Uterine prolapse  

Overview

Pelvic organ prolapse occurs when one or more of the pelvic organs slips down from their usual place and bulges into the vagina. It might be the womb (uterus), the gut, the bladder, or the top of the vagina.

Uterine prolapse is the protrusion of the uterus into the vaginal canal as a result of the uterus's support structures deteriorating. This is a prevalent, non-life-threatening illness that causes severe morbidity in women.

 A prolapse does not endanger one's life, but it can cause pain and suffering. Symptoms can typically be alleviated with pelvic floor exercises and lifestyle modifications, although medical therapy is occasionally required.

This article discusses the causes, assessment, and treatment of uterine prolapse, as well as the role of healthcare practitioners in evaluating and treating people with this problem.

 

Uterine prolapse definition

The displacement of the uterus from its original anatomical position into the vaginal canal, via the hymen, or through the introitus of the vagina is known as uterine prolapse. This is related to the deterioration of its supporting structures. Uterine prolapse is one of several disorders that fall under the umbrella term of pelvic organ prolapse. 

The uterus normally lies in the apical compartment of the pelvic organs. The uterosacral and cardinal ligament complexes support the uterus and vagina from the sacrum and lateral pelvic sidewall. The weakening of these ligaments permits the uterus to prolapse into the vaginal vault.

Although uterine prolapse is not a life-threatening condition, it can cause sexual dysfunction, poor body image, and a reduced quality of life owing to bowel or urine incontinence.

 

Epidemiology

Most studies include uterine prolapse and pelvic organ prolapse together, making it difficult to discern between the two. In a cross-sectional study of 1961 women, 9.7 percent of women aged 20 to 39 and 49.7 percent of women aged 80 and more had pelvic organ prolapse. As a result, roughly half of all women in the United States may be predicted to have some degree of pelvic organ prolapse in old age.

In less developed nations such as Nepal, more than one million women out of about 15 million women were discovered to have uterine prolapse, accounting for around 7% of the Nepalese female population.

The Oxford Family Planning Association research in the United Kingdom monitored almost 17 000 women between the ages of 25 and 39. The yearly incidence of prolapse hospitalization was 20.4/10 000, while the annual incidence of prolapse surgery was 16.2/10 000. Many studies fail to distinguish between prolapse of both pelvic organs and prolapse of the uterus alone, making determining the real incidence challenging.

 

Etiology 

Uterine prolapse has the same risk factors as other pelvic organ prolapses. According to the Oxford Family Planning Association study, the likelihood of pelvic organ prolapse increased with each subsequent delivery. Those with BMIs more than 25 were more likely to have uterine prolapse than women with normal BMIs. Age has been demonstrated to have a strong correlation with prolapse rates. Connective tissue abnormalities such as Marfan syndrome and Ehler's Danlos syndrome are also risk factors.

Despite the fact that vaginal birth is definitely connected, particular obstetric risk factors remain debatable. Macrosomia, a protracted second stage of labor, episiotomy, anal sphincter damage, epidural analgesia, and the use of forceps and oxytocin have all been hypothesized as risk factors but have yet to be proven.

Despite the fact that menopause is frequently identified as a risk factor for pelvic organ prolapse, a study of 270 women from the WHI experiment who had had hysterectomy discovered no link between oestrogen status (usage of hormone replacement medication) and prolapse.

 

Symptoms of uterine prolapse

The vision or sensation of a bulge in the vaginal region, combined with vaginal pressure, is the most prevalent complaint of female patients with uterine prolapse. Other symptoms include increased urine urgency or frequency, the sense that the bladder is not emptying completely, and dyspareunia. As the prolapse continues, the symptoms will appear gradually and may worsen over time.

The frequency and intensity of symptoms have been proven to grow as the severity of prolapse worsens. Specific symptoms experienced by patients, however, do not correspond well with the level of prolapse, and many individuals are entirely asymptomatic in the early stages of uterine prolapse.

