Postoperative Care and Complications Quiz

Genital Organs Displacement

• Displacement of a genital organ refers to its presence outside its normal anatomical position.
• Displacement can be categorized as vertical, antero-posterior, or sideward.
• Vertical displacement includes downward (prolapse) and upward displacement.

Types of Displacement

• Vertical Displacement: A downward shift of the uterus and/or other pelvic organs is called genital prolapse. An upward displacement can be caused by adhesions or tumors pushing on the uterus.
• Antero-Posterior Displacement: The anterior displacement involves the uterus shifting, often from acute AVF uterus, hypoplastic uterus, or uterovesical adhesions. Posterior displacement involves the uterus moving back, often in RVF uteri.
• Sideward Displacement: Displacement of the uterus to the right or left can result from the pressure of tumors or adhesions.

Genital Organ Prolapse

• Definition: Genital prolapse is the downward displacement of one or more genital organs beyond their normal anatomical position.
• Incidence: 5-10% and varies depending on antenatal care levels; prolapse is less common in Black and Asian women than white women.
• Cystourethrocele is the most common type of prolapse, followed by uterine descent and rectocele.

Etiological Factors

• Acquired Predisposing Factors (Childbirth): Childbirth is the most significant factor related to labor and delivery. Factors involve trauma, denervation issues, high parity, rapid deliveries, precipitate labor, and macrosomia. Factors during labor and delivery include pushing before full cervical dilation, prolonged second stage, neglecting perineal tears, and improper forceps use. The puerperium includes early ambulation and proper postnatal care.
• Menopausal Predisposing Factors (Estrogen Deficiency): Menopause leads to a decrease in vascularity and degeneration (atrophy) of ligaments, potentially contributing to prolapse.

Anatomy of Female Pelvis

• Pubocervical fascia: This fascia supports the organs like a hammock.
• Illustration of the female pelvis showing the relationship between the various anatomical structures.

Bladder Neck Prolapse/ Uterine or Vault Prolapse

• Illustration of bladder neck prolapse, showing the damaged anterior hammock support, and uterine prolapse showing damage to the posterior hammock support.

Prolapse (Descent) of the Bladder Neck and Uterus

• Illustration showing the prolapse of the bladder neck and uterus, including the prolapse of the anterior vaginal wall and pubocervical fascia. The diagram emphasizes the poor support of the uterus.

Bladder and Uterine Prolapse

• Illustration of a well-supported bladder neck versus one that is prolapsed. The illustration also displays a prolapsed uterus.

Cystocele (Anterior Vaginal Wall Prolapse)

• Diagram showing the pubic bone, arcuate tendon, lateral tear in pubocervical fascia, and uterus.
• Illustration detailing the anatomy of the female pelvis with a lateral defect in the pubocervical fascia presenting a cystocele.

Normal Position of the Uterus

• The uterus is centrally located in the pelvis, with the bladder anteriorly and the rectum posteriorly.
• In the erect posture, the uterus lies almost horizontally over the empty bladder.
• The cervix of the uterus is situated approximately at the level of the ischial spine.
• Different diagrams illustrate and label the various ligaments and anatomical structures that support the uterus, such as round, uterosacral, and cardinal ligaments.

Version, Anteverted, and Anteflexed Positions of the Uterus

• Version: The relationship of the whole uterus to the vertical axis, not the vagina.
• Anteverted: The uterus tilts forward (~90 degrees) with the cervical canal forward and upward. PV exam shows the cervical os pointing downward and backward (in its normal position)
• Anteflexed: The uterus inclines forward forming an obtuse angle (~170 degrees)

Slightly Dextroflexed and Dextrorotated Positions of the Uterus

• Slightly dextroflexed: The uterus is tilted to the right.
• Slightly dextrorotated: The uterus rotates clockwise (right) around its longitudinal axis bringing the cornu closer to the front.

RVF Uterus

• RVF uterus (retroverted and flexed) is angulated backward, and roughly 20% of uteri are found in this position. Illustration showing this position.

Uterine Supports

• Ligaments (true and false): Support the uterus.
• Peritoneal Reflections: Provide very weak support via uterovesical and Douglas pouches.
• Pelvic Floor: Provides indirect support.

Cervical (True) Ligaments

• Fan-shaped support.
• Runs from the base of the broad ligament to the lateral pelvic wall.
• Includes Ureter and Uretine art. (related structures)

Recto-uterine peritoneal fold

• Refers to the posterior aspect of the uterus.

