Inversion of uterus Definition The body of uterus

Inversion of uterus

Definition • The body of uterus is turned inside outside either partially or completely.

Types: • Acute: - It occur as complication of third stage of labor consequent to incomplete separation of placenta. • Chronic: - It can be: 1. Puerperal: - It is incomplete inversion occur at time of delivery passed unrecognized & discovered weeks or months later.

• Clinically presented as: 1. profuse vaginal discharge or bleeding due to infected & ulcerated endometrium. 2. Low backache. 3. Chronic pelvic pain. 4. Infected hemorrhagic mass in vagina. • Diagnosed by : 1. Mass through cervix. 2. Short uterine cavity by sound.

• Differential diagnosis: 1. Sloughing polyp. 2. Retained placenta. 3. Ulcerated prolapsed cervix. 4. Malignant tumor of vagina. • Treatment: - a. clear up the infection by keep the patient lying flat, douching the vagina with antiseptic & vaginal packing.

• b. Avelings repositer: - It consist of cup on metalic stem placed over inverted fundus with continuous pressure applied by bracing the patient waist & shoulder. It is successful within few days. • c. Traction of round ligament at laprotomy. • d. Surgical Rx in resistant cases by incision of constricting ring of cervix either through abdominal route (Haultains operation) or vaginal route (Spinellis operation).

• 2. Senile: - It is spontaneous inversion occur in old age especially if cervix has been amputated at high level. Clinically presented as above & usually mistaken with ulcerated prolapse. Treated by hysterectomy. • 3. Inversion by pednculated tumor: 1. Usually myoma arise by stalk attached to interior of uterus, it tend to expel into vagina. If pedicle is reluctant to stretch so traction produce dimple in uterine wall then sever inversion.

• Symptoms are similar to those of polyp as vaginal bleeding, vaginal discharge. • If it is overlooked; surgeon may cut through the fundus & open into peritoneal cavity while dividing what is regarded as pedicle, so the length of uterus should be tested by sound before cut the pedicle.

Uterine displacement

Position of uterus • Supra vaginal cervix is relatively fixed so that displacement of uterus is rotation of organ around this axis or bending of corpus on the cervix. Normally uterus has limited range of movement. • Factors affect its position are: 1. Full bladder. 2. Increased intra-abdominal pressure by cough, bear down. 3. Altered posture; uterus is lower when standing & lowest when squatting.

Backward displacement • Retroversion: - The axis of cervix is directed upward backward in relation to line drawn through long axis of trunk. • Retroflexion: - The long axis of corpus is bend backward on axis of cervix. • Usually retroversion retroflexion occur together. • Frequency: - It affect 15% of women.

Causes: • 1. Congenital : -All cases of retroversion in nullipara are belong this type. There is shallow anterior vaginal fornix with anterior vaginal wall & cervix appear continuous & vagina is shorter than average. • 2. Prolapse: - As uterus descend; it comes into line with vagina so it is slightly retroverted. • 3. Endometriosis: - If affect uterosacral ligament & P. O. D.

• 4. Tumors& adhesions: - Tumors lying in front of uterus push it backward & adhesions behind it may pull it backward. • 5. Puerperal: - When uterus involutes after pregnancy; retroversion is common since it fall backward while its controlling ligaments are slack & subinvoluted. It lasts for (3 -6 weeks), if uterus remain retroverted permanently; it is concluded that it was in similar position before pregnancy & recur back after each pregnancy.

Clinical presentation: • Symptoms: - 1. Symptom less if mobile retroverted uterus & the only risk is uterine perforation during instrumentation. 2. Spasmodic dysmenorrhea. 3. Low backache & pelvic pain. 4. Dyspaurenia: - Deeply seated pain because of direct pressure on uterus itself, it is position dependent so change in coital position reduce pain. 5. Pelvic congestion syndrome: - It occur due to torsion of broad ligament so

• Interfere with venous return & lymphatic drainage leaving pelvic organs congested & edematous. It cause deep dyspaurenia, congestive dysmenorrhea, menorrhagia, premenstrual backache, diffuse pelvic pain & leucorrhea. 6. Infertility: - due to cervix directed away from seminal pool & ejaculation directly into external os is less likely, also external os is closed by anterior vaginal wall. 7. Abortions.

