Genital Organs Displacement PDF

Genital Organs Displacement Ihab Samaha,MD 1  Genital Organ Displacement Displacement of a genital organ means its presence out its normal site. Types of displacement: Vertical Displacement: Downward Displacement: it is called genital prol...

Genital Organs Displacement Ihab Samaha,MD 1  Genital Organ Displacement Displacement of a genital organ means its presence out its normal site. Types of displacement: Vertical Displacement: Downward Displacement: it is called genital prolapse. Upward Displacement of the uterus: e.g. fundal adhesions pulling the uterus and cervical tumors pushing the uterus. Antero-posterior Displacement: Anterior Displacement: such as in acute AVF uterus (cochleate uterus), hypoplastic uterus and uterovesical adhesions. Posterior Displacement: such as in RVF uterus. Sideward Displacement: due to tumors pushing or adhesions pulling the uterus to result in right or left displacement of uterus. 2  Genital Organ Prolapse Definition: Genital prolapse is vertical downward displacement of one or more of the genital organs beyond the normal anatomical position. Incidence: 5-10% and varies between countries depending on level of antenatal care provided. Prolapse is less common in black and Asian than in white females. Cystourethrocele is the most common type, followed by uterine descent and rectocele 3  Etiological Factors All underlying mechanisms lead to weakness of the pelvic anatomical supports. Predisposing factors for genital prolapse Acquired predisposing factors: 1) Childbirth (Obstetric) predisposing factors: It is the most important and related to labor and delivery. They act through trauma or denervation. High parity, rapid successive deliveries, precipitate labor and macrosomia. Mismanagement of labor and delivery: During first stage: Pushing before full cervical dilatation, Squatting position Forceps, ventouse, and breech extraction before full cervical dilatation. During second stage: Prolonged second stage and fundal pressure. Neglected (unrepaired) perineal tears (hidden perineal tear). Improperly placed forceps may damage the pudendal nerve or the pelvic floor. During third stage: Crede’s method for placental delivery. During puerperium (after labor) include early ambulation, subinvolution, and lack of postnatal proper exercise. 2) Menopausal predisposing factors (estrogen deficiency): Lack of hormonal trophic impulses leads to decrease vascularity and degeneration (atrophy) of ligaments. 4 5 6 7 8 9 Uterus Normal Position Centre of pelvis with UB ant. & rectum post. Lying almost horizontal over empty UB in erect posture cx. Uteri almost at level of ischial spine 10 Uterus Normal Position Version: relation of uterus as a whole to Vertical axis of the Intraabdominal body and NOT Vagina pressure Anteverted: (~90 d.) Cervical canal directed forward & upward, while external cervical os is pointing downward & backward on PV exam. Maintained mainly by 11 Uterus Normal Position Flexion: refers to the relation between cervical axis and corporeal axis, i.e. inclination of body on cervix. Anteflexed: Body inclined forward, making an obtuse angle (~ 170 d.) Maintained by the tone of uterine muscles (congenitally inherent in myometrium) 12 Uterus Normal Position Slighltly dextroflexed (tilted to the right) Slightly dextrorotated [rotation along longitudinal axis, (torsion)] so as to bring lt. Cornu nearer to front. Imp. during CS 13 Uterus RVF uterus ~ 20 % 14 Uterus Uterine Supports Ligaments of the uterus (True & False) Anteverted anteflexed position of uterus. Peritoneal Reflections (Uterovesical & Douglas pouches): very weak support. Pelvic Floor: indirect support. 15 Uterus Supports: Cervical (true) ligaments Main support. Condensed pelvic fascia & pelvic cellular tissue, containing few smooth muscle fibres. One structure, can be divided into 3 pairs of ligaments, all attached to supravaginal cervix and upper vagina. 