Uterine Displacements And Utero-vaginal Prolapse

 

Definition and discussion

 

The cardinal ligaments (Mackenrodt’s) provide the major support for the uterus and vagina. These ligaments may be unduly stretched if the fetus is large or if forceps delivery is attempted before full cervical dilation.

 

Late sequelae and management.

 

If the cardinal ligaments do not return to normal after delivery, the uterus will sag backward and downward into the vagina. The uterus usually forms an acute angle with the axis of the vagina, which in itself tends to prevent proplase. Proplase of the uterus occurs when the cardinal ligaments and other supporting structures (e.g., uterosacral ligaments) relax and the relationship of the axis of the uterus to that of the vagina is altered.

Congenital defects account for descensus (prolapse) of the uterus in infants and nulliparas, but childbirth injury is responsible for its gradual development in multiparas. Cystocele and rectocele, which almost always accompany uterine prolapse, enlarge and pull down on the uterus and cervix, adding to the stress on the weakened cardinal ligaments. The more severe prolapse are seen in postmenopausal women when tissue atrophy eliminates whatever residual support existed. Degrees of prolapse are classified as follows:

1.First-degree prolapse. Cervix is situated between the level of the ischial spines and the vaginal introitus.

First degree

2.Second-degree prolapse. Cervix protrudes through introutius, but corpus remains within the vagina.

 

 Second degree

 

3.Third-degree prolapse. Complete prolapse; cervix and body of uterus protrude through vagina, and vagina is inverted. The extent of the defect is best evaluation by asking the woman to strain while lying down, by exerting traction on the cervix with a tenaculum, or by examining her while she is an upright position.

Complete or Third degree

 

4. Procidentia. Uterus, vaginal vault, rectum, and bladder, and perhaps the posterior cul-de-sac as well, protrude.

Symptoms of uterine prolapse reflects sensations produced by the weight of the descending structures and their protrusion through the vaginal introitus. Third-degree prolapse may eventuate in cervical ulceration and bleeding.

Transvaginal correction of the defect is preferable, but in selected individual (e.g., those who are aged) a pessary may be inserted to stabilized the uterus.

 

The goals of operative procedures are

·1   to correct the cystocele and rectocele,

·2   return the uterus to a forward position,

·3   shorten the elongated cervix, and

·4   shorten the cardinal ligaments.

 

Several procedures accomplish these goals:

 

1)      Manchester-Fothergill: amputation of the cervix, shortening of the cardinal ligaments, and plastic repair of the vagina.

2)      Vaginal hysterectomy.

3)      Colpocleisis (Le Fort’s procedure): obliteration of the vagina by approximation of the anterior and posterior walls.

 

Retroversion and lateral displacement

 

Definition and discussion.

 

Displacement indicates a movement from front to back or from side to side, rather than a descent, as in prolapse. The two types of displacement are:

1)      a change in the long axis of the uterus, for example, anteflexion, malposition, and retroflexion, and

2)      a change in the direction of the long axis of the uterus in relation to the vaginal canal, for example, lateral retroversion, and retrocession.

Most positional differences are simple anatomic variations. They are asymptomatic and have no clinical significance. Retroversion is the most common simple displacement caused by factors that are congenital or acquired after childbirth. Cul-de-sac disease may be responsible and is of clinical significance.

Lateral displacement may signal adnexal disease such as large ovarian tumor on the opposite side.

The supporting ligaments that hold the uterus in anteversion are the round and uterosacral ligaments. The uterosacral ligaments pull the cervix backward and upward; the round ligaments hold the fundus in the anterior position. These ligaments gradually regain their length and return the uterus to anteversion in two thirds of women within approximately 2 months after delivery; in one third of women the uterus remains retroverted.

 

Late Sequelae And Management

 

Uncomplicated retroversion as a sequel to childbirth is rarely symptomatic; low backache is not a symptom. Occasionally it may be difficult to conceive because the cervix points toward the anterior vaginal wall and away from the posterior fornix containing seminal fluid. Retrodisplacement is also clinically significant because it must occur first before the uterus can prolapse.

Infrequently, chronic pelvic congestion may accompany a chronically retroverted uterus and is credited as the cause of deep pelvic and low back pain, difficulty with evacuation of the rectum, menstrual abnormalities associated with an exaggeration of premenstrual tension, and dyspareunia.  The uterus may become boggy and congested, and the tubes and ovaries ( often containing multiple follicular cysts) often prolapse posteriorly into the cul-de-sac.

Surgical correction is necessary only if the woman has symptoms that may be related to uterine position. A properly placed pessary replaces the uterus in the anterior position.

If symptoms are relieved, it can assumed that uterine displacement had contributed to the symptoms. Even through pessaries are retained for short periods of time, the woman needs to follow principle of good hygiene to avoid vaginal infection.

¨      Some women can be taught to remove the pessary at night, cleanse it, and replace it when they get up in the morning. This practice helps to reduce the likelihood of pressure necrosis from irritation against the vaginal wall.

¨      If the pessary is always to be left in place, regular douching may be recommended to remove the increased secretions its presence may cause and to help prevent infection.

¨      The woman is encouraged to visit her health care provider frequently while the pessary is in place.

 

Pessary in place to hold posterior vaginal fornix, with it, attached cervix well backward and upward in pelvis.

