Uterine Prolapse

The uterus is a muscular organ that is supported by pelvic ligaments and muscles, which keep the organ in place. If these ligaments or muscles become weak or get stretched, they will not be able to support the uterus, which may result in uterine prolapse. Prolapsed uterus slips down from the normal position into the vaginal canal. Prolapse can occur at any age in women, but it mostly occurs after menopause in women with one or more vaginal deliveries. [1]

Stages of Uterine prolapse:

Prolapse of the uterus may be complete or incomplete. Complete prolapse occurs when uterus slip so far that some of the parts protrude out of the vagina to outside. In incomplete prolapse, the organ is partially slipped from its original place. Uterine prolapse is divided into various stages depending upon the severity of the disorder.

• In first-degree uterine prolapse, the cervix drops into the vagina.
• In the second degree prolapse, the cervix further slips downward near the opening of the vaginal canal.
• In third-degree uterine prolapse, the cervix comes out of the vagina.
• In fourth-degree prolapse, the entire uterus slips outside the vagina, and this condition is known as procidentia. It occurs due to the weakening of all the supporting muscles and ligaments. [2]

In most severe cases uterine prolapse may be associated with other disorders, which include:

The first condition that may be associated with uterine prolapse is known as bulging or herniation of the proximal vaginal wall. From this site, bladder enters into the vaginal canal, causing an increase in urinary incontinence, urgency, frequency, and retention.

Enterocele is another common disorder associated with uterine prolapse that causes herniation of the upper rear vaginal wall. A small portion of the intestine may bulge from this site, causing backache and pulling sensation, while the person is in standing position. This pain and discomfort are relieved when women lie down.

Rectocele is caused by bulging of the lower part of the vagina, which may be associated with a third or fourth-degree uterine prolapse. Rectum herniates into the vaginal canal from the lower rear part of the vaginal wall. It disturbs bowel movements, so severely causing difficulty in defecation. Women suffering from this condition may need to press the inner side of the vagina to empty the bowel and rectum.[3]

 

Symptoms of Uterine Prolapse:

Symptoms depend upon the severity of the disease. Common symptoms include:

• The feeling of pulling and heaviness or load in the pelvis
• Painful and uncomfortable sexual intercourse
• Increased vaginal discharge or bleeding
• Urgency, frequency, and leakage of urine that may be associated with bladder infections
• Disturbed and irregular bowel activities causing GI distress such as constipation
• Lower backache
• Protrusion of uterine tissue from the vaginal opening
• The feeling of something falling out of the vagina or sensations that feel like a ball in the pelvis
• Weak vaginal tissue [4]

Causes and Risk factors associated with Uterine Prolapse:

The uterine prolapse is due to the weakening of supporting tissues of the uterus. The weakening of pelvic tissues are caused by

• Pregnancy
• Difficult labor
• Trauma during delivery of the child
• Delivery of abnormal baby such as a large fetus
• Overweight or obese women
• Postmenopausal hormonal changes especially decreased estrogen levels
• Chronic bronchitis
• GI disorders such as straining and constipation
• Carrying heavy loads

Following factors may increase the risk of the prolapsed uterus include:

• One or more pregnancies and vaginal births
• Elderly women
• Women with high BMI
• History of pelvic surgery
• Family history of connective tissue disorders
• Being White or Hispanic  [5]

Diagnosis of uterine prolapse:

Uterine prolapse can be diagnosed by evaluating symptoms of the patient and by carrying out a pelvic examination.

Preparation for the pelvic exam:

If it’s your first time having a pelvic exam, schedule your examination on a date when you are not on period. However, if you are having menstruation problems, the doctor can schedule your examination during period days.

The procedure for the pelvic exam:

The physician will ask you to undress and put on a robe. You can add privacy by putting something around your waist during a breast examination. The doctor will ask you to lie on an examination table by spreading your legs and putting your feet on footrests called stirrups.

Visual examination:

The goal is to visually examine the vagina and vulva. The doctor performs this inspection for something that indicates sexually transmitted diseases and sores. Redness, cysts, discharge, and irritation may be seen.

Speculum examination:

For this procedure, a speculum is introduced into the vagina. The patient is advised to take a deep breath to relax their rectal, vaginal, and abdominal muscles during insertion. The doctor may warm-up the speculum before inserting it.

