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PELVIC O RGAN SUPPORT

A. Pelvic Diaphragm (main support)

B. Ligaments supporting the uterus
(endopelvic connective tissue
condensations).

✓ Vagina makes an angle of 45 degrees with

horizontal.
✓ Both vaginal walls opposing each other.
✓ Post. Vagina (approx.: 3 cm longer) longer than anterior (7cm avg.)

Normal position of uterus: Ante version and ante flexion.

Normal position of uterus maintained by ligaments.

✓ Anteversion: angle b/w long axis of vagina and

long axis cervix: 90 degree
✓ Anteflexion: angle between the long axis of
cervix and long axis of uterine body: 120 degree

What maintains anteflexion?

✓ Pubocervical ligament
✓ Round ligaments(false support)

What prevents retroversion?

✓ Uterosacral ligament
✓ Cardinal ligament also called as Transverse cervical ligament: Mackenrodt ligament.

Note: Broad Ligament: Sheet of peritoneum (double layer) extends from side of uterus
to lateral pelvic wall, no support.

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 Pelvic Diaphragm

✓ Puborectalis: Medial most fibers of

pubococcygeus: sling around rectum.

Pelvic Diaphragm is made up of:

✓ Levator Ani: Fibers of Pubococcygeus and iliococcygeus, also puborectalis (these

are the medial most fibers of pubococcygeus)
✓ Ischicocygeous/ Coccygeous. Pelvic Diaphragm is supplied by Pudendal nerve.
(S2,S3,S4)
✓ Most common cause of prolapse: Neuropathic: leads to weakening o f pelvic
diaphragm

Kegel’s Exercise: can strengthen the voluntary muscle, (pelvic diaphragm), no role in
strengthening ligaments.

Start exercise in pregnancy in 1 st trimester itself

can be started (restarted) within 24 following C.S/ Vaginal delivery

T Y PES O F PRO LA PSE

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Defined according to: De Lancey’s levels of uterine support.

Muscles forming Perineal

body:

1. Fibers of external anal

sphincter
2. Bulbospongiosus muscle
3. Fibers of levator ani
4. Superficial and deep
transverse perineal
muscle
5. Fibers from external
urethral sphincter.

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Level Defect
Level 1 ✓ Uterosacral ligaments ✓ Uterovaginal prolapse.
✓ Cardinal ligaments ✓ Enterocele
✓ Pubocervical Ligament ✓ Vault Prolapse

Level 2 ✓ Rectovaginal Septum ✓ Rectocele

✓ Pubocervical septum ✓ Cystocele
Level 3 ✓ Pelvic diaphragm ✓ Rectocele
✓ Urethrocele

Pro la p s e ( Etio lo gy Gra d ing & Clini ca l Pres enta tio n)

CAUSES OF PROLAPSE

✓ Age related weakening of muscles and support

Contributory factors:

1. Most imp: child birth

✓ Repeated child birth

✓ Frequentchild birth
✓ Faulty management of labor:
• premature bearing down
• Improper instrumentation

✓ Early resumption of strenuous exercise.

2. Increase in intraabdominal pressure: Cough, pelvic mass, weight lifting.

Grading of Prolapse:

To quantify the degree of prolapse:

✓ Jeffcoat’s classification
✓ Malpas classification
✓ Shaw’s classification

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 SHAWS CLASSIFICATION :

First degree: The cervix descents into the vagina but above the level of introitus.

Second degree: The cervix descents to the levelof the introitus

Third degree: The cervix is outside the introitus

Fourth degree: The entire uterus is outside the introitus. Also called as
PROCIDENTIA.

Baden walker’s Halfway system: Reference point hymen

POPQ Classifications: Pelvic organ prolapsed Quantification

✓ Standardized system
✓ Reference point hymen

Clinical features:

✓ Something coming out of vagina.

