PROLAPSE OF PELVIC

ORGAN/GENITAL PROLAPSE
INTRODUCTION:

Pelvic organ prolapse (POP) is one of the common clinical conditions met in
day-to-day gynecological practice especially among parous women.
It includes descent of the vaginal wall and/or the uterus. It is in fact a form of
hernia.
The incidence of prolapse is about 1 in 250 pregnancies. Symptomatic
prevalence of POP in Nepal is 6-7% (15-49yrs) and global estimated 2-20%
(>45yrs).
INTRODUCTION:

Uterine prolapse occurs when pelvic floor muscles and ligaments stretch
and weaken, providing inadequate support for the uterus. The uterus then
slips down into or protrudes out of the vagina.
Weakening of pelvic muscles that lead to uterine prolapse can be caused
by: damage to supportive tissue during pregnancy and childbirth; effects of
gravity; loss of estrogen.
INTRODUCTION:
• Pelvic organ prolapse is the abnormal descent or
herniation of the pelvic organs from their normal
attachment sites or their normal position in the
pelvis.
• The pelvic structures that may be involved
include the uterus (uterine prolapse) or vaginal
apex (apical vaginal prolapse), anterior vagina
(cystocele), or posterior vagina (rectocele).
Types of Pelvic organ prolapse:

1. Uterine prolapse: Descent of uterus &

cervix, down the vaginal canal due to weak
or damaged pelvic supported structures.
When the uterus supporting ligaments
(round ligament, uterosacral ligament, broad
ligament & ovarian ligaments )becomes
weak, prolapse take place.
 Degree of uterine prolapse:

• Prolapse of uterus may be one of three types , depending on

severity.
• First degree - The uterus sags downward from the normal
anatomic position into the upper vagina. The external os remains
inside the vagina
• Second Degree - The cervix is at or outside the vaginal introitous,
but the uterine body remains inside the vagina
• Third degree-. The uterine cervix and body and
the fundus descends to lie outside the introitus.

• Procidentia: involves prolapse of the uterus with

eversion of the entire vagina.
•Cystocele: Condition where the tissues
supporting the wall between bladder &
vagina weaken, allowing a portion of
bladder to descend & press into wall of
vagina.
 Urethrocele: Condition where urethra (Tube
leading from the bladder to outside of body)
descends & presses into wall of vagina .
A urethrocele rarely occurs alone, instead usually
accompanying a cystocele.
Prolapse of both part of bladder & urethra is
cystourethrocele.
• Rectocele: Condition where tissues supporting
the wall between vagina & rectum weaken
allowing the rectum to descend & press wall of
vagina.
•Enterocele: Condition when small intestine
falls down and bulges into the wall of
vagina.
Enterocele
• Vaginal vault prolapse: it is condition where top
of vagina descends in women who have had
hysterectomy.
Predisposing Factors

•Multiple pregnancies and vaginal births.

 Giving birth to a large baby.
 Increasing age.
 Frequent heavy lifting.
Predisposing Factors

• Chronic coughing
 Chronic constipation
 Prior pelvic surgery.
 Frequent straining during bowel movements.
 Genetic predisposition to weakness in
connective tissue.
Etiology

• Atonicity and asthenia after menopause

• Child birth
 Birth injury and excessive stretching of pelvic floor muscles
and ligaments.
 Peripheral nerve injury -pudendal nerve
 Ventouse extraction-before cervix is fully dilated
 Prolonged bearing down in second stage of labor
 Delivery at home, by untrained personnel
 Big baby
Etiology

• Nulliparous who have Spina bifida, congenital

weakness of pelvic floor muscles etc.
• Raised intra-abdominal pressure due to
Chronic bronchitis, abdominal tumors , ascites ,
obesity
• Surgeries such as Abdominoperineal excision of
rectum, Radical vulvectomy, Operations for
stress incontinence
Clinical features
• Depends on types of organ prolapsed. Women
with minor prolapse are asymptomatic.
However, vaginal or uterine descent at or
through the introitus can become symptomatic.
Symptoms may include;
• Sensation of vaginal fullness or pressure
• Sacral back pain with standing
Clinical features cont.
• Vaginal spotting from ulceration of the protruding cervix or
vagina
Coital difficulty
Lower abdominal discomfort
Aching discomfort in pelvic region,
Voiding and defecatory difficulties.
The feelings of bulging in vagina are especially noticeable
when sneezing or coughing, with physical exertion, after long
periods of standing or at end of the day.
Urinary problems
• The change in position of bladder than can
occur with prolapse may lead to stress
incontinence i.e. leaking of urine when coughing,
sneezing, laughing).
• Frequent urination
• Incomplete emptying of bladder.
• Urinary infections
Clinical features cont.