16 Uterus Supports: Cervical (true) ligaments Fan-shaped Runs in base of broad lig. to lateral pelvic wall. Ureter Uretine art. 17 Uterus Supports: Cervical (true) ligaments ureter Post. thickening Runs upw. & backw. round rectum to middle 3 pieces of S. Recto-uterine peritoneal fold. 18 Uterus Supports: Cervical (true) ligaments Pubocervical ligament Extends forwards beneath base of UB round urethra to post. surface of SP. Not well formed (not a true ligament) it allows for the distension of UB. 19 Uterus Other (False) ligaments Broad L. Round L. Ovarian L. 20 Etiological Factors Congenital predisposing factors (developmental factors): Congenital bony lesions such as split pelvis. Congenital lesions affecting pelvic innervation such as spina bifida and cauda equina. Collagen disease: Altered collagen metabolism Anatomical anomalies: Congenital shortness of the vagina and deep uterovesical or uterorectal (Douglas pouch) peritoneal pouches Congenital weakness of the connective tissues.. Race: A decrease in prevalence of prolapse amongst black women may be due to better connective tissue with greater collagen in ligaments, or lumbar lordosis which encourages diversion of abdominal forces towards the abdominal wall rather than pelvic diaphragm. Precipitating factors: They reveal prolapse when the supports are already weakened: Raised intra-abdominal pressure: chronic obstructive airways disease (COAD), smoking (cough), straining at stools with constipation, heavy physical works abdominal mass or ascites Factors causing traction on the uterus: as cervical polyp, fibroid. 21  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. 22 23 Sulci Bladder Ts Vag SubM. 24 25 26 27 28  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. 29 30 31 32 33 34 35  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. 36  Effect on the genital tract Effect on the vagina: Congestion, hypertrophy, and thickening of vaginal wall Chronic irritation resulting in keratinization and pigmentation Trophic ulcers which resist healing due to decrease blood supply (venous obstruction and congestion), decrease estrogen (after menopause), infection, irritation by urine and feces, friction with thighs and clothes 2- Effect on the cervix: Elongation of supravaginal portion of the cervix because vaginal wall pulls on the weak lower part of Mackenrodt’s ligament while the strong upper part of the ligament is fixing the upper part of the cervix. Congestion, hypertrophy, and thickening of epithelium. Trophic ulcers. 3- Effect on the uterus: Chronic congestion and hyperemia: result in dyspareunia, dysmenorrhea, dysuria, dyschesia, deep veins pain, deep backache, and dragging pain. Congestion of endometrium resulting in menorrhagia 37  Effect on urinary tract Effects on urethra: Urethrocele changes urethro-vesical axis resulting in stress incontinence Huge prolapse causes kinking of urethra resulting in dysuria and sometimes attacks of retention and masking stress incontinence Effects on the urinary bladder Cystocele leads to incomplete emptying of the bladder, increase residual urine, stasis, infection, and stone formation Chronic irritation resulting in hypertrophy Effects on ureters and kidney: Marked prolapse causes kinking of the ureter resulting in increase back pressure, hydroureter, and hydronephrosis Pyelonephritis and renal failure may result 38 Effects on the Rectum and Anal Canal Incomplete bowel emptying The patient learns to “splint” her vagina with her fingers to evacuate stool Constant desire for defecation, increased frequency Constipation, dyschesia and piles may develop due to straining 39 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 40 41  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 Bimanual examination for the uterus, ovaries, adnexa, and Douglas pouch. 42  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: Incomplete bowel emptying, Constant desire for defecation, increased frequency of defecation. Dyschesia and piles may develop due to straining. 43  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). 44  DD Anterior Vaginal Wall Prolapse: Differentiation of anterior vaginal wall prolapse from other conditions: Congenital anterior vaginal wall cysts e.g. Gartner’s cyst. 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 45  Posterior Vaginal Wall Prolapse: Rectocele Vs Implantation Dermoid /Vaginal cyst. 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). 46  Uterine Prolapse Uterine Prolapse Congenital Elongation of the Cervix Old age and high parity. Young age and in nulligravida. External os appears outside the vulva The fornices and the vaginal vault with shallow fornices. are at the normal level (the level of Elongation of suprvaginal portion of ischial spines). cervix The Portiovaginalis portion of It yields on straining and in volsellum cervix is elongated test. It does not yield on straining In 3rd degree prolapse and/or upon traction with a the thumb and fingers can meet together volsellum. above the fundus of uterus when the uppermost portion of the prolapsed mass is palpated (finger test or grip sign). 