Grade IV Utero Vaginal Prolapse (Procidentia): A Case Report

Introduction: The uterus is normally held in place inside the pelvis with various muscles, tissue, and ligaments. But because of pregnancy, childbirth or difficult labor and delivery, in some women the muscles become weaken. And also, as the woman ages and also with a natural loss of the hormone oestrogen, the uterus can drop into the vaginal canal, this cause the condition which is known as prolapsed uterus. There are different degrees, in which the fourth degree the entire uterus is outside the vagina and this condition is also called procidentia, which is caused by weakness in all of the supporting muscles [1]. Case Presentation: A female patient of 70 years was admitted to Gynae Ward, AVBRH on 2 nd June 2021 with a known case of Grade IV Utero Vaginal Prolapse (procidentia) for further management and known case of hypertension and type II diabetes melitus for 22 years. Patient came with a complain of something coming out of vagina for 5 years, increased frequency of micturition for 5 years and also complain of white discharge for 1.5 months. Case Study Lalawmpuii et al.; JPRI, 33(49A): 187-191, 2021; Article no.JPRI.73453 188


INTRODUCTION
The uterus is a muscle structure in the female reproductive system that sits between the bladder and the rectum in an inverted pear shape. The fundus is the large curving upper section where the fallopian tubes join to the uterus; the body, the main section of the uterus, begins right below the level of the fallopian tubes and continues downward till the uterine wall; and the uterus comprises four primary areas [2]. When the ligaments and muscles of the pelvic floor are stretched and weakened to the point where they can no longer support the uterus, this is known as procidentia. The uterus either slips into the vagina or bulges out of it when this happens. Uterine prolapse can affect any woman at any age, but it is more common in postmenopausal women who have had one or more vaginal deliveries [3].
Prolapsed uterus is also associated with being overweight and with having a persistent cough. It is the most common reason for hysterectomy in women aged over 50. Uterine prolapse can occur in women of any age. But it often affects postmenopausal women who've had one or more vaginal deliveries. Uterine prolapse can be categorized as incomplete or complete:  Incomplete uterine prolapse: when an incomplete uterine prolapse occurs, the uterus is partially displaced into the vagina but does not protrude  Complete uterine prolapse: when a complete uterine prolapse occurs, there is a portion of the uterus protruding out of the vaginal opening [4].
Uterine prolapse is described in 4 stages, indicating how far it has descended. Other pelvic organs (such as the bladder or bowel) may also be prolapsed into the vagina.
Stage Ithe uterus is in the upper half of the vagina Stage IIthe uterus has descended nearly to the opening of the vagina Stage IIIthe uterus protrudes out of the vagina Stage IVthe uterus is completely out of the vagina [5] The weakening of pelvic muscles and supporting tissues causes uterine prolapse. Pregnancy, difficult labour and delivery or trauma during childbirth, delivery of a large baby, being overweight or obese, reduced oestrogen levels after menopause, prolonged constipation or straining with bowel movements, chronic cough or bronchitis are all causes of weaker pelvic muscles and tissues. and repeated heavy lifting. One or more pregnancies and vaginal births, giving birth to a large baby, increasing age, obesity, prior pelvic surgery, chronic constipation or frequent straining during bowel movements, family history of connective tissue weakness, and being Hispanic or white can all increase your risk of uterine prolapsed [6].
Uterine prolapse is often associated with prolapse of other pelvic organs. The patient might experience:  Anterior prolapse (cystocele). Weakness of connective tissue separating the bladder and vagina may cause the bladder to bulge into the vagina. Anterior prolapse is also called prolapsed bladder.  Posterior vaginal prolapse (rectocele). Weakness of connective tissue separating the rectum and vagina may cause the rectum to bulge into the vagina. You might have difficulty having bowel movements [6].
Treatment for POP is based on severity of the prolapse and the patient's preferences, health, and symptoms. Conservative options, though associated with few adverse effects and costeffective, tend to work only for milder forms of POP and require a high level of commitment from the patient. Examples of conservative options are behaviour modification (e.g., weightloss diet, smoking cessation), PFM strengthening, and pessaries. Perform Kegel exercises regularly. These exercises can strengthen your pelvic floor muscles, especially important after you have These can reduce the risk of uterine prolapse. Using procedures that repair the supporting pelvic floor muscle or suspension and fixation of the prolapsed uterus via a mesh or synthetic suspension medium. Goals of conservative therapy are to improve symptoms, reduce POP progression, and delay or avoid surgery. A more radical approach would be a hysterectomy (removal of the uterus). The exact method to use depends on the individual health status, preference for sexual intercourse, decision to get pregnant, severity (degree) of prolapse and results from other treatment modalities [6,7,8].
Because they are delivered by dais (untrained midwives) and without much understanding, women who are delivered at home in India have a greater incidence and a more severe degree of uterovaginal prolapse. Patients are forced to bear down before the cervix has fully dilated without emptying the bladder [9].