 

Albert Smith’s pessary

 

Genital Fistulas

 

Definition and discussion.

 

A fistula is an abnormal or unnatural communication between one hollow viscus and another or from one hollow viscus to the outside.

 

Genital fistulas are located between the bladder and the genital tract (vesicovaginal, vesicocervical, vesicouterine), and between the ureter and the vagina (ureterovaginal), and between the rectum or sigmoid colon and other structures (entrovesical, entrouterine, entrovaginal).

 

Etiologic Factors

 

¨  Congenital anomaly,

¨  Gynecologic surgery,

¨  Obstetric trauma,

¨  Cancer,

¨  Radiation therapy,

¨  Gynecologic trauma,

¨  Infection

 

Discussion of obstetric-related urinary tract and rectovaginal fistulas as follows:-

 

 

Urinary tract fistulas

 

The most common urinary tract fistula (vesicovaginal) forms in the anterior vaginal wall. Historically, necrosis of the vesicovaginal septum from pressure during delayed labor was responsible for the fistula formation; this is seldom the case today because such labors would dictate cesarean delivery.

Today, operative injury near the uterovesical junction during radical hysterectomy for cancer is the primary cause of a fistula between the uterus and the bladder.

The woman with this abnormal opening is partially or completely incontinent, and urine passes through the vagina. A transvaginal surgical repair is possible in most cases.

 

 

 

Rectovaginal fistulas

 

The most common causes of this abnormal communication between the rectum and vagina are infection in the episiotomy, a suture placed through the rectal wall during repair, or an unrecognized rectal injury during parturition or vaginal repair.

Fistulas may form subsequent to extension of cervical cancer or radiation therapy. Trauma-induced fistulas are usually located near the introitus; those induced by cancer tend to be located higher in the reproductive structures.

 

Management

Surgical repair is possible but could be complicated by infection, which delays healing or causes the repair to breakdown.

Preoperative preparation is necessarily prolonged to allow for 2 days of liquid diets, enemas, and antibiotic therapy. A temporary colostomy may be indicated before surgical correction of a complicated rectovaginal fistula.

 

General Nursing Care

 

Nursing care of women with pelvic relaxation problems and fistulas requires sympathetic understanding and encouragement because the women’s emotional reactions are often intense. Women with vesicovaginal or rectovaginal fistulas may become withdrawn because of embarrassment about odors and soiling of their clothing beyond their control.

The nurse needs to use a very sensitive approach in suggesting hygienic practices that reduce bad odors.

If the woman has a rectovaginal fistula, there is a constant oozing of fecal material into the vagina, which may be temporarily lessened by giving a high enema; preoperatively, the woman is encouraged to do this before going out of the house. A soft rubber catheter is used if enemas are given in the preoperative period and should be directed carefully on the side of the rectum opposite the fistula. Although a constipating diet will give temporary relief by discourage fecal material from entering the vagina through the fistula, Constipation will eventually cause pressure and may possibly aggravate the condition; it may even cause the fistula to enlarge. Therefore the woman is advised against restricting diet and fluids in an effort to control bowel action. After surgery, enemas are contraindicated until healing is complete.

 

Perioperative Care

 

It is fruitless to perform surgery until inflammation and induration have subside. This preoperative period may extend to 3 to 4 months. Surgical repair is made through a suprapubic incision into the bladder. The fistulous tract is then dissected out and closed.

In the first postoperative week the woman can expect drainage from the bladder through both a suprapubic and a urethral catheter, usually connected to a suction apparatus set at gentle pressure is mandatory.

¨      Urinary and vaginal drainage are noted.

¨      Vaginal douches may be ordered; douching is accomplished gently and with gentle fluid pressure.

¨      Bed rest or restriction to the hospital room may be needed for several days because the drainage tubes need to be suctioned.

¨      The nurse is challenged to institute measure to prevent physical complications of immobility (especially pneumonia, D.V.T, constipation) and emotional discomfort from sensory deprivation.

¨      Repair of fistulas is not  always successful, and repeat surgeries may be needed.

¨      The nurse needs to employ a variety of techniques and understanding patience when a woman’s anxiety and irritation are expressed.

¨      The woman needs encouragement from nursing and medical staff, and she needs assurance that they understand her problem.

¨      Perineal cleansing is done at least twice daily and after each voiding and defecation.

¨      Local application of an ice pack helps to reduce swelling and promotes comfort. Ice packs are always covered before application to the skin A disposable glove filled with ice serves as an adequate ice pack and is easily made and inexpensive to use.

¨      An indwelling catheter attached to continuous drainage may be in place for 24 to 48 hours.

¨      Urinary output and character of urine are monitored.

¨      After removal of the catheter, the woman is encouraged to void in the usual way.

¨      Within 7 to 10 days following surgery, daily vaginal douching with normal saline may be prescribed.

¨      Whether douches are ordered immediately after surgery or at a late date, sterile equipment and sterile solution is used.

¨      Discharge planning includes instruction for continued douching at least once per day, following by a tub bath.

¨      Laxative are to be keep stools soft and prevent constipation to minimize stress on the surgical site.

¨      The woman is encouraged to follow up her medical care by keeping scheduled appointments.

 

 

 

 

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