CHRISTIAN COLLEGE OF NURSING,
NEYOOR
SEMINAR ON
UTERINE
DISPLACEMENT
SUBMITTED BY SUBMITTED TO
P.Anne Jakuline Princy Dr.R. Arzta Sophia, Ph.D(N)
M.Sc (N) II year HOD of OBG Department
UTERINE DISPLACEMENT
Introduction
The uterus is not in a fixed position in pelvis. Minor variations in position
occur with changes in posture with straining and with full bladder or rectum.
The commonly occurring displaced positions are retroversion, prolapse and
inversion of uterus.
Retroversion of uterus
Definition
Retroversion is the turning background of the uterus with the long axis of
the corpus and cervix in fine and the whole organ turns background in relation
to the long axis of the birth canal.
Retro flexion is a bending backwards of the corpus on the cervix at the
level of the internal os
The two conditions are usually present together and are referred to as
retroversion-flexion or retro displacement.
Degree of displacement
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 internal os.
Causes
Developmental
Retro displacement is quite common in fetuses and young children. Due
to development defect there is lack of tone of the uterine muscles.
Acquired
Puerperal due to stretched ligaments caused by childbirth.
Prolapse
Fibroid tumour in the anterior or posterior wall of the uterus produces
heaviness making it fall behind.
Pelvic adhesions: Adhesions either inflammatory, operative or due to
endometriosis pull the uterus posteriorty.
Incidence
The Condition is seen in about 15 to 20% of normal women.
Sign and Symptoms
Chronic premenstrual pelvic pain due to varicosities in broad ligament
Backache
Dyspareunia.
Diagnostic Findings
On bimanual examination body of the uterus is felt in the posterior fornix
land cervix directed upwards.
On Speculum examination, the cervix is viewed easily and the external os
points forwards..
Prevention
The following guidelines to be followed during weeks after childbirth or
abortion to prevent retroversion.
To empty the bladder regularly.
To increase the tone of the pelvic by regular exercise.
To encourage lying in prone position for half to one hour once or twice
daily between 2 to 4 weeks postpartum.
Treatment
Pessary: It is less commonly used in present day gynaecologic practice. It
may be indicated for
Pessary test
Subvolution of uterus
Uterine prolapse
Prolapse of uterus refers to a collapse descend or change in the position
of the uterus in relation to surrounding structures in the pelvis. It occurs when
pelvic floor muscles and Ligaments stretch and weaken providing inadequate
support for the uterus. The uterus then descends into the vaginal canal. It
usually happens in women who had one or more vaginal birth.
Associated conditions
Cystocele
It is a herniation or bulging of the upper two thirds of the anterior vaginal
wall, where a part of the bladder bulges into the vagina. This leads to urinary
frequency, urgency, retention and incontinence.
Urethracele
Where us herniation of the upper posterior vaginal wall, where a portion
of small bowel bulges into the vagina. Standing leads to a pulling sensation and
backache and this is relived on lying down.
Retrocele
There is a herniation of the middle third of the posterior vaginal wall where the
rectum bulges into the vagina. This makes bowel movement difficult to the
point that the woman may need to push on the inside of vagina to empty the
bowel.
Degree of prolapse
First degree
The uterus sags downward from the normal anatomic position into the upper
vagina. The external os remains inside the vagina.
Second degree
The cervix is at or outside the vaginal introitus, but the uterine body remains
inside the vagina
Third degree
This type is also referred to as complete prolapse or procidentia. The entire
uterus descends to lie outside the introitus.
Causes
Stretching of the pelvic support system:-long and difficult childbirth or
multiple child birth causes muscles and ligaments that normally hold the
uterus in place to become stretched and slack.
Pelvic relaxation that happens during pregnancy:- There is softening of
the pelvic tissue and laxity of the supports during pregnancy as the weight
of the gravid uterus continuously bears down upon the pelvic diaphragm.
Chronic increase in intra-abdominal pressure such as may be associated
with obesity, abdominal or pelvic tumours.
Ascites or repetitive downward thrust of intra abdominal pressure due to
constipation or chronic cough
Normal aging and lack of estrogen hormone after menopause
Symptoms
A feeting of something coming down per vagina, especially while
moving about
There may be variable discomfort on walking when the mass comes out
of the introitus.
Backache or dragging pain in the pelvis, which may be relieved on lying
down
Dyspareunia
Urinary symptoms( in presence of cystocele)
Difficulty in passing urine
Patient may have to elevate the anterior vaginal wall for emptying the
bladder.
Incomplete emptying of the bladder causing frequent desire to pass urine.
Urgency and frequency of micturition which may also be due to cystitis.
Stress incontinence usually due to associated urethrocele.
