A 55 year old female presented to the OBG department with complaints of pain in lower abdomen, the flanks, dysuria, urinary incontinence and constipation since one month.
She felt a mass protruding per vagina a year ago, but it didn’t interfere with her daily activities.
She has a past history of three caesarean deliveries.
Obstetric Score of the patient is G3P3A0L3.
Menstrual history is normal.
She does not have a history of any connective tissue disorder, hypertension, diabetes mellitus, cardiac, respiratory and thyroid disorders.
General Physical Examination
The female patient was conscious, alert, cooperative and well oriented to time, place and person. She was moderately built and well nourished.
No pallor, icterus, cyanosis, clubbing, lymphadenopathy or edema.
Blood pressure- 108/82 mm of Hg
CVS – S1, S2 heard. No murmur.
RS – B/L normal.
Abdomen – Soft bowel sounds present.
P/V Examination – Protrusion of globular mass outside vaginal introitus.
Total RBC count– 4millions/cu mm
Total WBC count– 7500/cu mm
Platelet count– 1.3lakhs/ cu mm
BT– 1min 55sec
Card HIV– negative
HCV antibody test-negative
Card test HBs Ag– Non- reactive
T3 – 1.14mg/ml
T4 – 6.8 micrograms/dl
TSH – 2.41 pIU/ml
PAP smear report:
Suggestive of atrophic smear. No dysplastic cells seen.
USG scan of abdomen and pelvis
Liver, GB, pancreas, spleen, kidneys and UB are normal.
Both ovaries atrophied and no ovarian/adnexal mass is seen.
Uterus- Prolapsed uterus (size- 86×31×50mm) with hypertrophied cervix.
Differential Diagnosis :
Procidentia/ Uterine prolapse Grade 4
Since the patient had grade 4 uterine prolapse, she underwent a vaginal hysterectomy under spinal anesthesia.
Uterine prolapse is the descent of uterus per vagina due to loss of anatomical support of the uterus by pelvic floor muscles and uterosacral, round, broad and cardinal ligaments.
Uterine prolapse can be categorized as incomplete and complete.
Incomplete uterine prolapse: Uterus partially displaced into vagina but doesn’t protrude out.
Complete uterine prolapse: Portion of uterus protrudes outside vagina.
The condition is graded by the level of descent of uterus into vagina:
Grade 1- Descent of uterus to upper vagina
Grade 2- Descent of uterus to introitus of vagina.
Grade 3- Descent of cervix outside introitus of vagina.
Grade 4- Descent of cervix and uterus outside vagina.
Signs and symptoms include uterine protrusion from vaginal opening, backache, pelvic heaviness and pulling, sense of ‘dragging’ pain in the groin, dysuria, urinary incontinence, retention of urine in bladder, susceptibility to UTIs, vaginal bleeding or discharge, abdominal cramping, constipation and ulceration of exposed tissue.
Symptoms are often exacerbated by chronic coughing, straining or prolonged standing.
The most probable causes of uterine prolapse are obesity, genetic predisposition, excessive straining during bowel movements, multiple deliveries, trauma during childbirth per vagina, weakness of pelvic supports due to aging, decreased estrogen levels and disorders of connective tissue.
Treatment options include hormone replacement therapy, insertion of vaginal pessary, exercises to strengthen pelvic muscles and in severe cases, surgery.
Though uterine prolapse is often asymptomatic but patients should approach a doctor without any hesitation as early as possible to prevent progress to manifestation of urological symptoms.
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