ	ㅤ
Surgical constrictions	1 - 5
Anatomical constrictions	1, 2, 4
Narrowest Constriction	4 > 5

Management:

• Mnemonic: 1st step → Push in with Johnson (Manual replacement) umbrella → if not working → Sudden Halt (Haultain)
1. Resuscitate and call for help.
2. Stop oxytocin.
3. Manual replacement of uterus
• Johnson's technique
• Do not try to separate placenta.
4. If fails, give tocolytics and re-attempt manual replacement.
5. If fails, Abdominal surgery: Huntington's/Haultain method.
6. Post replacement management: 
1. Stop tocolytic
2. remove placenta
3. start oxytocin to prevent re-inversion
4. give antibiotics

Outdated Surgeries:

• O’ Sullivan hydrostatic method.

• Spinelli Sx (Vaginal Sx).

Vaginal Prolapse

Vaginal Prolapse Types

• 1: Cystocele (Anterior)

• 2: Urethrocele (Anterior)

• 3: Enterocele (Posterior, Upper)

• 4: Rectocele (Posterior, Middle)

• 5: Laxed Perineum (Posterior, Lower)

Vaginal De Lancey Support Levels

• LEVEL 1 (Supports Upper 1/3rd of Vagina)
• Supporting Structures
• Uterosacral Ligament
• Cardinal Ligament
• Defects Lead To
• Apical Prolapse
• Vault Prolapse
• Elongation of Cervix: Supravaginal Part
• Note
• Congenital Cervical Elongation
• Portio Vaginalis Part of Cervix Elongated
• Enterocele

• LEVEL 2 (Supports Middle 1/3rd of Vagina)
• Supporting Structures
• Paravaginal Tissue
• Arcus tendinous fascia pelvis
• Defects Lead To
• Rectocele
• Cystocele

• LEVEL 3 (Supports Lower 1/3rd of Vagina)
• Supporting Structures
• Perineal Body
• Muscles Attached To It
• Defects Lead To
• Urethrocele
• Laxed Perineum

Anterior Vaginal Wall

Posterior Vaginal Wall

General Note

• Management for Vaginal Prolapse: Same for all age groups and parity.

Outdated Surgery for Enterocele

• Moscowitz Repair

• Halban Repair

• Douglus (POD) ammachi → no longer in Moscow () → banned (Halban)

Prevention

• Kegel's Exercise

• Perineal Exercise

Vault Prolapse

• Prolapse of Vaginal Stump After Hysterectomy.

Prevention of Vault Prolapse After Hysterectomy

• Uterosacral Suspension (Prophylactic)

Management of Vault Prolapse

• Vaginal Surgery
• Uterosacral Suspension (Both Prophylactic and Therapeutic)
• Sacrospinous Fixation
• Le Fort Colpocleisis

• Abdominal Surgery
• SacroColpopexy (Difficult but Best Results):
• Mesh attached to Sacral Promontory and Vaginal Stump.

• Most Commonly Done:
• Uterosacral Suspension / Sacrospinous suspension

• Remember
• Burch Colposuspension
• Gold std for Stress Urinary Incontinence
• commonly done → Transobturator Sling/ TVT
• not Vault Prolapse.
• Call and suspended (Colposuspension) from Church (Burch) → bcz she urinated in church when stressed

Ureteric Injury

• Most Common Site During Hysterectomies
• "Water Under Bridge" (2 cm lateral to internal os) > Pelvic Brim (2nd M/C)

• Maximum Risk
• Wertheim's Hysterectomy

• Most Common Injury Seen With
• TAH (Simple Hysterectomy)

Vesicovaginal Fistula

Diagnosis

Methylene Blue 3 Swab Test (IOC)

Observation	Fistula
Uppermost Cotton Swab: Wet with Urine + Not Blue	Ureterovaginal Fistula
Middle + Lowermost Cotton Swab: Wet with Urine + Blue	Vesicovaginal Fistula
Only Lowermost Cotton Swab: Wet with Urine + Blue	Urethrovaginal Fistula

Features

• Most Common Urinary Fistula (m/c urinary fistula)

• Most Common Cause (m/c cause):
• Developed Countries:
• Hysterectomy
• Developing Countries:
• Obstructed Labour

• IOC (Investigation of Choice):
• Methylene blue 3 swab test ??

• Gold Standard/most benificial:
• Cystoscopy

Time of Repair

• Diagnosed at time of Sx/within 24 hours of symptoms:
• Immediate repair

• 24 hours of symptoms/post-obstructed labour:
• Repair after 6 weeks

• Technique:
• Chassar moir technique
• Latzko technique
• Mnemonic: Chase the Leak

Post-Op Instructions

• Continuous bladder drainage: 2 weeks

• Antibiotics: 2 weeks

• No P/S , P/V exam (Per Vaginal Exam), intercourse: 3-6 months

• No pregnancy: 1 year

Youssef syndrome

• Classic triad
1. Amenorrhea
2. Cyclical hematuria
• Also called menouria
• Menstrual blood enters bladder through fistula
• Presents as hematuria
3. Absence of urinary incontinence

• Occurs due to vesicouterine fistula

• Etiology
• Lower-segment cesarean section

Stress incontinence

• Burch colposuspension

• Tension free vaginal taping

• Vaginal approach
• Kelly repair
• Pacey repair

• Combined
• Pereyra operation