Pap smear:

A small spatula can be used to swipe the cervix, before removing the speculum. The spatula gathers cells for a pap smear. By examining the cells, the doctor may look for sexually transmitted diseases or cancer, to know the cause of uterine prolapse.

Manual examination:

The manual examination is performed by inserting two fingers into the vagina after putting on lubricated gloves while feeling the abdomen with the other hand to check for irregularities in the vagina and uterus. During this procedure, the doctor can determine the size of the uterus. [6]

Surgery for Uterine prolapse:

Surgery is not recommended for mild or moderate cases of uterine prolapse. Surgery is considered in nonresponsive cases. Two types of surgical procedures are recommended for uterine prolapse, which includes obliterative and reconstructive.

Obliterative surgery closes or narrows the part or whole of the vagina. In this surgery, more support is offered to the organs that have slipped or sagged from their original place and outing pressure on the vaginal walls. This is the treatment of choice in the case of elderly women who cannot tolerate bigger surgical procedures, failed previous surgery, or who can not tolerate other procedures. After this obliterative surgery, women will be unable to perform sexual intercourse.

Reconstructive surgery helps to mend the pelvic floor and return the tissues and organs to their normal place. This procedure is performed by incisions in the abdomen or vagina. Laparoscopic procedures are generally used for reconstructive surgery. In this procedure, small incisions are made in the wall of the abdomen, and organs are placed in position with the help of certain surgical instruments. Reconstructive surgeries are of several types to restore the function and place of pelvic organs. They include:

Uterosacral ligament suspension and sacrospinous ligament fixation:

This procedure is formulated for enhancing the support of vaginal vault and uterus. Vaginal mesh is useful for fixation or suspension of the sagging vaginal organs. The surgeon incises the vagina and attaches the uterus to a ligament in the pelvis by stitches. These stitches mostly dissolve over time or become permanent.

Anterior and posterior colporrhaphy:

This procedure is designed for making the tissue those tissues tighter and stronger, which supports the pelvic organs in place. When the bladder drops and presses against the front of the vagina, it can be corrected by anterior repair. When the rectum drops and pushes into the back of the vagina, it is fixed by using the posterior repair technique. Prolapse can be repaired by using vaginal mesh or tissues by an approach through the vagina.

Sacrocolpopexy and Sacrohysteropexy:

The goal here is to anchor and fix organs that have dropped down by the use of surgical mesh. Sacrocolpopexy is a method to repair the prolapse of the uterus, while sacrohysteropexy is a method to fix the prolapse of the vaginal vault. Cuts are made in the abdomen during this operation. This operation can also be carried out by the laparoscopic approach. To help lift sagging organs into place, vaginal mesh is used to repair prolapse, by putting mesh under the vaginal skin.

Efficacy of Surgical Procedures:

There is an 80% to 90% success rate for Uterosacral ligament suspension and Sacrospinous ligament fixation. The same success rate is achieved by Sacrocolpopexy and Sacrohysteropexy. Vaginal mesh surgery has a success rate of 80 to 95%, according to recent studies. But it acts as a double-edged sword because there is always a chance that another part of the vagina may prolapse. [7]

Non-Surgical Treatment for Uterine Prolapse:

Non-surgical treatment for the pelvic organ prolapse, as the uterus is modified according to the patient’s age, number as well as the type of surgeries patient has gone through previously, prevailing health condition, and last but not the least how much symptoms disturb patient’s life.

The following are the main non-surgical treatments for the uterine prolapse used worldwide. They are done either alone or in combination, depending chiefly on the type and the extent of prolapse:

Vaginal Pessary:

Vaginal Pessary is the first method widely recommended to women with uterine prolapse. It is a device made of rubber or silicone with the biggest advantage of its ability to be removable easily. Women with mild to moderate uterine prolapse are directed to place Vaginal Pessary into the vagina. This method is most favorable for women who plan to conceive in the future life or do not want to undergo the surgical procedure due to any reasons. Women who choose this method are prescribed topical estrogen by their doctor. Topical Estrogen prevents all sorts of irritation caused by the device. It is available as a gel or a lotion over the counter and applied directly to the areas that are affected.