The pelvic exam, in addition to symptoms described by patients, is critical in the diagnosis of uterine prolapse due to direct view of the prolapsed section. During the Valsalva technique and while the patient is at rest, a pelvic exam should be conducted. For staging reasons, the prolapsed section is seen in relation to the hymen or introitus.

 

Diagnosis

Laboratory Studies

  • The workup of uterine prolapse from the perspective of an emergency physician consists of recognizing the uncommon but dangerous consequences associated with uterine prolapse (infection, urinary obstruction, hemorrhage, strangulation).
  • In mild instances, laboratory investigations are unnecessary.
  • Order a CBC, basic metabolic panel, urinalysis, pregnancy tests, and cervical cultures if needed to rule out additional illnesses in the differential diagnosis.
  • In rare cases of probable cancer, a Papanicolaou test (Pap smear cytology) or biopsy may be necessary, however this should be deferred to the primary care physician or gynecologist.

 

Imaging Studies

When the history and physical examination point to other processes in the differential diagnosis, a pelvic ultrasound examination may be helpful in distinguishing prolapse from other disease. Although MRI has been used to stage prolapse, it is not typically recommended as an emergency diagnostic.

 

Types of prolapse

The 4 main types of prolapse are:

  • The bladder bulging into the front wall of the vagina (anterior prolapse)
  • The womb bulging or hanging down into the vagina (uterine prolapse)
  • The top of the vagina sagging down – this happens to some women after they have had surgery to remove their womb
  • The bowel bulging forward into the back wall of the vagina (posterior wall prolapse)

It is possible to have more than one of these at once. Pelvic organ prolapse is often graded on a scale of 1 to 4, with 4 indicating severe prolapse.

 

Management

Treatment for uterine prolapse is mostly determined by the severity of a patient's symptoms. Pelvic floor muscle training and vaginal pessaries are examples of conservative therapy. There are also several surgical treatments for therapy.

Correct diagnosis and care of uterine prolapse can have a significant influence on a patient's quality of life and have long-term physical and mental health consequences. Patients with uterine prolapse should be properly counseled by healthcare providers so that they may make informed decisions and select the therapy that is best for them.

Vaginal pessaries are silicone items that are put into the vagina to give support for prolapsed pelvic organs. Vaginal pessary has been proven to be an effective remedy in 84 percent of instances of advanced pelvic organ prolapse, with moderate side effects occurring in 31 percent of cases. While pessaries can not repair pelvic organ herniation, they can alleviate symptoms and slow the course of prolapse. Patients must be fitted with a pessary and may have to try on many pessaries before finding the right one.

When being fitted for a pessary, patients should have an empty bowel and bladder. A single finger should be able to be swept between the pessary and vaginal walls by the examination. The patient should be able to comfortably walk, bend, and pee without changing the pessary. Vaginal irritation/ulceration, discharge, discomfort, bleeding, and odor are all side effects of pessary installation.

Regular reassessments of pessary fit should be undertaken to ensure that the pessary is not rubbing against the vaginal mucosa, which can cause irritation and predispose patients to infection. Movement of the pessary into the bladder or rectum, resulting in fistula, fecal impaction, and urosepsis, is a rare consequence. Patients with dementia or poor follow-up are not suitable candidates for pessary implantation because they require frequent cleaning and adjustment of position to avoid problems.

After a thorough conversation with the patient about the patient's desire for future vaginal intercourse, the impact on body image, cultural beliefs, alternative therapies, and potential problems, the choice for surgical management should be taken. The scope of this page does not allow for detailed discussions of surgical methods.

As a therapy for uterine prolapse, a hysterectomy can be done vaginally or transabdominally. Vaginal methods have been proven to be less intrusive and to allow for the treatment of pelvic floor abnormalities. Additional treatments can be performed concurrently to limit the likelihood of further pelvic organ prolapse.

Uterine preservation techniques have also been created to help patients who want to save their uterus or preserve their fertility in the future. Another advantage of a patient-centered lifestyle is a natural transition to menopause.

