Displacement of Uterus

 UTERINE DISPLACEMENT :- 

The uterus is not a fixed organ. Minor variations in position in any direction occur constantly with changes in posture, with straining, with full bladder or loaded rectum. Only when the uterus rests habitually in a position beyond the limit of normal variation, should it be called displacement.

RETROVERSION

DEFINITION:-

Retroversion (RV) is the term used when the long axes of the corpus and cervix are in line, and the whole organ turns backwards in relation to the long axis of the birth canal.

Retroflexion signifies a bending backwards of the corpus on the cervix at the level of internal os. The two conditions are usually present together and are loosely called retroversion or retrodisplacement. 

DEGREES :-

Conventionally,three degrees are described.

• First degree -The fundus is vertical and pointing towards the sacral promontory.
• Second degree - The fundus lies in the sacral hollow but not below the internal os.
• Third degree:-The fundus lies below the level of the internal os. 

CAUSES :- 

 1.Developmental

 2..Acquired

1. Developmental :- Retrodisplacement is quite common in fetuses and young children. Due to developmental defect, there is lack of tone of the uterine muscles. The infantile position is retained. This is often associated with short vagina with shallow anterior vaginal fornix.
2. Acquired :-

• Puerperal: The stretched ligaments caused by childbirth fail to keep the uterus in its normal position.A subinvoluted bulky uterus aggravates the condition.

• Prolapse: Retroversion is usually implicated in the pathophysiology of prolapse which is mechanically caused by traction following cystocele.

• Tumor: Fibroid, either in the anterior or posterior wall produces heaviness of the uterus and hence, it falls behind.
•  Pelvic adhesions: Adhesions, either inflammatory, operative, or due to pelvic endometriosis,pull the uterus posteriorly.

CLINICAL PRESENTATION :- 

1.Mobile Retroverted uterus 

Symptoms

• Chronic premenstrual pelvic pain
• Backache
• Dyspareunia
• Infertility

 Sign :-

Bimanual examination :- 

a. The cervix is directed upwards and forwards. 

b. The body of the uterus is felt through the posterior fornix.its found continuous with the cervix and it moves when the cervix is pressed up . The size of the uterus is difficult to assess at times. 

2. Fixed retroversion :- 

• Menstrual abnormalities
• Congestive dysmenorrhoea
• Chronic pelvic pain
• Dyspareunia

MANAGEMENT:-

Corrective treatment :-

1.Pessary

2.Surgical

• Pessary:- Pessary is less commonly used in present day gynecologic practice. 

It may be indicated 

1. for pessary test
2. In subinvolution of uterus
3. In pregnancy when spontaneous correction to anteversion fails by 12th week. 

Hodge - Smith pessary is used. The pessary act by stretching the urerosacral ligaments so as to pull the cervix backwards. 

• Surgical treatment :- 

       Surgical correction is indicated :

1. Cases where the ' Pessary test ' is positive indicating that the symptoms are due to retroversion. 

2. Fixed retroverted uterus producing symptoms like backache or dyspareunia. 

The principle of surgical correction is Ventro suspension of the uterus by complicating the round ligaments of both the side extraoperitonialy to the under surface of the anterior rectus sheath. This will the uterus forwards and maintains it permanently in the same position.