Exercise of the Pelvic Floor Muscles:

Pelvic organs are composed of pelvic muscles, which are supported by various ligaments. Pelvic Floor Muscle exercises are designed and performed in a way that they support and strengthen pelvic muscles and ligaments. These include Kegel exercises. Kegel exercises tighten and release pelvic floor muscles. The pain and discomfort caused by uterine prolapse are relieved and eased by strengthening muscles. In this way, pelvic organs are better supported. The doctor who is treating the prolapse teaches the patient to tighten, identify, and release muscles of the pelvic floor. The exercises are usually done twice a day.

Kegel exercises are performed in the following way:

 i) The patient is asked to contract the pelvic floor muscles. This is very similar to the act of trying to prevent passing gas.

 ii) The patient is asked to hold the contraction for five seconds and then asked to relax the muscles for another five seconds. If the patient is unable to hold contractions for five seconds, she is directed to start with two seconds contraction followed by three seconds of relaxation.

iii) The patient is asked to build up the stamina of holding contractions for 10 seconds at a time.

iv) Three sets of 10 repetitions are aimed each day.   [8]

Lifestyle Modification and Home Remedies:

Following modifications and home, remedies may help to relieve the discomfort caused by uterine prolapse:

• The patient should avoid lifting heavy objects.
• The patient should try to control the cough.
• If the patient is obese or overweight, she should try to lose some weight.
• The patient should consume a high-fiber diet, and intake of fluids should be increased so constipation is avoided.
• Kegel exercises should be performed regularly to support the muscles and ligaments. [9]

References:

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[1] Doshani, A., Teo, R. E., Mayne, C. J., & Tincello, D. G. (2007). Uterine prolapse. BMJ (Clinical research ed.), 335(7624), 819–823. https://doi.org/10.1136/bmj.39356.604074.BE

[2] Shek, K., & Dietz, H. (2016). Assessment of pelvic organ prolapse: a review. Ultrasound In Obstetrics & Gynecology, 48(6), 681-692. https://doi.org/10.1002/uog.15881

[3] Tsikouras, P., Dafopoulos, A., Vrachnis, N., Iliodromiti, Z., Bouchlariotou, S., & Pinidis, P. et al. (2013). Uterine prolapse in pregnancy: risk factors, complications and management. The Journal Of Maternal-Fetal & Neonatal Medicine, 27(3), 297-302. https://doi.org/10.3109/14767058.2013.807235

[4] Shrestha, B., Onta, S., Choulagai, B., Paudel, R., Petzold, M., & Krettek, A. (2015). Uterine prolapse and its impact on quality of life in the Jhaukhel-Duwakot Health Demographic Surveillance Site, Bhaktapur, Nepal. Global health action, 8, 28771. https://doi.org/10.3402/gha.v8.28771

[5] Vergeldt, T. F., Weemhoff, M., IntHout, J., & Kluivers, K. B. (2015). Risk factors for pelvic organ prolapse and its recurrence: a systematic review. International urogynecology journal, 26(11), 1559–1573. https://doi.org/10.1007/s00192-015-2695-8

[6] Milart, P., Woźniakowska, E., Czuczwar, P., & Woźniak, S. (2015). Pelvic organ prolapse in women: how is it diagnosed and treated currently?. Przeglad menopauzalny = Menopause review, 14(3), 155–160. https://doi.org/10.5114/pm.2015.54338

[7] Hemming, C., Constable, L., Goulao, B., Kilonzo, M., Boyers, D., Elders, A., Cooper, K., Smith, A., Freeman, R., Breeman, S., McDonald, A., Hagen, S., Montgomery, I., Norrie, J., & Glazener, C. (2020). Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs. Health technology assessment (Winchester, England), 24(13), 1–220. https://doi.org/10.3310/hta24130

[8] Giarenis, I., & Robinson, D. (2014). Prevention and management of pelvic organ prolapse. F1000prime reports, 6, 77. https://doi.org/10.12703/P6-77

[9] Choi, K. H., & Hong, J. Y. (2014). Management of pelvic organ prolapse. Korean journal of urology, 55(11), 693–702. https://doi.org/10.4111/kju.2014.55.11.693