Bowel problems : A rectocele can result in

constipation or difficulty emptying bowel.
 Dull backache
Discharge from vagina
Difficulty in walking, working, lifting, standing
Clinical features cont.

• Ulcer on prolapsed part.

 Sexual problem
 Painful or difficult penetration
 Loss of urine during intercourse (Cystocele/
urethrocele)
 Psychological: loss of self esteem & negative
self image.
Diagnostic procedures
• History taking
· Physical examination:
 Pelvic examination
 Vulva examination
 Stress incontinence test: Asking patient to strain
/cough.
 Speculum test: To assess degree of prolapse, condition
of cervix & vagina.
 Bimanual examination: To note size, position,
degree of mobility of uterus
Other supportive investigations
include:
 Urine RE/ME, Culture
 Blood urea, Sugar
 X-ray, ECG
 High vaginal Swab
• Cystoscopy
 CT Scan
Management

• Management is based on type of prolapse, age

of woman, severity, current health status & her
plans regarding children.
 Conservative Management:
• Abdominal exercise
 Loosing excess weight
 Treatment of chronic cough and constipation
 Avoid heavy weight lifting
 Avoid future pregnancy too soon and too many by use
of contraception
 Pelvic floor exercise to strengthen the muscles. ( Kegel
Exercise)
 Estrogen therapy for post menopausal women
Abdominal exercises
Pelvic floor muscle
Conservative Management:

• Nutritious food i.e. high fiber and protein diet

• Avoid carrying heavy loads & works after
delivery
• Stop smoking
Kegel exercises
Mechanical (Pessaries)

• A ring pessary is a device which is inserted into

upper part of vagina to provide support to pelvic
structures. Pessaries are made up of silicon and
available in different sizes. It can be placed for 3-
4 months.
• A pessary does not cure uterine prolapse; it only
holds the genital tract in position.
Pessaries
PESSARY
Silicon Rubber
Indications for Pessary:

 Symptomatic POP

 Young women who is planning a pregnancy

 During early pregnancy 1st trimester (up to 18 weeks, when the uterus
becomes sufficiently enlarged to sit on the brim of the pelvis)
 Puerperium – to facilitate involution
Contra-indications of Pessary:

Foul smelling discharge (infection)

Ulceration if it is at the level where pessary is to be kept

Undiagnosed vaginal bleeding

Pelvic inflammatory disease

Non-compliance with follow up

Persistent vaginal erosions

Pessary follow up

There are no clear evidence for pessary care. Within 2 to 4 weeks check to
see if the client is satisfied or whether another size is needed.
Advise the women to remove the silicone pessary at least every 3 months
and reuse it after washing it with water or soapy water.
Women who are not able to perform self-care should return for follow-up
at 3 months interval.
Rubber pessary should be changed every months.
Complications of pessary:

Vaginal discharge

Vaginal bleeding

Vaginal pain

Vaginal erosion

Vaginal fistula (VVF,RVF)

Surgical
• Surgery is the treatment of symptomatic prolapse where
conservative management has failed or is not indicated.
• The types of surgery depends on the age of patient, her
desire to retain uterus, her menstrual history, general
condition and degree of uterine prolapse.
The goal of surgery is to :
• Relieve symptoms
• Restore anatomy
• Restore sexual function
Surgical management:
• Anterior colporrhaphy: It is performed to repair
a cystocele and cystourethrocele.
• Posterior colporrhaphy and
colpoperineorraphy: It is done to correct a
rectocele and repair a deficient perineum. It is
commonly combined with an anterior
colporraphy or a vaginal hysterectomy requiring
pelvic floor repair and as part of Forthergill’s
repair.
Anterior colporrhaphy
• Forthergill's repair (Manchester operation): In
this operation, part of the cervix is removed, and
the ligaments of the surrounding uterus are
stitched together.
• This procedure preserves menstrual and
childbearing function. It is suitable for women
under 40 yrs, and who desire to retain their
menstrual and reproductive function.
• Vaginal hysterectomy with pelvic floor
repair: It is suitable for women over the age
of 40 years, those who have completed
their families and have no desire to retain
their childbearing and menstrual function.
• Cervicopexy or Purandare’s operation for
congenital or nulliparous prolapse without
cystocele.
• In this surgery, cervix is anchored to the anterior
abdominal wall or sacrum to lift the uterus back
into its proper position.
Nursing Management