Pubocervical Ligament

• Extends forward beneath the base of the bladder, the urethra, to the posterior surface of the spinal column.
• It is not a well-formed ligament; rather, it allows for bladder distension.

Other (False) Ligaments

• Broad, Round, and Ovarian ligaments.

Etiological Factors (Developmental Factors)

• Congenital bony defects (e.g., split pelvis).
• Congenital conditions affecting pelvic innervation (e.g., spina bifida, cauda equina).
• Collagen disease (altered collagen metabolism).
• Anatomical abnormalities in the vagina and utero-vesical/uterorectal pouches.
• Weakness of connective tissues
• Race (black women less prone to this)
• Chronic obstructive airway disease, smoking, straining, heavy physical work.

Precipitating Factors

• Factors that cause prolapse when supports are weakened: raised intraabdominal pressure (e.g., chronic obstructive airway disease), smoking, straining, heavy physical work. and masses/traction on the uterus (e.g., polyps, fibroids).

Vaginal Wall Prolapse

• Anterior: Cystocele (bladder prolapse), Urethrocele (urethra prolapse), and Cysto-urethrocele (combined).
• Posterior: Enterocele (prolapse of upper part of the posterior vaginal wall), Rectocele (prolapse of lower part of the posterior vaginal wall).

Uterine Prolapse (degrees)

• First Degree: Cervix is below the ischial spines (not protruding).
• Second Degree: Cervix and part of the uterus protrudes in the vaginal opening
• Third Degree: Entire uterus (cervix and body) lies outside the vulva.

Combined Prolapse (Utero-Vaginal) and Vagino-Uterine

• Utero-Vaginal: Uterine prolapse precedes vaginal prolapse, usually in young women, with a typical pattern
• Vagino-Uterine: Vaginal prolapse precedes uterine prolapse, typically in older women, with a pattern of extensive cystocele.

Effects on the Genital Tract

• Vaginal effects: Chronic irritation, thickening and pigmentation, congestion.
• Cervical and uterine effects: Elongation, congestion, hypertrophy/thickening, and trophic ulcers. -Urinary effects: Urethrocele changes can result in stress incontinence, and huge prolapse may result in dysuria and retention. Bladder involvement may lead to incomplete emptying, residual urine buildup, infection, and possibly chronic irritation leading to hypertrophy.
• Rectal effects: Incomplete bowel emptying, increased defecation desire (frequency), and potential constipation complications.

Clinical Picture/Symptoms

• Mass: A mass, often palpable, in the vagina, particularly during straining.
• Pain: Pain in the back, lower abdomen from stretching of the ligaments, relieved by lying down in some cases
• **Vaginal/Sexual: ** Blood-stained vaginal discharge, vaginal pain, lack of sexual satisfaction, and vaginal ulcer/infection in some cases.

Examination

• General physical exam (abdominal, predisposition, precipitating causes).
• Examination under non-straining and maximal straining (Valsalva) conditions.
• Pelvic exam to assess tissue type and degree of prolapse.

Investigations

• Preoperative preparation (x-ray, imaging, blood work, etc.)
• Evaluation for medical conditions (e.g., chronic cough, urinary infections).

Differentiation of conditions

• Anterior Vaginal Wall Prolapses: Differentiate from other conditions such as Gartner's cysts and Uretral diverticulum.
• Posterior Vaginal Problems: Differentiate Rectocele, Enterocele, and Implantation Dermoid/Vaginal Cysts.

Uterine Prolapse:

• Distinguish between Congenital Elongation (Young, Nulligravida) and normal aging related elongation situations (Older high parity).

Differentiation between uterine prolapse and masses protruding from the vulva

• Fibroid polyp: Absence of the external os, the cervix is normally positioned, sound can go deep inside uterine cavity.
• Inversion of uterus:Absence of the external os, the mass is covered by smooth endometrium, sound can't go deep inside uterine cavity
• Cauliflower carcinoma: The mass is friable, necrotic, indurated at the base and bleeds on touch.

Prophylactic Measures

• Proper obstetric care during all stages of labor and delivery.
• Postnatal pelvic floor exercises.
• Limit use of forceps.
• Cesarean section when indicated.
• Avoid smoking, straining, constipation, heavy physical work.

Management of Prolapse

• Conservative techniques (pessaries, Kegel exercises, estrogen hormones, behavioral alterations).
• Corrective surgery is indicated when conservative treatment isn't sufficient: Only when symptoms warrant it.

Reconstructive Surgery

• Support weak, prolapsed tissue by suturing to bone or using mesh. Surgical techniques include strengthening of the fascia and application of mesh/synthetic materials.

