RVF uterus &uterine inversion (Undergraduate)

1. Retroverted Retroflexed Uterus
(RVF)
Undergraduate
Dr/ Ahmed Walid Anwar Morad
Assistant professor of OB/GYN
Benha University
2017

3. RVF
Backward displacement of the uterus where
angles of version and /or flexion looks
backward (15-20%)

4. Etiology
• Congenital : asymptomatic ,no treatment.
• Acquired:
– Puerperal: why?♦ ♦ ♦
– Support → Laxity of supporting ligament
– Weight → Bulky uterus and soft LUS
– Pull → Prolonged dorsal position
– Push → Longstanding bladder distention
– Pelvic pathology
– Push: fibroid
– Pull: adhesion
– Prolapse: cause or result of RVF

5. Types of RVF
1. Mobile RVF
2. Fixed RVF

6. Degrees of RVF
RVF
Degree
Fundus
direction
Ex. Os
direction
1st
Sacral
promontory
Downward
2nd
Sacral cavity Forward
3rd
Sacral tip Up & forward

7. Diagnosis
• Symptoms:
– Asymptomatic: 50%
– Symptomatic:
• Pelvic congestion symptoms ?
• Pain:
– Low backache ( pressure on uterosacral & pelvic congestion)
– Dyspareunia ( ovary, uterus & pelvic congestion)
– Spasmodic dysmenorrhea ( cervical obstruction& hypoplasia)
• Infertility ????
• Complication during pregnancy: abortion ,incarceration ,
anterior sacculation

8. Signs:
– PV and bimanual:
• Posterior lip is 1st
to be felt
• Direction of ex. Os
• Body of uterus ( most common mass in Douglas pouch)
– Uterine sound: confirm direction
– Pessary test. ???
Special investigations:
– US
– HSG: lateral view
Diagnosis

9. Differential diagnosis
Causes of:
– Mass in Douglas pouch
– Deep Dyspareunia
– Low back pain

10. Treatment lines
• No treatment : if no symptoms
• Prophylactic treatment: during puerperium
• Active treatment
– Fixed RVF: treatment of the cause
– Mobile RVF:
• Palliative: pessary treatment
• Operative treatment: positive pessary test
• Treatment of incarcerated RVF gravid uterus

11. Prophylactic treatment
(during puerperium)
• Avoid full bladder.
• Lying on abdomen one hour daily to
encourage AVF.
• Postnatal examination (after 3 weeks)
– Discover RVF
– Pessary correction

12. Palliative treatment
(Hodge-smith pessary)
• Indications:
– Pessary test
– Puerperal: RVF
– Pregnancy: RVF during pregnancy till 14th
week ??
– Patient: refuse, unfit, or has contraindications to operations
– Certain cases of infertility when other causes were
excluded

13. Surgical treatment
(if positive pessary test)
• Abdominal: laparotomy/laparoscopy
– Ventrosuspension: plication and suturing of both
round ligaments to anterior rectus sheath ( modified
Gilliam's operation)
– Ventrofixation: fundus suturing to anterior abdominal
wall (Bad, posterior sacculation during pregnancy)
– Baldy- Webster operation: round ligament passed
through broad ligament and sutured to back of the
uterus

14. Surgical treatment
(if positive pessary test)
• Vaginal:
– Open Douglas pouch : shortening of uterosacral
ligament.
– Open uterovesical pouch: plication of round
ligament.

15. Surgical treatment
(if positive pessary test)
• Inguinal: Plication of round ligament through
inguinal incision.
• RVF uterus & prolapse: fothergill operation

20. Treatment of incarcerated RVF
gravid uterus
• Catheterization of the bladder.
• Manual correction of uterus.
• Mobile: Pessary till 14th
week.
• Fixed :laparotomy to cut adhesion.

21. Uterine inversion

22. Uterine inversion
• Def : the uterus is turned inside out.
• Types:
– Acute: puerperal inversion during or
immediately after labor.??????
– Chronic : gradual descent of the fundus
through dilated cervix may be:
• puerperal or
• non puerperal

23. Degrees of uterine inversion

24. Chronic uterine inversion
• Causes:
– Puerperal: not recognized after labor.
– Fundal tumor.
– Senile due to:
• Atrophy
• Decreased tone

25. Chronic uterine inversion
• Symptoms:
– Discharge
– Vaginal bleeding
– Pain:
• Chronic pelvic pain
• Dyspareunia
– Infertility
– Mass in vagina or protrude outside vulva

26. Chronic uterine inversion
• Signs:
– PV & bimanual:
• Cupping of the uterus: 1st
& 2nd
degree
• Absent uterus: 3rd
degree.
• Mass: red infected in vagina or protrude outside
vulva.
– Uterine sound: short distance.
• DD:
– Mass in vagina
– Mass at vulva

27. Treatment
• Senile inversion: vaginal hysterectomy.
• Malignant tumor: according to staging.
• Fundal myoma: according to age
Young age Old age
Myomectomy & correction of
inversion
Hysterectomy

28. Treatment
• Puerperal:
– Prophylactic: early recognition and treatment.
– Conservative: Aveling repositor.
– Surgical: failed conservative treatment.

29. Surgical treatment
(Chronic puerperal inversion)
• Old age: hysterectomy.
• Young age:
– Vaginal: division of cervical ring then
correction of inversion
• Ant. (Spinelli)
• Post. (Kustner)
– Abdominal:
• Traction on depressed fundus by volsellum
( Huntington)
• Division of cervical ring and pulling on fundus
– Ant. (Dobbin)
– Post. (Haultain)

30. Acute inversion ttt

31. Thank You
Any Questions or
Comments?