• Assessment:
• History
• Physical examination
• lab reports
Nursing Diagnosis

• Impaired Physical Mobility related to uterine prolapse, as evidenced by

difficulty ambulating, discomfort, or limitations in performing activities of daily
living
• Impaired Urinary Elimination related to uterine prolapse, as evidenced by
symptoms such as stress urinary incontinence, urgency, or difficulty emptying
the bladder.
• Deficient Knowledge regarding uterine prolapse and its management, as
evidenced by the patient’s inquiries or lack of awareness about the condition,
treatment options, and preventive measures.
• Risk for Impaired Skin Integrity related to the protrusion of the uterus into the
vaginal canal, as evidenced by pressure on surrounding tissues and potential
for friction or irritation
Nursing Diagnosis

• Acute pain related to surgical wound.

• Impaired Skin integrity related to surgical
wound.
• Risk for surgical wound infection
• Risk for surgical complication related to
Knowledge deficit
Nursing Interventions

Mobility Enhancement:
• Encourage the patient to engage in regular, low-impact
exercises to strengthen pelvic floor muscles.
• Teach pelvic floor exercises (Kegel exercises) to improve
muscle tone and support the uterus.
• Collaborate with physical therapists to develop a
personalized exercise plan tailored to the patient’s needs.
Skin Integrity Management

• Assess for signs of skin breakdown in the perineal

area and provide guidance on proper hygiene
practices.
• Encourage the use of barrier creams or ointments to
prevent friction and irritation.
• Collaborate with wound care specialists if skin
integrity is compromised.
Bladder and Bowel Management
• Implement bladder training techniques to address
symptoms of stress urinary incontinence.
• Recommend timed voiding and strategies to
improve bladder emptying.
• Provide guidance on dietary modifications,
hydration, and fiber intake to manage bowel
symptoms.
Pelvic Floor Muscle Training
• Guide the patient in performing pelvic floor exercises
regularly to strengthen and tone the pelvic muscles.
• Monitor the patient’s technique and provide feedback
to ensure the correct execution of exercises.
• Utilize biofeedback or electrical stimulation, if
available and appropriate, to enhance muscle training.
Nursing Interventions

Manage Pain
• Assess vital sign
• Assess pain intensity, severity, aggravating
factors.
• Keep patient in comfortable position
• Enhance relaxation techniques
• Administer analgesics.
Maintain skin integrity
• Do sterile dressing monitor condition of wound.
• Encourage to take diet containing protein
vitamin C, and Zinc for wound healing
Maintain temperature

• Monitor vital signs.

• Administer prescribed antibiotics.
• Maintain aseptic wound status.
Patient education

• Maintain personal hygiene and wound care

• Explain about disease, cause, symptoms, &
prevention.
• Teach not to do strenuous activities for 6-8
weeks.
• Maintain ideal body weight
Prevention of Pelvic organ
prolapse
• Careful attention during childbirth can do much to
prevent prolapse.
• Prevention of anemia and maintenance of ideal
weight gain during pregnancy.
• Antenatal physiotherapy including relaxation exercise
do play much role in prevention.
• The proper management and supervision of second
stage of labour .
Prevention of Pelvic organ
prolapse cont.
• Early postnatal ambulation and regular postnatal exercise is
beneficial.
• Avoidance of heavy work and domestic duties for the first
six months of delivery.
• Maintain reasonable interval between pregnancies.
• Avoid multiparity by using contraceptive devices.
• Regular exercise to strengthen pelvic floor is more important
in menopausal women.