47 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: 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 48  Prophylactic Measures Avoid the predisposing and precipitating factors: Proper obstetrical care: Proper management all stages of labor. Postnatal pelvic floor exercises. Shortening the second stage of delivery. Limit the use of forceps. Cesarean section is to be performed when indicated: e.g. those who have already had prolapse prior to pregnancy, or have skin markers for collagen disorder. Avoid smoking, straining at stool, constipation and heavy physical work. Improved management of chronic obstructive airway disease (COAD) Proper support of the vaginal vault after hysterectomy 49 Management of Prolapse Conservative Management Corrective Surgery Should be treated only when it is symptomatic (Be certain symptoms are due to Prolapse ) Interferes with the normal activity of the woman The patient seeks treatment 50  Conservative Management Encouraging behavioral alterations Estrogenic hormones improving elasticity, thickness, and blood supply of the vaginal skin It increases muscle tone in the pelvis and make the fascia more resistant to breaking. They can be used to relieve symptoms in mild prolapse, and in menopausal women and at the preoperative phase. Pelvic muscles training, rehabilitation and Kegel exercises: The exercises are rather prophylactic and may help in minor degrees only. Kegel exercises for the pelvic muscles: The patient identifies the muscles by stopping her urine in midstream. She then contracts these muscles 10 to 20 times for 5 seconds. This is to be repeated three times a day. 51  Pessaries Indications When planning for pregnancy, In pregnant women and after pregnancy, Advanced age and medically debilitated women. Preoperative period: for healing of decubitus ulcers. As a therapeutic test to confirm that surgery might help The patient is preferring conservative management Types Older pessaries were made of rubber and had to be changed every 3 months. The modern pessary is made of inert plastic and can be left in place for up to a year provided there are no adverse symptoms or signs. The most common pessary is ring-shaped as the Smith-Hodge ring. The proper size of pessary should be selected. Care : Regular and frequent cleaning of the device. Regular checking of the vaginal skin for infection and abrasion Oral or vaginal estrogens will help in protecting the mucosa. Complications Vaginal ulceration Incarceration and impaction leading to vaginal discharge and bleeding Infection, dyschesia, dysuria, fistula with neglected pessary. 52  Reconstructive Surgery The basic principle of this approach is to Support weak and prolapsed tissue by suturing it to bone, either directly or indirectly by interpositioning of mesh. The aim is to restore the anatomy as close to the original anatomy as possible. Reconstruction may be through Strengthening of the original fascia Application of a variety of meshes and synthetic material 53 54  Reconstructive Surgery for Prolapse Pre-operative Preparations General preparations: dietary control for obesity, treatment of chronic cough and chest infection, bed rest, avoid lifting any weight, and treatment of anemia. Treatment of medical conditions Constipation, masses or ascites, and renal infection. Local preparations: Ulceration of the cervix [reposition, estrogen and Silver nitrate] Local douching and estrogen Daily vaginal pack soaked in saline to decrease congestion Treatment of urinary tract stone and infection Timing of operation: Postmenstrual phase in menstruating patients. After delivery: 3- 6 months after delivery 3-6 month following a previous attempt of repair Following 1 week local estrogen application in postmenopausal women 55 Choice of the operation Type and extent of the descent surgery should be tailor made not only to rectify the defect but also to suit the individual patient’s requirement. Sexual activity Desire for future fertility Vaginal suturing should be with interrupted stitches. Synthetic absorbable fine sutures are preferable. Absolute hemostasis and an adequate surgical technique are Mandatory 56  Anterior Repair The principle objective is reduction of the cystocele, repair fascial defects and suturing of the bladder and endopelvic fascia and excision of redundant vaginal wall. Postoperative complications Approximately 50% of patients will encounter postoperative urinary retention following an anterior repair, which can be avoided by using a suprapubic catheter (This allows the patient to void spontaneously and is more comfortable and less prone to urinary infection than a urethral catheter). The catheter is clamped on the second postoperative day and is removed when the patient is voiding amounts greater than 200 ml with a residual urine volume of less than 100 ml. Development of incontinence in a patient who was previously dry. It is likely to be caused by interference with the sphincter mechanism during dissection leading to inadequacy support and elevation of that region. 