Patient Information
A female patient of 70 years was admitted to Gynae Ward, AVBRH on 2 nd June 2021 with a known case of Grade IV Utero Vaginal Prolapse (procidentia).

Present Medical History
A female patient of 70 years old was brought to AVBRH on 2 nd June 2021 with a complain of something out of the vagina for 5 years, increased frequency of micturition for 5 years and also complain white discharge for 1.5 months.

Past Medical History
My patient was a known case of hypertension and type II diabetes melitus for 22 years and was on medication of Tab. Telma AM, Tab. Aldactone, Tab. Voglibose and Tab. Met XL for 2 years.

Family History
Patient had been married for 55 years and had 4 children. Belongs to joint family, husband, his son and families. The other family members do not have any communicable or hereditary disease except for the patient herself having hypertension and type II diabetes melitus in the past 22 years. The type of marriage of the patient and her husband is non-consanguineous marriage. The other family members are healthy.

Diagnostic Assessment
Patient had undergone blood investigation, 2D echography and radiology.

2) Surgical management:
Patient had undergone pre-anaesthesia checkup (PAC) on 3 rd June 2021 and was prepared for total hysterectomy.

3)
Nursing management: Observed for vaginal bleeding, monitor vital signs and 4 hourly charting of random blood sugar. Provide pain management and prevent patient from risk of infection. Assessment of complication of uterine prolapse and give health education to patient and family members.

DISCUSSION
A female patient of 70 years was admitted to Gynae Ward, AVBRH on 2 nd June 2021 with a known case of Grade IV Utero Vaginal Prolapse (procidentia) for further management and known case of hypertension and type II diabetes melitus for 22 years. Patient came with a complain of something coming out of vagina for 5 years, increased frequency of micturition for 5 years and also complain of white discharge for 1.5 months.
A study called "Clinical epidemiological investigation of uterine prolapse" was conducted. The goal of the study is to collect epidemiological data on uterine prolapse in a clinical environment as well as identify risk factors so that suitable preventative actions can be adopted. The information was collected from the patients admitted in this study utilising a study proforma and a descriptive case control study. Statistical approaches were used to compare and analyse the data. According to the findings, uterine prolapse accounts for around 5.9% of all gynaecological patients admitted during the study period. The average age of uterine prolapse presentation was 50.1 years. The case had a larger mean number of deliveries than the control, which had a mean of four deliveries. Only 13.9 percent of 130 individuals had a positive result. This concluded that, uterine prolapse is highly linked to age, parity, and birth location. The risk factors for uterine prolapse are simple to avoid. To lower the incidence of prolapse and the morbidity associated with it, a public health awareness programme must be implemented [10].

CONCLUSION
The weakening of the muscles and tissues of the pelvic floor can cause procidentia, or uterine prolapse. Symptoms may appear gradually, and you may not notice them at first. For some people, lifestyle adjustments and pelvic floor exercises may be enough to alleviate the symptoms. Others may benefit from a vaginal pessary to alleviate their problems. If nonsurgical therapy does not relieve the symptoms, surgery may be required [11].