• Signs: - 1. The cervix come into view unusually easily & external os directed forward. 2. By bimanual exam. The body of uterus should felt in P. O. D. 3. Tenderness is striking feature. • Diff. diagnosis: - 1. Tubal or overian tumor prolapsed in P. O. D. 2. Fecal mass or mass in lower bowel. 3. Endometriosis in P. O. D. 4. Hematoma or abscess in P. O. D. 5. Leiomyoma or other tumor in posterior uterine wall.

Prevention: • 1. Regular emptying of bladder to avoid over distension. • 2. Early ambulation. • 3. Pelvic floor exercise. • 4. Encourage lying face downward for halfone hour once or twice daily to enhance ante version. The important time is between (10 -28 days) after labor since before that the uterus is large so promontory of sacrum prevent that.

Treatment: • A. Mobile: - No Rx since it is symptom less & the patient should reassure that it is normal. • B. Fixed: - Rx should directed primarily to the disease that cause retroversion. Laparoscopy is helpful if there is other symptoms. • Methods of replacement: 1. Bimanual replacement: - By move cervix backward; this rotate fundus forward

• Until it can caught by abdominal hand & maneuvered into final position. 2. Pessary use: - It holds the uterus in normal position temporarily & cant cure retroversion except in puerperium. Hodge pessary is the most efficient, it put tension on posterior vaginal fornix & uterosacral ligament so hold cervix backward. It is used in: a. Pessary test: - When there is doubt whether the symptoms are caused by displacement, pessary can be used as therapeutic test.

• The pessary is inserted and ask patient to report any change in symptoms at end of one month, if no response; retroversion is blameless but if symptoms improved continue for 2 -3 months. b. pregnancy: - if uterus not corrected its position by (10 -12 weeks). 3. Surgery: - A. Indications: - 1. If retroversion cause symptoms proved by adequately controlled pessary test. 2. If cause sever dyspaurenia. 3. As part of operation for associated endometriosis & myoma.

• 4. In few cases of infertility & habitual abortions. B. Methods: - 1. baldy Webster op. : - Loops of round ligament passed through posterior & anterior leaves of broad ligament & stitched together behind uterus. 2. Gilliams op. : - By bring loop of each round ligament out through internal abdominal ring & suture to back of rectus sheath using permanent suture. 3. Laparoscopic ventrosuspension. 4. Shortening of uterosacral ligament.

Retroverted gravid uterus • It affect (15%) of all pregnancies. • The outcome can be: 1. Spontaneous correction: - occur by tenth week in nearly all pregnancies. 2. Sacculation of uterus: - The fundus remain beneath sacral promontory so pregnancy continue to grow by expanding anterior wall of uterus. It produce saccule or diverticulum, if passed unrecognized; the body of uterus remain in pelvis act as tumor obstruct delivery & safe Rx is C/S.

• 3. Impaction of uterus (incarcerated uterus): - a. Failure of fundus to clear above the promontory of sacrum & impacted into pelvis at (12 -14 weeks). b. Uterus fill the pelvis & displace the fundus of bladder upward & the base forward. c. Clinically acute retention of urine due to interfere with opening of internal urethral sphincter posteriorly. d. Impaction occur in those with small pelvis & those with myoma in posterior uterine wall.

• e. Diagnosed by soft tender tumor arise from pelvis & mistake with uterus. Vaginally it is difficult to find cervix which is drawn high up in anterior fornix. f. Diff. Diagnosis: - 1. Other causes of urine retention. 2. Other tumors occupy P. O. D. as haematocele. g. Treatment: - 1. Slow drainage of bladder while keep the patient prone on exaggerated Sims position.

• 2. If no spontaneous correction; continue drainage & large pessary inserted into vagina. 3. If this fail; surgical treatment by one of above surgery.