• Clinical manifestation

• Differential Diagnosis

• NORAINI RAIMI BINTI SAJARI

 CLINICAL MANIFESTATIONS
OF UTERINE PROLAPSE
• Predominantly middle age or post menopausal
women
• Symptoms not always be related to the degree of
prolapse

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 CLINICAL MANIFESTATIONS

• Patient complaints of something coming down per vagina /

swelling in the vagina /difficulty in walking
• Symptoms worse at time with gravity (e.g after long periods
of standing or exercise)
• Better when gravity is not factor, e.g lying supine
• Symptoms prominent at times of abdominal straining (e.g
during defecation)
• Dyspareunia
• Excessive white or blood-stained discharge per vaginum is
due to associated vaginitis or decubitus ulcer.
Urinary Symptoms (presence of Cystocele)
• Difficulty in passing urine,
• Frequent desire to pass urine.
• Urgency and frequency of micturition may also be due
to cystitis.
• Painful micturition is due to infection.
• Stress incontinence is usually due to associated
urethrocele.

Bowel Symptoms (presence of rectocele)

• Difficulty in passing stool/Fecal incontinence.
5
 CLINICAL EXAMINATION OF PROLAPSE

Bimanual
Visual Speculum
pelvic
inspection Examination
Examination

Rectal and
Neuromuscular
rectovaginal
examination
examination

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 VISUAL INSPECTION
1. On coughing in dorsal position patient is examined and
the pelvic organs prolapse are noted. Presence of external
os in the prolapsed mass indentifies the cervix and
consequently uterine descent.
2. Presence of rugosities on anterior vaginal wall denotes
good oestrogen level. In post-menopausal women vaginal
wall is smooth, dry and thinned.
3. Presence of decubitus ulcer (if any) is noted. Its number,
size, location and character are described.
4. Any pigmentation of prolapsed vaginal wall is noted.
5. Vulval atrophy if present is noted.
6. Gaping of introitus is noted.
7. Perineal body is examined and its length is noted.
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 SPECULUM INSPECTION
Aim: To define the extent of the prolapse and establish the
compartments of the affected vagina (anterior, posterior or apical)

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To assess the prolapse
• Ask the woman to lie on her left
side and bring her knees up to her
chest.
• Use a univalve Sims speculum,
placing a small amount of
lubricating jelly on the blade.
• Insert the blade to hold back the
posterior wall.
• Ask the women to cough while
you look for uterine descent and
the bulge of a cystocoele
• Repeat, using the speculum to
hold back the anterior vaginal wall
to see a rectocoele or
enterocoele.
SPECULUM INSPECTION

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Findings of Speculum Examination
Bulging:
1. Anterior vaginal wall
• Upper ⅔rd : Cystocele
• Lower ⅓rd : Urethocele
2. Posterior vaginal wall
• Upper ⅓rd or apical part :Enterocele
• Middle part :Rectocele
• Lower ⅓rd :Incomplete perineal tear/
relaxed perineum

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 BIMANUAL INSPECTION
• To assess the sixe and mobility of the uterus
• To note for any adnexal masses
• To note elongation of cervix:
• Vaginal elongation of cervix: Deep vaginal fornices.
• Supravaginal elongation of cervix: Shallow vaginal
fornices
• If fundus of uterus is also outside the introitis, it is
3˚ uterine prolapse (also known as procidentia)
• Procidentia cannot be diagnosed by inspection only. The
fundus of the uterus must be palpated outside the
introitus

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 RECTAL & RECTOVAGINAL INSPECTION
Per rectal examination
 To distinguish the rectocele
from enterocele. In rectocele
finger in rectum will bulge into
the vaginal lumen.

Rectovaginal examination
• Diagnose an enterocele.
• Differentiate between a high
rectocele and an enterocele.
• Assess the integrity of the
perineal body.
• Detect rectal prolapse.
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DIFFERENTIAL DIAGNOSIS OF UTERINE
PROLAPSE

Congenital
Chronic uterine
elongation of
inversion
cervix

Pedunculated
Large Uterine
fibroid or
Polyp
Endometrial polyp
 DIFFERENTIAL DIAGNOSIS OF UTERINE
PROLAPSE
1. Congenital elongation of cervix
• It is usually un-associated with prolapse
• Vaginal part of the cervix is elongated
• External os lies below the level of ischial
spines
• Vaginal fornices are narrow and deep
• Cervix looks conical
• Uterine body is normal in size and in
position

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CERVICAL ELONGATION VS UTERINE PROLAPSE

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 DIFFERENTIAL DIAGNOSIS OF UTERINE
PROLAPSE
2. Chronic uterine inversion
• Leading protruding mass is broad
• There is no opening visible on the leading
part
• It looks shaggy
• Internal examination reveals cervical rim
is on the top of the mass
• Rectal examination confirms the absence
of the uterine body and cup-like
depression is felt.

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 DIFFERENTIAL DIAGNOSIS OF UTERINE
PROLAPSE
3. Pedunculated fibroid or Endometrial polyp
• Leading protruding mass is broad
• There is no opening visible on the leading part
• Mass is saggy
• Internal examination reveals the pedicle coming out through the
cervical canal or arising from the cervix
• Rectal examination reveals normal shape and position of the
uterus

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DIFFERENTIAL DIAGNOSIS OF CYSTOCELE
1. Gartner’s Cyst
• Situated anteriorly or antero-laterally and of variable sizes
• Rugosity of the overlying vaginal mucosa are lost
• Vaginal mucosa over it becomes tense and shiny
• Margins are well defined
• It is not reducible
• There is no impulse on coughing
• The metal catheter tip introduced per urethra fails to come
underneath the vaginal mucosa
References

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