GYN 16

• Retroversion


  The term used when the long axis of the corpus and cervix are in line and the whole organ turns backwards in relation to the long axis of the birth canal
• Retroflexion


  A bending backwards of the corpus on the cervix at the level of internal os
• Degrees of retroversion

  • First degree: The fundus is vertical and pointing towards the sacral promontory
  • Second degree: The fundus lies in the sacral hollow but not below the internal os
  • Third degree: The fundus lies below the level of the internal os
• Causes of retroversion


  • Developmental
  • Acquired
• Developmental retroversion


  Quite common in fetuses and young children due to lack of tone of the uterine muscles, the infantile position is retained
• Acquired retroversion


  • Puerperal: Stretched ligaments caused by childbirth fail to keep the uterus in normal position
  • Prolapse: Retroversion is usually implicated in the pathophysiology of prolapse
  • Tumor: Fibroid causes heaviness of the uterus and it falls behind
  • Pelvic adhesions: Pull the uterus posteriorly

  
• Retroversion is present in about 15-20% of normal women
• Symptoms of mobile retroverted uterus


  • Chronic premenstrual pelvic pain
  • Backache
  • Dyspareunia
• Signs of retroversion


  Bimanual examination: (a) Cervix directed upwards and forwards, (b) Body of uterus felt through posterior fornix

  Speculum examination: Cervix comes into view easily, external os points forwards

  Rectal examination: Confirms diagnosis

  
• Retroversion per se has got practically no adverse effect either on fertility or in early pregnancy
• Corrective treatment for retroversion

  • Pessary
  • Surgical
• Pessary


  Stretches the uterosacral ligaments to pull the cervix backwards

  
• Surgical treatment


  Ventrosuspension of the uterus by plicating the round ligaments extraperitoneally to the anterior rectus sheath
• Pelvic organ prolapse (POP) is a form of hernia involving descent of the vaginal wall and/or the uterus

  
• Supports of the uterus

  • Upper tier: Endopelvic fascia, round ligaments, broad ligaments

  Middle tier: Pericervical ring, pelvic cellular tissues, Mackenrodt's, uterosacral and pubocervical ligaments

  Inferior tier: Pelvic floor muscles, endopelvic fascia, levator plate, perineal body, urogenital diaphragm

  
• Supports of the anterior vaginal wall

  • Positional support: Vaginal axis

  Pelvic cellular tissue: Endopelvic fascia, posterior urethral ligament, pubocervical fascia

  
• Supports of the posterior vaginal wall

  • Endopelvic fascial sheath

  Uterosacral ligament attachment

  Levator ani muscles and fascia

  Levator plate

  Perineal body and urogenital diaphragm

  
• Etiology of pelvic organ prolapse

  • Predisposing factors: Acquired, Congenital

  Aggravating factors
• Acquired predisposing factors for prolapse

  Vaginal delivery with injury to supporting structures: Overstretching of ligaments, Breaks in endopelvic fascia, Overstretching of perineum, Imperfect repair of injuries, Loss of levator function, Neuromuscular damage, Subinvolution of supporting structures

  
• Prolapse


  Unusual in cases delivered by cesarean section
• Causes of prolapse


  1. Overstretching of the Mackenrodt's and uterosacral ligaments

  2. Premature bear down efforts prior to full dilatation of the cervix

  3. Delivery with forceps or ventouse with forceful traction

  4. Prolonged second stage of labor

  5. Downward pressure on the uterine fundus in an attempt to deliver the placenta

  6. Precipitate labor
• In these conditions, the uterus tends to be pushed down into the flabby distended vagina

  
• Other causes of prolapse

  1. Overstretching and breaks in the endopelvic fascial sheath

  2. Overstretching of the perineum

  3. Imperfect repair of the perineal injuries

  4. Poor repair of collagen tissue

  5. Loss of levator function

  6. Neuromuscular damage of levator ani during childbirth

  7. Subinvolution of the supporting structures
• Factors contributing to subinvolution of supporting structures


  • Ill-nourished and asthenic women
  • Early resumption of activities which greatly increase intra-abdominal pressure before the tissues regain their tone
  • Repeated childbirths at frequent intervals
• Congenital prolapse


  Congenital weakness of the supporting structures responsible for nulliparous prolapse or prolapse following an easy vaginal delivery
• One should exclude an occult spina bifida and associated neurological abnormalities in congenital prolapse
• Etiology of pelvic organ prolapse

  • Clinical factors
  • Anatomical factors
  • Predisposing factors
  • Aggravating factors
• Clinical factors


  • Gravitational stress due to human bipedal posture
  • Anterior inclination of pelvis directing the force more anteriorly
  • Stress of parturition (internal rotation) causing maximum damage to puborectal fibers of levator ani
  • Pelvic floor weakness due to urogenital hiatus and the direction of obstetric axis through the hiatus
• Anatomical factors


  • Inherent weakness (genetic) of the supporting structures
• Acquired factors


  • Trauma of vaginal delivery causing injury (tear or break) to ligaments, endopelvic fascia, levator muscle, perineal body, nerve (pudendal) and muscle damage due to repeated child birth
• Congenital factors


  • Genetic (connective tissue disorders), decreased ratio of type I collagen
  • Marfan or Ehlers-Danlos syndrome
  • Spina bifida
• Predisposing and aggravating factors

  • Postmenopausal atrophy
  • Poor collagen tissue repair with age
  • Increased intra-abdominal pressure as in chronic lung disease (COPD) and constipation
  • Occupation (weight lifting)
  • Asthenia and undernutrition
  • Obesity, smoking
  • Increased weight of the uterus as in fibroid or myohyperplasia
  • Multiparity
• These factors possibly operate where the supports of the genital organs are already weak
• Ultrasonography (3D) with color thickness mapping and MRI study of the levator ani muscle revealed loss of levator ani bulk in women with POP and stress incontinence
• MRI demonstrate more vertical axis and wider genital hiatus in women with POP
• Clinical types of pelvic organ prolapse

  • Vaginal prolapse
  • Uterine prolapse

  
• Vaginal prolapse can occur independently without uterine descent, but uterine prolapse is usually associated with variable degrees of vaginal descent
• Types of vaginal prolapse

  • Anterior wall prolapse (cystocele, urethrocele)
  • Posterior wall prolapse (relaxed perineum, rectocele)
  • Vault prolapse (enterocele, secondary vault prolapse)

  
• Cystocele


  Laxity and descent of the upper two-thirds of the anterior vaginal wall, resulting in herniation of the bladder
• Urethrocele


  Laxity of the lower-third of the anterior vaginal wall, resulting in herniation of the urethra