✓ Dragging sensation in lower abdomen.
✓ Problem in urinating and defecating
✓ Constipation makes prolapse worse.
✓ Splinting: reposition the prolapse to
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urinate and defecate.
✓ Increased risk of UTI
✓ +/- Stress incontinence
✓ Decubitus ulcer: is caused because of venous
congestion
✓ Needs treatment before any surgery.
✓ Treatment: Glycerin and Acriflavine packing

Treatment of Prolapse in Postmenopausal Women

SURGICAL TREATMENT OF PROLAPSE:

✓ Post-menopausal women
✓ Vault/ post hysterectomy prolapse
✓ Multiparous young women
✓ Nulliparous

Post-menopausal women

Vaginal hysterectomy + Pelvic floor repair

Anterior Colporrhaphy
Posterior Colporrhaphy
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Perineo-raphy

Enterocele should be corrected → Failure to correct

enterocele→Future vault prolapse.

Enterocele repair:

1. Moschowitz repair
2. Halbans repair Previously
3. Mac Culls culdoplasty: it also helps to suspend the vaginal vault to uterosacral
ligaments

Post-menopausalwomenwho can’t tolerate prolonged anesthesia. E.g : Medical

comorbidities →Lefortscolpocleisis

✓ Ant and post vaginal walls opposed together

✓ only done for women who don’t want coitus
✓ important to rule out any malignancy/ pre malignancy of uterus and cervix
before this procedure.

Q. Post-menopausal woman who is v.v high risk, recent history of M.I, Anesthesia is
C/I, what can we do? Pessaries

✓ Establish the proper fit

✓ ensured by Valsalva test.
✓ Ensure that she passes urine with pessary
fitted inside.
✓ Ensure that it’s not too tight.
✓ One finger can be moved around the pessary.

Indication of pessary:

1. Anesthesia is C/I
2. Pregnancy
Pessary should be removed at-18 weeks and recheck if required bcz mostly
spontaneous reduction happens after 2 nd trimester.

Vault prolapse surgery:

1. Earlier: Uterosacral suspension

2. Sacrospinous fixation
Both of the above procedure is done via
vaginal route.

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 Sacrospinous fixation: vaginal vault is suspended to the sacrospinous ligament, if we
go more laterally: can injure pudendal nerve and vessels
just behind the ischial spine.

3. Best surgery: Sacro colpopexy: via Abdominal

route, danger of the surgery is median sacral
vessels over the sacrum can be damaged.

Treatment of Prolapse in Multiparous Young Women

✓ a/k Fothergill repair.
✓ Fothergill surgery is done for genital prolapse and is
suitable for women under 40 years who are desirous of
retaining their menstrual function.

Steps:

1. Preliminary D and C
2. Amputation of the cervix
3. Suturing of Mackenrodt ligaments in the front of the
cervix
4. Anterior colporrhaphy if required
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5. Colpo-perineorrhaphy if required

Complications: Amputation of the cervix → incompetent os, habitual abortions,

preterm deliveries. Therefore, this procedure is done for multiparous women who
have completed their families.

Shirodkar modification: used for nulliparous women, cervix is not amputated

Treatment of prolapse in Nulliparous young woman

✓ Inherent congenital connective tissue disorder.

✓ Treatment of choice: Sling Surgery
✓ Sling operations are best suited for cases of nulliparous prolapse.
✓ It is also done in cases where young women with prolapse are desirous of
retaining their menstrual and child -bearing functions.
✓ It strengthens the weake ned supports such as Mackenrodt and uterosacral
ligaments of the uterus, by using nylon or Dacron tapes as slings to support

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A. Anterior Sling Surgeries:

Purandare’s: attached to rectus sheath.

Khanna’s abdominal sling operation: attached to

ASIS.

Complications of Anterior sling operation:

Future enterocele

B. Posterior Sling Surgery: Shirodkar

C. Composite sling: Virkud Sling Surgeries

Best for Nulliparous prolapse:

Sacrocervicopexy, mesh is used.