57 58 Posterior repair The principal objectives is reduction of the rectocele, suturing of the levator ani muscles anterior to the rectum, repair of the perineal body, correction of existing entero-cele or prevention of potential enterocele. Repair fascial defects that allow herniation of rectocele. Open the upper posterior vaginal wall for plication of the rectovaginal connective tissues. Postoperative complications: Constipation and incomplete bowel emptying. Sexual dysfunction because of excess narrowing of the vagina. 59 60  Repair of Douglas Pouch Hernia Vaginal methods for repair Vaginal incision: wedge-shaped (∆) excision of perineal skin (base at the posterior commissure) and open the vagina longitudinally high up until the cervix. The entire posterior wall of the vagina must be dissected to its apex Dissection of the sac from the vagina and open the sac, reduce its contents, excise the sac, and close Douglas pouch by purse-string suture. Support of Douglas pouch by approximating the 2 uterosacral ligaments in midline. Several high purse-string sutures are applied around the neck of the sac. The remaining peritoneum is excised. The uterosacral ligaments are then plicated. Closure: excise the redundant vaginal wall and close it by continuous or interrupted sutures Abdominal methods for repair: Enterocele can be repaired abdominally by excision of herniated peritoneum with transverse approximation of utero-sacral ligaments or purse- 61 string sutures.  Vaginal Hysterectomy And Pelvic Floor Repair Vaginal hysterectomy with support of the vaginal vault by the transverse cervical and uterosacral ligaments. When these tissues are inadequate, the vaginal apex may be suspended from the sacrospinous ligaments or the iliococcygeus fascia.. If there is associated rectocele and a deficient perineum, the procedure is followed by colpo- perineorrhaphy. 62  Abdominal Sling Operation (Sacral Cervicopexy) The uterus is supported by nylon tape or mesh to form artificial uterosacral ligament. Complications Intestinal obstruction, blood vessels injury (external iliac blood vessels and median sacral blood vessels), psoas spasm and pain in upper part of left thigh. 63  Fothergill’s operation (Manchester’s Repair) It is the operation of choice in uncomplicated Utero- vaginal prolapse when uterus is to be preserved but NO future child bearing is required. It is a combination of: Amputation of Cx., Fixation of the Mackinrodt’s ligaments to the anterior of Cx. Ant. Colporrhaphy. D&C is a must. Post. Colporrhaphy to be performed only if rectocele is present Perineorrhaphy is usually not required 64  Fothergill’s Operation Not useful if ligaments are weak & Uterus is of normal size. Technically difficult operation, requiring high degree of surgical skill. Threat of short-term complications. Real possibilities of long term complications. Recurrence/Failure. Sling operations are better alternatives 65  Fothergill’s Operation (Manchester repair) Complications of Manchester repair: Long operative time. Excessive blood loss during surgery. Risk of injury of urinary bladder, ureter, and rectum High amputation of cervix may lead to habitual abortion or repeated premature labor due to cervical incompetence Subsequent fibrosis in the cervix may lead to infertility, dysmenorrhea, hematometra, or failure of the cervix to dilate during labor (cervical dystocia) Dyspareunia due to vaginal narrowing or tender scar Recurrent prolapse is not rare because of the pull down action of the uterine weight. 66 Lefort Operation (Partial Colpocleisis) LeFort operation obliterates the central portion of the vaginal canal, leaving lateral channels for drainage of uterine and cervical secretions. Advantages: can be done under local anesthesia, and affords minimal surgical trauma Complications and disadvantages: After surgery the ability for intercourse well be lost Normal diagnostic access (D&C) is impossible Urinary incontinence resulting from downward displacement of the urethra by traction. 