Factors of normal genital positioning
The physiological position of the internal reproductive organs is the result of the coordinated work of several anatomical and functional systems. Three main factors preventing displacement are distinguished:
- Presence of the uterine ligamentous apparatus. It is anatomically divided into three functional groups: suspending, fixing, and supporting complexes.
- Intrinsic tone of the reproductive organs. The ability of tissues to maintain elasticity directly depends on sex hormone levels, correct nervous system function, and age-related changes in the female body.
- Interrelation of internal organs. Normal topography is impossible without the coordinated functioning of the diaphragm, anterior abdominal wall muscles, and pelvic floor structures.
Any persistent deviations from this norm are considered malpositions. Most often they develop against the background of past trauma, inflammatory diseases, or tumor growth. Displacements can occur in both the vertical plane (up or down) and the horizontal plane.
Hyperanteflexion: excessive anterior tilt
Hyperanteflexion is a pathological flexion in which an acute angle (less than 70°) forms between the body and the cervix.
Most somewhat less commonly, inflammatory processes in the pelvic cavity become the cause. The clinical picture is usually dictated by the underlying disease. Patients experience primary infertility and menstrual cycle disorders (algomenorrhea, hypomenstrual syndrome).
Diagnosis is based on complaints and a vaginal examination. The physician detects a small, sharply anteriorly displaced uterus, an elongated conical cervix, and a narrow vagina with flattened fornices.
Treatment aims at eliminating the root cause (etiotropic therapy). To relieve severe pain 2–3 days before menstruation, symptomatic therapy is prescribed:
- Spasmolytics and analgesics (drotaverine, metamizole sodium).
- Antiprostaglandin drugs (indomethacin, phenylbutazone).
Retroflexion: posterior displacement of the uterus
In retroflexion, the angle between the body and the cervix is open posteriorly (the body is displaced backward and the cervix forward). This alters pelvic biomechanics: the bladder loses the cover of the uterus, and bowel loops begin to constantly press against the anterior surface of the uterus and the posterior wall of the bladder. Prolonged pressure contributes to pelvic organ descent.
Two forms of the pathology are distinguished:
- Mobile. Occurs due to decreased ligamentous tone resulting from birth trauma, tumors, asthenic build, or rapid weight loss. During bimanual examination, the physician can easily return the uterus to its normal position manually.
- Fixed. Resulting from adhesions following inflammation or endometriosis. Manually returning the organ to the correct position is generally impossible.
Symptoms include dull lower abdominal pain (especially before and during menstruation), menometrorrhagia, and dysfunction of adjacent organs. If the form is asymptomatic, treatment is not indicated. In the presence of complaints, the underlying disease is treated, sometimes resorting to laparoscopy to clarify the diagnosis and eliminate the causes of pain. Surgical correction to hold the uterus, pessaries, and gynecological massage are considered obsolete today.
Pelvic organ prolapse
Descent and prolapse of the uterus and vagina represent the most significant problem among all positional anomalies. Due to the anatomical continuity of supporting structures, prolapse pulls adjacent organs along with it, causing severe complications: urinary incontinence or anal sphincter incompetence.
Main variants of prolapse:
- Cystocele (cystocele): descent of the anterior vaginal wall, frequently accompanied by herniation of part of the bladder. The anatomical prerequisite is a defect in the pubocervical fascia.
- Rectocele (rectocele): descent of the posterior vaginal wall, which may be accompanied by herniation of the anterior rectal wall.
- Enterocele (enterocele): descent of the posterior vaginal fornix of varying severity.
Briefly: answers to topical questions
Which ligaments form the suspending apparatus of the uterus?
The suspending apparatus of the uterus is formed by a complex of ligaments connecting the uterus, fallopian tubes, and ovaries to the pelvic walls and to each other. It includes:
- Round ligaments of the uterus (ligg. teres uteri) — originate from the uterine horns, run toward the internal rings of the inguinal canals, and branch out in the fatty tissue of the pubis and labia majora.