U rina ry I nco ntine nce:

✓ m/c cause of incontinence of urine in young women: “Stress Incontinence”

✓ Few droplets of urine pass in response to increased abdominal pressure.
✓ m/c urinary incontinence in older women (>60 year): Detrusor instability leads to
urge incontinence, inability to hold even small amount of urine, can be associated
with symptoms of overactive bladder (increased frequency, Dysuria, Nocturia)
✓ Urinary incontinence is of two main types: stress and urge urinary incontinence,
that may occur in isolation or present as mixed urinary incontinence.
✓ Stress incontinence is the involuntary loss of urine when intravesical pressure
exceeds the maximum urethral pressure with increase in the abdominal pressure
i.e. coughing or sneezing
✓ Urge urinary incontinence is the involuntary leakage of urine accompanied by or
immediately preceded by urgency. This is a symptom -based diagnosis; the cause
may or may not be detrusor overactivity, based on urodynamic observation.
✓ Normally 1st sense to pass urine/ urge: at 150 ml

Causes of Stress urinary incontinence:

1. Weak supports of urethra: There is

straightening of the urethrovesical angle

2. Intrinsic sphincter defect due to trauma, nerve

damage

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 Tests for urethral hypermobility:

✓ Q tip test is done for stress incontinence.

✓ A Q-tip cotton swab stick dipped in Xylocaine jelly
placed in urethra
✓ The patient is asked to strain or cough.
✓ Initially the stick will be parallel to the floor
✓ This angle increases by 20 degrees or more in
cases suffering from GSI.
✓ A positive test indicates sufficient degree of
bladder neck descent.
✓ Unfortunately, all patients with GSI may not have a positive test.
✓ This test is not very specific.

Other test: Bonnies test, Marshall test, Marchetti’s test.

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Mild Symptoms of SUI: Try Pelvic floor exercises first.

Surgica l trea tm e nt o f SU I :

Pre surgery evaluation:

1. Rule out UTI

2. Confirm genuine SUI (If there is any doubt history)

Can do: Pressure urodynamic studies.

The various operations done for genuine stress incontinence (GSI) are as follows:

1. Kelly’s plication:

2. Needle suspension
surgeries.

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Starney’s Pereyra’s
3. Colposuspension:
Ureteropubic Urethropexy

Best Sx for SUI: Bursch

Colposuspension.

5 year success rate: 85-90%

Bursch: Realigns Normal intrabdominal

location of urethra, corrects hypermobility.

✓ Bleeding from retro pubic vessels: Immediate

packing, can take care of venous oozes.
✓ Put a finger inside the vagina to lift ant. Vaginal
wall → retro pubic vessels becomes prominent: hence can be ligated.

4. Now a days: Six of choice for SUI: Midurethral slings.

Transvaginal tape: Tension-free vaginal sling procedures.

TVT is a minimally invasive procedure that involves the

placement of a polypropylene mesh (tape) underneath the
mid urethra.

MOA of Midurethral sling:

✓ Buttress the urethra, whenever there is increase in

intrabdominal pressure: urethra is going to compress against the sling and it
closes.
✓ Hence Midurethral sling are effective for both urethral hypermobility and
intrinsic sphincter defect
✓ Hence surgery of choice for SUI.

Disadvantage:

TVT:

✓ Go through the retro pubic space.

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 ✓ Bladder injury chances are more.

Trans obturator tape (Preferred over TVT)

✓ With the TOT procedure, the tape for the sling is

routed through a 3mm incision within both inguinal
(groin) folds and through the obturator foramen
✓ The mesh tape is manually guided through a small
incision in the vagina and positioned under the
urethra.
✓ Avoid retro pubic space.
✓ Avoid bladder complications.
✓ But there is a potential to damage the obturator vessels.

GENI T O U RI NARY F I ST U LAS

✓ Most of the times these fistulae present with continuous dribbling of urine.
✓ If it’s a large fistula, then the bladder will not fill.
✓ If fistula is small: she can hold urine or pass urine
normally but she is always wet.

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Whenever do a CS for obstructed labor: Prolonged

urethral catheterization postop for 7 -10 days.

Case 1:

✓ Can see the fistulous opening on the ant. Vaginal

wall and or feel the fistulous opening.
✓ Usually obstetric fistulas are big fistulas.
✓ Most imp investigation in this scenario is: Urine
culture sensitivity examination.
✓ Best way to take sample: Catheter sample.

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✓ Larger fistula: might need suprapubic catheter sampling

When to repair?? After 3 months, after puerperium.

✓ Meanwhile keep her on prolonged catheterization and treat UTI

Case 2:

Post hysterectomy c/o dribbling of urine (usually presents within 10 days)

P/S examination: Pooling of urine but we can’t see feel a fistulous opening.