Choice of Operation

• Type and extent of descent/prolapse.
• Patient's requirements (e.g., sexual activity, desire for fertility).
• Vaginal suturing with interrupted sutures.
• Synthetic absorbable sutures are preferred.

Anterior Repair

• Aims at reducing cystocele, repairing fascial defects, suturing the bladder/endopelvic fascia, and removing redundant vaginal wall.
• Postoperative urinary retention. Complications including urinary retention.

Posterior Repair

• Aims at reducing rectocele, closing the levator ani, repairing the perineal body, and preventing potential enterocele. Repairing Defects.
• Associated complications include constipation and bowel emptying; issues in the pelvic floor

Repair of Douglas Pouch Hernia

• Vaginal methods: Wedge-shaped incision allows for reduction reduction of sac, contents excision, and Douglas pouch closure with purse string sutures. Support with uterosacral ligaments.
• Abdominal methods: (for enterocele): Excision of herniated peritoneum and approximation of uterosacral ligaments.

Vaginal Hysterectomy and Pelvic Floor Repair

• Support vaginal vault structures with transverse cervical and uterosacral ligaments when these are insufficient. Following by colpo-perineorrhaphy if necessary.

Abdominal Sling Operation

• Uterus support using nylon tape or mesh (Sacral Cervicopexy).
• Post-operative complications are possible and include, bowel obstruction, blood vessel injury or issues related to the psoas muscle.

Fothergill's Operation (Manchester Repair)

• Preferred if uterus is to be preserved, but future fertility isn't required
• Includes amputation of cervix, fixation of Mackenrodt's ligaments, anterior and posterior colporrhaphy, and D&C (if necessary).
• Important to consider complications including excessive operating time, blood loss, risk of cervix injury, potential infertility, dysmenorrhea and recurrence.
• Alternatives include sling operations for better results.

Lefort Operation

• Obliterates the central portion of the vaginal canal, while preserving lateral channels for drainage. Advantages of this procedure include minimal trauma, and suitability for local anesthesia.
• Disadvantages of this procedure include the loss of intercourse ability, and difficulty with D&C in certain cases.
• May lead to issues with urinary incontinence

Post-operative care

• Early: Vaginal packing and antibiotics, analgesic management for 24 hours, monitoring residual urine volume, and follow-up on urinary tract.
• Remote follow-up: Avoid strenuous activity, pelvic rest and other measures.

Post-operative Complications

• Immediate: Shock, hemorrhagic, neurogenic shock, hemorrhage, infection, pulmonary, rectum injuries
• Delayed: Vaginal stenosis, fistula, fibrosis, recurrence of prolapse (5-10%).

Recurrent Prolapse

• Factors relating to earlier preparation, surgical operation, postoperative care and possible recurrence of problems.

Vault Prolapse

• Increased intra-abdominal pressure leads to vault prolapse, more common in total hysterectomy
• Treatment options include both abdominal sacrocolpopexy, vaginal sacrospinous fixation, and Le Fort repair.

Retroverted-Flexion Uterus

• Backward displacement of the uterus.
• Most cases are congenital.
• Incidence: 20-25%. Few cases lead to adverse effects.

Causes of Retroverted Uterus

• Congenital: usually mobile, asymptomatic
• Acquired: often fixed, symptomatic, factors including labor problems, full bladder, uterine issues, inflammatory conditions, pelvic tumors (i.e., adhesions).

Clinical presentation of Asymptomatic Retroverted Uterus

• Commonly discovered during unrelated examinations.
• Pain symptoms include congestive dysmenorrhea, dyspareunia, backache; symptoms of possible issues associated with pressure
• Potential problems related to urinary or GI tract abnormalities can result in symptoms associated with defecation, and urination issues

Prophylaxis

• Postpartum exercises, good bladder emptying habits, avoidance of activities, care of the pelvis.

Active Management (for mobile RVF)

• Conservative: Smith-Hodge pessary to re-align the uterus and correct cervix position
• Indications: RVF symptoms, previously repeated abortions of a pregnant patient, use as preventative measure.

Curative Surgical Techniques

• Abdominal Operations:
• Modified Gilliam's operation; plication of round ligaments (with non-absorbable material).
• Vaginal Operations:
• Plication of uterosacral ligaments (e.g., through Douglas pouch).

Management of Fixed/Uncorrected RVF with Infertility

• Postcoital testing.
• Abdominal positioning, Artificial insemination, and other management related to the problem.