67 Postoperative Care After Surgery Early Postoperative Remote Postoperative Vaginal pack catheter for Avoid lifting heavy weight for 24 hours to prevent one month reactionary hemorrhage Avoid coitus for 2 months Analgesics and antibiotics (including anti-anerobes ) Avoid pregnancies for 2 years The amount of residual If delivery occurs, patient urine needs to be checked must deliver in hospital with before discharge. ( it should generous episiotomy, avoid NOT exceed 30 ml) prolonged 2nd stage (prophylactic forceps), or by cesarean section in case of soft tissue Obstruction 68  Postoperative Complications Immediate Postoperative Delayed Postoperative Shock: anesthetic, Vaginal stenosis leading hemorrhagic, and neurogenic dyspareunia shock Fistula in case of injuries Hemorrhage: 1ry and 2ry of urinary bladder and Infection: wound, urine, and rectum pelvic Fibrosis leading to soft Pulmonary: due to DVT tissue obstruction in next delivery Injuries of urinary bladder and rectum Recurrence of prolapse (5% -10%) Special complications depending on type of operation 69  Recurrent Prolapse Recurrence of prolapse following successful operation. [5 -10%] Etiology: Improper preoperative preparations: Improper preparation of the general condition: Persistent cough, anemia, persistent constipation and presence of ascites and abdominal mass Improper local preparation: Trophic ulcers, infection, marked menopausal atrophy, developmental weakness, persistent UTI Improper timing of operation Improper operative technique: Bad choice of operation: e.g., vaginal hysterectomy without pelvic floor repair or Fothergill operation without amputation of cervix Failure to identify and treat Douglas pouch hernia Failure to correct RVF at surgery. Bad surgical hemostasis resulting in hematoma and infection 70  Recurrent Prolapse Improper postoperative care: Early ambulation and lifting weights Infection and breaking down of sutures and 2ry hemorrhage Persistence or recurrence of predisposing factor such as smoking Early intercourse or pregnancy Bad management of labor and delivery after operation Management: Treatment of the cause of recurrence Type of re-operation: according to type of prolapse and condition of the patient Fibrosis induced by the first operation makes the 2nd trial difficult Timing of operation: at least 3-6 months following previous 71 trial Vault Prolapse Increases in intra-abdominal pressure directed against the top of an inadequately supported vagina result in prolapse of the vaginal vault. Etiology: usually following hysterectomy More common in total hysterectomy Bad choice of operation as in case of abdominal operation in presence of weak pelvic floor which must be repaired or doing vaginal hysterectomy without pelvic floor repair. Neglected enterocele. Lack of surgical prophylaxis which are: During abdominal operations: Total abdominal hysterectomy instead of subtotal hysterectomy Suturing round, Mackenrodt’s, and may be uterosacral ligaments to vaginal vault. During vaginal operations: Suturing vaginal vault to Mackenrodt’s and uterosacral ligament The following factors predispose to vault prolapse: Total abdominal hysterectomy instead of subtotal hysterectomy Shortening of the anterior vaginal wall Postoperative pelvic infections after primary repair operations 72  Clinical picture: there is descent [inversion] of vaginal vault on straining Surgical correction of vault prolapse: Abdominal operations: Abdominal sacrocolpopexy: the vaginal vault is fixed to the sacral promontory with autologous or synthetic material. Vaginal operations: Sacrospinous fixation: Vaginal vault is opened and sutured to sacrospinous ligament on both sides. It permits restoration of a normal vagina, preserves normal vaginal axis, so, decreases recurrence, and avoid complications of abdominal operations The LeFort operation 73 Retroverted -Flexion Backward displacement of the uterus where the angles of version and flexion look backward. Incidence: 20-25%, in most cases it is congenital without adverse effects. 74  Causes Congenital retroversion: The uterus is usually mobile and asymptomatic. It is significant in congenital prolapse and some degree of uterine hypoplasia. Acquired: usually fixed and symptomatic. Puerperal RVF: the predisposing factors are (1) stormy labor leading to lax uterine support and prolonged recumbence (2) full urinary bladder (3) uterine subinvolution (increase bulk and weight of the uterus while lower segment is soft) Inflammatory causes: as in pelvic hematocele, abscess, PID and endometriosis. They lead to adhesions in Douglas pouch, which pull the uterus backward. Neoplasm: mass in uterovesical pouch as ovarian cyst pushes the uterus or posterior wall myoma pulls the uterus backward. Prolapse: causes stretching of ligaments. 