- Broad ligaments of the uterus (ligg. lata uteri / lig. latum uteri) — double folds of peritoneum running from the lateral margins of the uterus to the lateral pelvic walls.
- Suspensory ligaments of the ovary (lig. suspensorium ovarii) — continuations of the broad ligaments between the ampulla of the tube and the pelvic wall.
- Ovarian proper ligaments (lig. ovarii proprium) — originate from the uterine horn and run to the inner pole of the ovary.
Which anatomical structures make up the fixing apparatus of the uterus?
The fixing apparatus of the uterus is represented by ligaments that ensure the organ is held in its physiological position. The main anatomical structures of this apparatus include:
- Cardinal ligaments of the uterus (ligamenta cardinalia) — their shortening and plication are used to reinforce the fixing apparatus in the surgical treatment of prolapse.
- Uterosacral ligaments (lig. sacrouterinum) — consist of muscle bundles, run posteriorly from the uterus to the rectum, and securely hold the uterus in place.
Which muscles form the supporting apparatus of the pelvic floor?
The supporting (pelvic floor) apparatus is formed by the muscles and fascia of the pelvic floor (perineum). It includes:
- Deep transverse perineal muscle — runs from the inner surface of the inferior margin of the pubic symphysis and participates in the fixation of the vagina.
- Levator ani muscle (m. levator ani) — plays the primary role in supporting the pelvic organs. It consists of three paired muscles:
- Pubococcygeus muscle (m. pubococcygeus);
- Iliococcygeus muscle (m. iliococcygeus);
- Ischiococcygeus muscle (m. ischiococcygeus).
What complications from adjacent organs are caused by pelvic organ prolapse?
Pelvic organ prolapse leads to anatomical and functional incompetence of adjacent systems. The following groups of complications are distinguished:
- Urological complications: difficulty urinating, presence of residual urine, stasis and infection of the urinary tract, urinary incontinence. With prolonged complete prolapse, hydronephrosis, hydroureter, and ureteral obstruction develop.
- Proctological complications: development of constipation and anal sphincter incompetence.
What degrees of uterine descent and prolapse are distinguished in gynecology?
Incomplete and complete uterine prolapse are distinguished:
- Incomplete uterine prolapse — the cervix descends to the level of the genital hiatus or extends beyond it, while the uterine body maintains its position within the vaginal canal.
- Complete uterine prolapse (Prolapsus uteri totalis) — the entire uterus protrudes beyond the genital hiatus.
To memorize the three factors holding the uterus, use the «Ligaments-Tone-Neighbors» rule: the ligamentous apparatus, intrinsic organ tone, and interrelation with adjacent structures (diaphragm, abdominal wall, pelvic floor).
Class and exam questions
Why is retroflexion of the uterus dangerous?
In this position, the bladder remains uncovered, and bowel loops constantly press against the uterus and the posterior wall of the bladder. Long-term, this contributes to pelvic organ descent or prolapse.
How to distinguish mobile retroflexion from fixed retroflexion?
During a bimanual vaginal examination, a mobile uterus is easily returned to its normal position by the examiner. In the fixed form (due to inflammation or endometriosis), this is impossible.
Is asymptomatic retroflexion subject to treatment?
No, if a posterior displacement of the uterus is detected incidentally and causes no symptoms, medical intervention is not required.
What is a cystocele?
This is the prolapse of the anterior vaginal wall along with a part of the bladder. The pathology develops against the background of a defect in the pubocervical fascia.
What else to study on this topic
- Etiopathogenesis of genital infantilism as a cause of hyperanteflexion
- Differential diagnosis of the causes of fixed retroflexion (inflammatory processes vs. endometriosis)
- Mechanisms of urinary incontinence development in pelvic organ prolapse
- Pharmacological action of antiprostaglandin drugs in algomenorrhea
- The role of the pubocervical fascia in the formation of cystocele
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