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Prolapse is defined as the displacement of an organ from its normal anatomical position.
Supports of the Uterus





- Anteflexion

- Anteversion


- Levator ani (hiatal plate)

- Perinei muscles


- Uterosacral

- Mackenrodt’s


- Endopelvic

- Pelvic floor


Anteflexion: Angle between the long axis of the uterus and cervix (bent of the uterus on itself) = 120-135°

Anteversion: Angle between the cervix and vagina = 90o (remember: v for version, v for vagina)

Retroversion is the first step in the development of prolapse uterus.


Levels of Support of Uterus


Level 1: uterosacral and cardinal ligaments


Level 2: levator ani muscle (pelvic floor)


Level 3: perineal muscles forming perineal body


Support of Vagina


Also know: De lancey's three level systems of support



Structures included

Defect can lead to

Level I

Cardinal and uterosacral ligament

Apical prolapse, enterocele

Level II

Paravaginal attachments (pelvic fascia and paracolpos)

Lateral or paravaginal anterior vaginal wall defect

Level III

Perineal body, levator ani muscle (They

support distal 1/3 of vagina & introitus)

Anterior and posterior vaginal wall prolapse, gaping introitus, perineal descent

Etiology of Prolapse



• Traumatic childbirth

• Repeated pregnancies

• Precipitate labor

• Imperfect repair of perineal injuries

• Postmenopausal atrophy

• Chronic cough/constipation

• Malnourishment

• Large ovarian tumor, fibroid

• Connective tissue disorders (Ehler-Danlos syndrome, Marfan syndrome)

• Neurological anomalies (spina bifida occulta)


Genital Prolapse

  1. Uterine
  2. Vaginal
    1. i. Anterior wall
      - Cystocele (Upper two third)
      - Cystourethrocele
      - Urethrocele (Lower one third)
    2. Posterior wall
      - Lax perineum (Lower one – third)
      - Rectocele (Middle one – third)
      - Enterocele (Upper one third)
  • Cystocele is the MC type of vaginal prolapse.

 Vaginouterine Prolapse (More Common)

 Uterine/Uterovaginal Prolapse (Less Common)

 Traction variety

 Pulsion variety

 • Vagina prolapses first and then, due to traction, pulls cervix and uterus

 • Uterus pro lapses first and then drags vagina later

 • Supravaginal elongation is present

 • Supra vaginal elongation not seen

 • Uterocervical length (UCL) is increased

 • UCL is not increased


In congenital prolapse/ congenital elongation of cervix, intravaginal elongation is seen.


Pelvic organ prolapse quantification (POP-Q): it is a newer classification system to grade the prolapse in which hymen is the reference point.


Newer classification for prolapse - POP - Q Classification


More recent grading system of prolapse considers the individual pelvic organ and its distance in relation to the hymen. Pelvic Organ Prolapse Qualification identifies several points (total 9) within and around the vagina and measures the distance of each point from the hymens while the patient performs valsalva. The points which lies inside vagina is reported as negative number and which lies outside as positive. Staging is done according to the measurement.

Degrees of Prolapse

  • First degree: descent of cervix into the vagina (external os is at the level of ischial spine in normal anatomical position)
  • Second degree: descent of cervix up to the introitus
  • Third degree: descent of cervix outside the introitus
  • Fourth degree (procidentia): whole uterus (including the fundus) is outside the introitus

Decubitus Ulcer

  • Decubitus ulcer is the ulceration of the prolapsed tissue due to friction, congestion, and circulatory changes in the dependant part of the prolapse.
  • Reduction of the prolapse into the vagina and daily packing (glycerin acriflavine tampon) heals the ulcer in a week or two.
  • Glycerin = hygroscopic agent and acriflavine = yellow colored dye that helps in epithelization.

Surgical Treatment for Prolapse

Age, parity status, and /type of prolapse are the factors that decide the type of surgery.


Conservative Treatment (Uterus-preserving Surgeries)


It is done for young patients desirous of further childbearing/menstrual function



  • Fothergill's operation
  • Shirodkar’s uterosacral ligament advancement

Abdominal (Sling Surgery/Cervicopexy)

  • Purandare
  • Shirodkar
  • Khanna
  • Virkud (composite sling)

Radical Surgery

  • For old patients, family complete, postmenopausal women who are medically fit for surgery
  • Vaginal hysterectomy with or without anterior and posterior colporrhaphy is the best surgery:

Anterior colporrhaphy: repair of cystocele and cystourethrocele


Posterior colporrhaphy: repair of rectocele and lax perineum

Key Points of Various Surgeries

  1. Fothergill's repair (Manchester operation): Main step is amputation of cervix.
    • Initially, the operation was thought to preserve the fertility status of the patient.
    • But as it is associated with a lot of complications, it is not a preferred option nowadays.
    • Various complications include:
    1. Primary hemorrhage / secondary hemorrhage
    2. Repeated second trimester abortions due to cervical incompetence
    3. Preterm labor /PROM
    4. Cervical stenosis
    5. Cervical dystocia
    6. Infertility due to cervical factor
  2. Shirodkar's uterosacral ligament advancement surgery (modification of Fothergill's operation): There is no amputation of cervix, and so the complications of Fothergill's operation are not there. It is preferred in young women desirous of further childbearing.
  3. Purandare's cervicopexy (dynamic sling and open sling): Central part of Mersilene tape is fixed anteriorly over the exposed isthmus. The two ends of tape are attached to the posterior rectus sheath.
    Good abdominal muscle tone is prerequisite for this surgery. If the anterior abdominal tone is poor, this surgery should not be done. Postsurgery, the uterus becomes retroverted and the POD becomes deep. Hence, enterocele is a long-term complication of this surgery. Enterocele formation can be prevented by Moschowit's/ Halban's surgery in which POD is obliterated.
  4. Shirodkar sling (static sling): Mersilene tape is placed posteriorly on the cervix and anchored to sacral promontory (anterior longitudinal ligament).
    On the left side, the tape has to pass below the mesentery of sigmoid colon to reach sacral promontory. On the left side, a loop is created over the psoas muscle to avoid obstruction to the rectosigmoid.

    1. Injury to sigmoid colon, mesentery, and ureters
    2. Hemorrhage from pre-sacral mesenteric vessels
    3. Intestinal obstruction
    4. Injury to genitofemoral nerve (present in psoas muscle)
  5. Khanna sling: Mersilene tape is anchored to anterior superior iliac spine.
  6. Composite sling (Virkud): As the complications of Shirodkar sling are mainly on the left side in this surgery, on right side the tape is attached to sacral promontory and on left side the tape is attached to rectus sheath (left-sided Purandhare + right-sided Shirodkar).
  7. Vaginal hysterectomy with pelvic floor repair: Women above 40 years who have advanced uterine prolapse with cystorectocele, have completed their families, and are not interested in further childbearing or menstruation are fit for surgery.
  8. Le Fort's repair (complete colpocleisis): It is done in very elderly postmenopausal women who are unfit for major surgery (with medical complications such as heart failure, past history of myocardial infarction, severe hyper tension, etc.).
    This procedure can be performed under local anesthesia and sedation. Prior to the procedure, PAP smear and pelvic use should be done to rule out cervical dysplasia and pelvic pathology. Vaginal sexual activity is not possible after this surgery. If sexual function is desired, Goodell-Powel surgery (partial colpocleisis) is done (modification of Le Fort's repair).

Indications of Ring Pessary

  1. Early pregnancy (up to 18 weeks)
  2. Puerperium
  3. Patients unfit for surgery

It is never curative, only palliative.

Vault Prolapse

It is a long-term complication of any hysterectomy and occurs more frequently after vaginal as compared to abdominal. It can be prevented by vault suspension at the time of primary surgery.



  • Transvaginal sacrospinous ligament fixation
  • Transabdominal sacrocolpopexy: mesh is attached to vault and sacral promontory

Sacrocolpopexy is considered the gold standard operation for vault prolapse.


Prevention – Kegel Exercises

Kegel exercise are pelvic floor exercises which consist of contracting and relaxing the muscles that form part of the pelvic floor.


The aim of Kegel’s exercises us ti improve muscle tone by strengthing the pubococcygeus and muscles of the pelvic floor. They are good for treating first degree vaginal prolapsed, preventing uterine prolapsed, and to aid with child birth in females and for treating prostate pain and swelling resulting from benign prostatic hyperplasia (BPH) and prostatitis in males.These exercises reduce premature ejaculatory occurrences in men as well as increase the size and intensity of erections.


Kegel's exercises may be beneficial in treating urinary incontinence in both men and women. The treatment effect might be greater in middle aged women in their 40s and 50s with stress urinary incontinence alone.

Time for initiating Kegel's exercise in pregnant females

  • In 1 trimester
  • Following vaginal delivery-after 24 hours
  • Following cesarean section-after 24 hours

Limitations of kiegels exercises


Kiegels exercise has a limited effect as it affects mainly voluntary muscles viz bulbocavernous, levator ani, and superficial and deep transverse perineal muscles and not the main fascial supporting tissues

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