75 Degrees First degree: The fundus is directed to the promontory of the sacrum, the cervix is directed downward and forward, and the body and the cervix are in one line with the vagina. Second degree: The fundus is directed to the body of the sacrum, the cervix is directed forward, and the uterus lies horizontal. Third degree: The fundus is directed to the tip of the sacrum, the cervix is directed upward and forward, and the uterine fundus lies lower than the cervix. 76  Mobile RVF: may be temporarily corrected by manual manipulation, at pelvic examination. Fixed RVF: can not be corrected by manual manipulation. This may be found in presence of adhesions 77  Clinical presentation: Asymptomatic: it is accidentally discovered in most of cases. Signs: Pain: The posterior lip of the cervix is first to be Congestive dysmenorrhea. felt Deep dyspareunia external os is directed downward and Deep backache due to stretch of uterosacral forward, or forward, or upward and forward ligament. according to the degree of RVF. Dull deep pelvic or iliac fossa pain. The uterine body is felt as a mass in Dysuria and dyschasia Douglas pouch through the posterior Menorrhagia and or vaginal discharge vaginal fornix. Pressure symptoms: causes frequency of Examination for mobility and degree of micturition and sense of incomplete defecation. RVF, and ovarian prolapse in Douglas Effects of RVF on pregnancy: pouch. Abortion: It is uncommon and usually occurs at If sounding is done for any reason, its 12-14 weeks direction confirms the diagnosis. Incarcerated pregnant RVF uterus. Investigations: Infertility: RVF is uncommon cause of infertility. It is only considered if no other causes Pessary Test: it is used to check if the are found. Mechanism of infertility in RVF: symptoms are due to RVF (if it is mobile). Hodge-Smith pessary is inserted to correct The cervix is directed away from the seminal pool RVF. in the posterior vaginal fornix. Kinking of cervical canal due to acute retroflexion. Ultrasonography. Congested endometrium interfering with Laparoscopy: if it is going to be done for implantation of the fertilized ovum. other reason. Hypoplasia of the uterus in some cases of Investigations for the cause of RVF e.g. congenital RVF. endometriosis. Anovulation due to pelvic congestion. Dyspareunia interfering with complete 78 intercourse.  Prophylaxis: Postpartum early ambulation, pelvic floor exercise, regular empty of the urinary bladder, lying on the abdomen an hour daily, and avoid causes of subinvolution. Proper management of pelvic hematocele, abscess, PID and endometriosis. Plication of round ligaments after operations associated with risk of adhesions as myomectomy and endometriosis to keep the uterus anteverted. Active Management (for mobile RVF): Conservative Management (palliative): Smith-Hodge pessary. The pessary stretches the posterior vaginal fornix and overlies the uterosacral ligaments, thus, the cervix is pulled backward and the uterus is kept anteverted. Indications of conservative approach: To test if the symptoms are merely due to RVF. Pregnant lady with previous repeated abortions attributed to RVF. As prophylaxis after delivery. 79  Curative (Surgical): Indications: Symptomatic cases which relieve on pessary test e.g. dyspareunia. Infertility (RVF is a rare cause of infertility). In association with some operations as myomectomy and endometriosis. Operative techniques: Abdominal Operations: Modified Gilliam’s operation (ventrosuspension): A loop of each round ligament is pulled through the internal inguinal ring, and they are sutured to the anterior aspect of the anterior rectus sheath. This leads to shortening of the round ligaments and pulling the uterus forward. Plication of round ligaments: by non-absorbable material e.g. silk. Vaginal Operations: Plication of uterosacral ligaments through an opening in Douglas pouch. Retoversion is corrected by suturing Mackenrodt’s ligaments in front of the cervix in Fothergil’s operation in cases of uterine prolapse. Management for Fixed RVF: It depends on the underlying pathology. Management of RVF with infertility: Perform postcoital test to assess cervical factor. Advise the woman to lie on her abdomen after coitus, so that the cervix external os comes at the seminal pool. Artificial insemination husband could be carried out. Ventrosuspension might be helpful. 80