InOPD we can perform 3swab test

Meth ylene blue - 3 s wa b tes t

Procedure:

✓ A catheter is introduced into the bladder through the urethra and bladder is
filled with methylene blue dye.
✓ The vaginal cavity is packed with three sterile cotton swabs.
✓ The swabs are removed after some time and eva luated for staining

Results:

✓ If there is a VVF present, the methylene blue dye stains the uppermost swab.
✓ If the lowermost swab gets stained, the leak is from the urethra --> urethrovaginal
fistula
✓ If the swabs do not take up the stain, but get wet with u rine, the leak is from the
ureter-->ureterovaginal fistula

Only clinical advantage of a 3-swab test:

✓ Can tell if there is a ureterovaginal fistula.

✓ Can tell if there is a VVF / urethrovaginal
fistula

Best investigation in case of VVF is Cystoscopy

• No. of fistula
• Exact location
• Proximity of fistula to ureter.

If ureterovaginal fistula is suspected then: Further investigation: IVP or CT

Pyelogram

Surgeries done for VVF:

Fig: 32.47

1. Chassar Moir technique via vaginal

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 2. Latzko technique

Note:

✓ In Chassar Moir technique fistulous tract is excised.

✓ In Latzko technique fistulous tract is not excised but buried in vagina.

3. Intraabdominal repairs:
✓ V. large fistulas
✓ Failed vaginal repair
✓ Fistula very near to ureter

V.rare: Uterovesical fistula: has been seen post

C.S.

✓ Urinary continence +
✓ Menouria Youssef syndrome

H Y ST ERECT O MY :

✓ Total hysterectomy: Uterus+ cervix removed.

✓ Subtotal hysterectomy:
Fig: Removal of body of uterus only, cervix not
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Routes:
1. Abdominal: for larger uterus, >12 -week size
2. Vaginal
3. Laparoscopic
4. Laparoscopic assisted Vaginal
5. Robotic
✓ Vaginal and Laparoscopic route: Shorter hospital stay, earlier recovery,
Noincision, Lesser post pain, earlier ambulation.
✓ These are the Advantages over abdominal route.

Traditional technique of Hysterectomy:

a. Abdominal: Heaney’s Hysterectomy

b. Vaginal: Ward- Mayo’s Hysterectomy.

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Abdominal: Heaney’s Hysterectomy

First Clamp: The clamp that is placed first when we go via

abdominal routeis at the Tubo -ovarian pedicle.

2ndclamp is applied at the level of uterine artery.

3rd clamp: On transverse

cervical ligament, post on the
uterosacral ligament.

Note: In this we just remove

the Uterus and we just remove
the cervix and the facia
covering it, no additional
structures are touched.

To remove tubes and ovaries with the specimen: Clamp is applied at the
infundubulopelvic ligament, round ligament is cut separately.

Vaginal Hysterectomy:

1. First clamp is placed on Transverse ligament and the uterosacral ligament.

2. 2nd clamp on the uterine artery
3. Last clamp on the Tubo-ovarian pedicle.

Types of Hysterectomy

Piver Rutledge classification:

✓ Total 5 types of hysterectomy

✓ Type 4 and 5 are pelvic exenteration
✓ Type: 1

✓ Type: 2

✓ Type:3

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 Note: The more lateral we go , the more dissection of vital structure is involved.
Type 1 Type 2 Type 3
Simple Extra fascial Modified Radical Radical Meig’s
Wertheim’s
Uterus and covering facia Parametrium removed at Lateral to ureter
the level of ureter
Uterine vessels ligated At the level of ureter At their origin from
close to cervix internal iliac artery
Uterosacral ligated close Midway to rectum Near rectum
to the uterus.
Vaginal cuff is not 1-2 cm of vagina is ≥2cm of vagina is
removed removed removed.

