Uterine prolapse

Definition

Uterine prolapse is falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal.

Alternative Names

Pelvic relaxation - uterine prolapse; Pelvic floor hernia; Prolapsed uterus

Causes, incidence, and risk factors

The uterus is held in position in the pelvis by muscles, special ligaments, and other tissue,. The uterus drops into the vaginal canal (prolapses) when these muscles and connective tissues weaken.

Uterine prolapse usually happens in women who have had one or more vaginal births. Normal aging and lack of estrogen hormone after menopause may also cause uterine prolapse, Chronic cough and obesity increase the pressure on the pelvic floor and may contribute to the prolapse.. Uterine prolapse can also be caused by a pelvic tumor, although this is rare.

Chronic constipation and the pushing associated with it can worsen uterine prolapse.

Symptoms

• A feeling as if sitting on a small ball
• Difficult or painful sexual intercourse
• Frequent urination or a sudden, urgent need to empty the bladder
• Low backache
• Pain during intercouse
• Protruding of the uterus and cervix through the vaginal opening
• Repeated bladder infections
• Sensation of heaviness or pulling in the pelvis
• Vaginal bleeding or increased vaginal discharge

Many of the symptoms are worse when standing or sitting for long periods of time.

Signs and tests

A pelvic examination performed while the woman is bearing down (as if trying to push out a baby) will show how far the uterus comes down.

• Uterine prolapse is mild when the cervix drops into the lower part of the vagina.
• Uterine prolapse is moderate when the cervix drops out of the vaginal opening.

The pelvic exam may reveal that the bladder, front wall of the vagina (cystocele), or rectum and back wall of the vagina (rectocele) are entering the vaginal area. The urethra and bladder may also be positioned lower in the pelvis than usual.

A mass may be noted on pelvic exam if a tumor is causing the prolapse (this is rare).

Treatment

Treatment is not necessary unless the symptoms are bothersome. Most women seek treatment by the time the uterus drops to the opening of the vagina.

Uterine prolapse can be treated with a vaginal pessary or surgery.

VAGINAL PESSARY

A vaginal pessary is a rubber or plastic donut-shaped device that is inserted into the vagina to hold the uterus in place. It may be a temporary or permanent form of treatment. Vaginal pessaries are fitted for each individual woman. Some pessaries are similar to a diaphragm device used for birth control. Many women can be taught how to insert, clean, and remove the pessary herself.

Pessaries may cause an irritating and abnormal smelling discharge, and they require periodic cleaning, sometimes done by the doctor or nurse. In some women, the pessary may rub on and irritate the vaginal wall ( mucosa), and in some cases may damage the vagina. Some pessaries may interfere with normal sexual intercourse by limiting the depth of penetration.

LIFESTYLE CHANGES

Weight loss is recommended in women with uterine prolapse who are obese.

Heavy lifting or straining should be avoided, because they can worsen symptoms.

Coughing can also make symptoms worse. Measures to treat and prevent chronic cough should be tried. If the cough is due to smoking, smoking cessation techniques are recommended.

SURGERY

Surgery should not be done until the prolapse symptoms are worse than the risks of having surgery. The specific type of surgery depends on:

• Degree of prolapse
• Desire for future pregnancies
• Other medical conditions
• The women's desire to retain vaginal function
• The woman's age and general health

There are some surgical procedures that can be done without removing the uterus, such as a sacrospinous fixation . This procedure involves using nearby ligaments to support the uterus. Other procedures are available.

Often, a vaginal hysterectomy is used to correct uterine prolapse. Any sagging of the vaginal walls, urethra, bladder, or rectum can be surgically corrected at the same time.

Expectations (prognosis)

Most women with mild uterine prolapse do not have bothersome symptoms and don't need treatment.

Vaginal pessaries can be effective for many women with uterine prolapse.

Surgery usually provides excellent results, however, some women may require treatment again in the future.

Complications

Ulceration and infection of the cervix and vaginal walls may occur in severe cases of uterine prolapse.

Urinary tract infections and other urinary symptoms may occur because of a cystocele. Constipation and hemorrhoids may occur because of a rectocele.

Calling your health care provider

Call for an appointment with your health care provider if you have symptoms of uterine prolapse.

Prevention

Tightening the pelvic floor muscles using Kegel exercises helps to strengthen the muscles and reduces the risk of uterine prolapse.

Estrogen therapy, either vaginal or oral, in postmenopausal women may help maintain connective tissue and muscle tone.

References

Lentz GM. Anatomic defects of the abdominal wall and pelvic floor: abdominal and inguinal hernias, cystocele, urethrocele, enterocele, rectocele, uterine and vaginal prolapse, and rectal incontinence: diagnosis and management. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive Gynecology. 5th ed. Philadelphia, PA: Mosby Elsevier;2007:chap 20.