Retention of urine may rarely occur.
Bowel symptoms (in presence of rectocele)
Difficulty in passing stool.
Patient may have to push back the posterior vaginal wall to complete the
evacuation of feces.
Fecal incontinence may be associated.
Excessive white or blood stained discharge per vagina due to associated
vaginitis and ulceration.
Examination and diagnosis
Inspection and palpation.
Vaginal, rectal and recto vaginal examination.
Pelvic examination in dorsal positions
Management of uterine prolapse
Preventive
Adequate antenatal and intranasal care:-
To avoid injury to the supporting structures during vaginal
delivery, either spontaneous or instrumental.
Adequate postnatal care: To encourage early ambulation and pelvic
floor exercises (kegal's exercise) during puerperium.
General measures. To avoid strenuous activities, chronic cough,
constipation and heavy weight lifting
Limiting and spacing pregnancies avoid pelvic relaxation.
Conservative
Estrogen replacement therapy may improve minor degree
prolapse in post-menopausal women.
In mild cases, exercise help. to strengthen pelvic floor muscles may
Obese patients may be instructed to reduce weight in order to reduce
pressure on pelvic organs.
To avoid wearing constructive clothing such as girdles.
Non-surgical management
pessary may be placed inside the vagina to support the pelvic organs for
patients who do not desire surgery.
Surgical management
It depends on the anatomical alteration of structures and the degree of
prolapse.
Anterior colporrhaphy for correction of cystocele and urethrocele.
Fothergill's or Manchester operation:- This is designed to correct uterine
descend associated with cystocele and rectocele where preservation of
uterus is desired.
Vaginal hysterectomy with pelvic floor repair.
Complications following surgical management.
Immediate
Haemorrhage within 24 hrs following surgery (primary) or between 5th to
10th days (secondary)
Retention of urine
Infection leading to cystitis
Wound sepsis
Late
Dyspareunia
Recurrences prolapse
Infertility
Cervical incompetency
Chronic inversion of uterus
This type of inversion is a condition where the uterus becomes turned
inside out, the fundus prolapsing through the cervix.
Causes
Fundal pressure
Congenital weakness
Excess cord traction during the 3d stage of labour
Uterine weakness
Short umbilical cord.
Types of inversion
Incomplete inversion
The fundus protrudes through the cervix and lying inside the vagina.
Complete inversion
Whole of the uterus including the cervix are inverted. The vagina may
also be involved.
Signs and symptoms
Sensation of something coming down per vagina
Irregular vaginal bleeding
Offensive vaginal discharge
Diagnostic Findings
On Inspection the protruding mass appears globular with no opening in
the leading past. A tumour may be present at the bottom.
On vaginal examination, the cervical rim is either, felt high up or not felt.
A cup shaped depression felt at the fundus or the uterus is not felt in
position.
On recto abdominal examination, displacement of uterus or fundal
depression is felt.
Uterine sound test demonstrates shortness or absence of uterine cavity.
Examination under anesthesia may be needed to confirm the diagnosis
Treatment
Rectification of inversion by surgery of removal of the uterus us
determined by such factors such as age, parity and associated
complications.
Improvement of general condition by treatment anaemia and local sepsis
is done if required prior to surgery
Hysterectomy following rectification
Journal Abstract
Hillary E. Boortz, et. al. conducted a study on "Migration of intrauterine
devices: Radiologic findings and implications for patient care" reported that;
Intrauterine devices are a commonly used form of contraception
worldwide. However, migration of the IUD from its normal position in the
uterine fundus is a frequently encountered complication, varying from uterine
expulsion to displacement into the endometrial canal to uterine perforation.
Expulsion or intrauterine displacement of the IUD leads to decreased
contraceptive efficacy and should be clearly communicated. Embedment of the
IUD into the myometrium can usually be managed in the outpatient clinical
setting but occasionally requires hysteroscopic removal. Complete uterine
perforations in which he IUD is partially or completely within the peritoneal
cavity. Careful evaluation for intra-abdominal complications is also important,
since they may warrant urgent or emergent surgical intervention. The
radiologist plays an important role in the diagnosis of IUD migration and should
be familiar with its appearance at multiple imaging modalities.
Summary
Till now we have discussed about introduction, definition, degree, causes,
incidence, signs and symptoms, clinical examination management, nursing
management and prevention of uterine displacement.
Bibliography
Dutta.D.C, "Textbook of obstetrics" 6th edition published by New book
agency (p) Ltd.
Jacob annamma, "A comprehensive Textbook of midwifery" 1st
edition published by Jitender (p) vij.ltd
Lewis; A text book of "medical surgical nursing" vol-2 published by
Jaypee brothers.
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