Complications of Hysterectomy:
a. Immediate complications:
✓ Haemorrhage: m/c
✓ Injuring to adjacent structure: Bladder injury -1%, chances of ureter injury are
lesser, bowel injuries.
b. Delayed complications:
✓ Post-operative complications: Fever, Infection: Pelvic infection, wound
infection, urinary tract infection, post -operative vault infection (lead to
persistent bleeding or discharge PV)
✓ 2-4 months later: there can be vault prolapse.
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Ureter Injuries:

✓ Most common location: Danger area - 1.5 cm lateral to cervix, crossing of uterine
artery over ureter
✓ Risk of ureteric injuries is more with Radical
types of hysterectomy.
✓ Risk of ureteric injuries is more with abdominal
hysterectomy than vaginal.
✓ 2nd m/c site of ureteric injuries: crossing of
ureter over the bifurcation of the common iliac
artery, while clamping the infundubulo pelvic
ligament.

Means of protecting ureter:

1. Know the anatomy and the potential sites.

2. Identification of ureter during surgery.

How to identify ureter:

1. Peristalsis due to flow of urine.

2. Longitudinal vessels running over the ureter.

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3. Palpate the ureter: Characteristic snap is felt

V ulv a Relev a nt Ana to m y a nd Clinic a l Co nd itio ns

Labia majora: Hair bearing skin, Apocrine sweat glands are

present
Tumours of Apocrine Sweat glands is known as
Hidradenoma of vulva.
Labia Minora: Have no hair, Rich in connective tissue,
allows for mobility of skin of vulva in this area.

Fourchette: Two L. minora fuse.

Post. Commissure: Two L. Majora fuse.

Fossa Navicularis: Depression between the

vaginal opening/ hymen and the posterior
fourchette.

Vestibule: Area bound by the labia minora on both

sides.

Structures opening into vestibule:

a. Urethra
b. Vagina
c. Bartholin gland duct (Bartholin’s gland is
homologous to Cowper’s glands in the male)
d. Skene’s duct (Paraurethral glands of Skene
are Homologous to prostate glands in male)

Hymen
✓ Membrane covered by epithelium on both sides.
✓ Usually ruptures during childhood
✓ Only remnants remain after childbirth: c/a carunculaemyriteformes.
✓ Hymen has got nothing to do with virginity.

True virgin: False virgin:

Hymen intact
✓ L. majora opposed and firm
✓ L. minora hiding underneath
(doesn’t protrude out)
✓ Vagina narrow
Hymen intact but they are not virgin, they
have other features
✓ Labia majora not opposed (wide apart)
✓ Cutaneous labia minora
✓ Vagina roomy and capacious

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 Blood supply:

✓ Mainly Internal pudendal artery (branch of internal iliac artery.)

✓ Mons pubis is also supplied by External pudendal artery (br of Femoral artery)

Nerve supply:

✓ Anterosuperior: ilioinguinal and genital branch of genitofemoral (branch of lumbar

plexus)
✓ Posterior inferior: Posterior cutaneous nerve of thigh (Branch of sacral plexus)
✓ Rest of vulva is supplied by: Pudendal nerve (S 2, S3, S4)

Bartholin Gland Cyst:

✓ Cystic swelling of vulva: m/c cyst swelling of vulva.

✓ Pea sized gland: located in the superficial perineal pouch
✓ Duct opens into the vestibule/vagina
✓ Just outside the hymen at the junction of Ant 2/3 and posterior 1/3 of the hymen.

Function of gland:

✓ Secrete alkaline mucus at the time of coitus.

✓ Epithelial lining of gland: Columnar
✓ Of duct: Transitional
✓ Of opening/mouth of duct: Structure Squamous epithelium.

Note: Any histology form of malignancy can arise from Bartho lin gland.
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Bartholin’s gland cyst

✓ Initially blockage of duct: Swelling (sterile fluid)

✓ c/o: swelling lump in vulva, tenderness absents.
✓ Superinfection of this cyst contents: Bartholin’s abscess.
✓ m/c organism which is involved in super infection: E. coli
✓ Bartholin’s abscess: V. painful condition, swelling red warm tender.

Bartholin’s gland swelling:

Treatment:

Bartholin’s abscess: Incision and drainage with

antibiotic cover.

Bartholin’s cyst:

TOC: Marsupialization,

If >40 year: Excision of the entire cyst

because of chances of malignancy.

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