Uterine retroversion definition:
Retroversion: the long axis of the uterus is directed backwards.
Retroflexion: the uterus is curved backwards.
Uterine retroversion incidence:
15 % of normal females have RVF.
A. Mobile RVF:
1) Congenital: usually asymptomatic.
2)Acquired: * Fibroid: of anterior wall pushing the uterus backwards.
* Puerperal RVF: due to lax ligament & ↑ uterine weight.
B. Fixed RVF:
due to pelvic adhesions e.g. endometriosis.
1) 1st degree: the fundus of uterus points towards the sacral promontory.
2) 2nd degree: the fundus of uterus points towards the sacral concavity.
3) 3rd degree: the fundus of uterus points towards the sacral tip.
Uterine retroversion C/P:
1) Asymptomatic: in 50 % of cases (mainly congenital type).
Symptoms due to pelvic congestion: congestive dysmenorrhea,
menorrhagia & leucorrhea.
Symptoms due to abnormal position of the uterus:
a) Low backache: due to traction on the uterosacral ligament.
b) Infertility :in 25 % of cases due to:
♦♦♦Dyspareunia due to congested ovaries in Douglas pouch.
♦♦♦External os directed away from the seminal pool (posterior fornix).
♦♦♦Pelvic adhesions fixed RVF, also affecting the tube.
c) Complications during pregnancy: as abortion (rare)
incarcerated retroverted gravid uterus.
1) PV examination: * the external os is directed forwards & downwards.
* Mass in Douglas pouch in 3rd degree.
2) Bimanual examination: the uterus is felt through the posterior fornix.
C. Special tests:
1) Uterine sound: detects the position and direction of uterus in case of obesity.
2) Pessary test: if symptoms are improved, the RVF is the cause of symptoms.
Uterine retroversion and retroflexion videos:
Uterine retroversion video by Dr Tahir A Siddqui ( consultant sonologist ) at Gujranwala, Pakistan.
Uterine retroversion and retroflexion PPT (power point presentations):
Retroverted Retroflexed Uterus (RVF) Undergraduate Dr/ Ahmed Walid Anwar Morad Assistant professor of OB/GYN Benha University 2017
1. Retroverted Retroflexed Uterus (RVF) Undergraduate Dr/ Ahmed Walid Anwar Morad Assistant professor of OB/GYN Benha University 2017
2. RVF Backward displacement of the uterus where angles of version and /or flexion looks backward (15-20%)
3. 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
4. Types of RVF 1. Mobile RVF 2. Fixed RVF
5. Degrees of RVF RVF Degree Fundus direction Ex. Os direction 1st Sacral promontory Downward 2nd Sacral cavity Forward 3rd Sacral tip Up & forward
6. 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
7. 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
8. Differential diagnosis Causes of: – Mass in Douglas pouch – Deep Dyspareunia – Low back pain
9. 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
10. 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
11. 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
12. 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
13. Surgical treatment (if positive pessary test) • Vaginal: – Open Douglas pouch : shortening of uterosacral ligament. – Open uterovesical pouch: plication of round ligament.
14. Surgical treatment (if positive pessary test) • Inguinal: Plication of round ligament through inguinal incision. • RVF uterus & prolapse: fothergill operation
15. Treatment of incarcerated RVF gravid uterus • Catheterization of the bladder. • Manual correction of uterus. • Mobile: Pessary till 14th week. • Fixed :laparotomy to cut adhesion.
16. Uterine inversion
17. 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
18. Degrees of uterine inversion
19. Chronic uterine inversion • Causes: – Puerperal: not recognized after labor. – Fundal tumor. – Senile due to: • Atrophy • Decreased tone
20. Chronic uterine inversion • Symptoms: – Discharge – Vaginal bleeding – Pain: • Chronic pelvic pain • Dyspareunia – Infertility – Mass in vagina or protrude outside vulva
21. 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
22. Treatment • Senile inversion: vaginal hysterectomy. • Malignant tumor: according to staging. • Fundal myoma: according to age Young age Old age Myomectomy & correction of inversion Hysterectomy
23. Treatment • Puerperal: – Prophylactic: early recognition and treatment. – Conservative: Aveling repositor. – Surgical: failed conservative treatment.
24. 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)
25. Acute inversion ttt
26. Thank You Any Questions or Comments?