Patients undergoing uterine-sparing therapies require ongoing monitoring for gynecological cancer surveillance; consequently, uterine preservation is not recommended in patients with a history of uterine or cervical disease. In comparison to hysterectomy with prolapse correction, hysteropexy provides for less intraoperative blood loss, a shorter operational duration, and a speedier recovery.

Colpoclesis is a noninvasive, obliterative surgical procedure that includes suturing the vaginal walls together to totally occlude the vaginal canal and provide muscle support for the remaining pelvic organs. This surgery is appropriate for post-hysterectomy individuals who do not want to have vaginal intercourse in the future. 

 

Exercises

Mild uterine prolapse can be managed with Kegel exercises, weight loss, and avoiding hard lifting. The ability to do a correct Kegel is critical to the treatment's effectiveness. These exercises, which may be done anywhere and at any time, can help strengthen the pelvic floor muscles. While in the clinic, your health care practitioner or physical therapist can train you on how to execute a correct Kegel, and appropriate technique can be evaluated.

Biofeedback is a method that is sometimes used. During biofeedback therapy, a gadget will evaluate appropriate muscle contraction, pelvic floor strength, and Kegel timing. This encourages proper exercise technique.

 

To perform a proper Kegel:

  • Tighten the pelvic floor muscles, as if you are attempting to stop urinating and hold for 5 seconds
  • Take a 5-second break and repeat for three sets, 10 times per day.

 

The ultimate aim is to hold the contraction for 10 seconds on each repetition of the workout. Speak with your health care practitioner if you have any questions or if you need an examination and treatment for uterine prolapse symptoms. They can advise you on the best course of therapy for you.

 

Surgical treatment

A significant number of patients had continence surgery with suburethral tape treatments at the same time as uterine prolapse surgery, both alone and in conjunction with vaginal prolapse repairs. Hysterectomy for uterine prolapse can be done either abdominally or vaginally, albeit vaginal hysterectomy is more common in the UK.

The most difficult task in uterine prolapse surgery is preventing further prolapse of the vault or the anterior or posterior walls of the vagina. The loss of integrity of the cardinal-uterosacral ligament complex and the weakening of the pelvic diaphragm are not corrected by hysterectomy alone.

There are several techniques available to maintain the vaginal vault during hysterectomy. These include vaginal treatments such as McCall culdoplasty, uterosacral ligament plication, sacrospinous or prespinous stabilization for vaginal vault prolapse, and sacrocolpopexy (performed via an open procedure or laparoscopically). abdominal sacrocolpopexy was related with a lower recurrence of vault prolapse and less dyspareunia than vaginal sacrospinous colpopexy.

 

Differential Diagnosis

Uterine prolapse is most commonly identified through a physical exam following a chat with the patient about their medical history. Urethral prolapse, cystocele, enterocele, rectocele, abscess, and gynecologic tumor are all potential diagnosis.

 

Staging

There are several staging methods that have been used to classify pelvic organ prolapse. Many approaches, however, rely on interobserver reliability, need many measurements, and make stage agreement among various examiners problematic.

In 2002, the Pelvic Organ Prolapse Quantification (POP-Q) technology was developed. It solely considers the most distal section of the prolapsed segment in respect to the hymen, with measurements proximal to the hymen marked by negative numbers and measures distal to the hymen denoted by positive values, with the hymen serving as a reference point of "0." While the patient is doing the Valsalva technique, measurements are obtained. 

  • Stage 0: no demonstrable prolapse
  • Stage 1: the most distal portion of the prolapsed segment is >1 cm above the level of the hymen
  • Stage 2: the most distal portion of the prolapsed segment is >1 cm or less proximal or distal to the hymen
  • Stage 3: the most distal portion of the prolapsed segment protrudes >1 cm below the hymen but 2 cm less than the total length of the vagina
  • Stage 4: complete eversion of the vagina

 

Prognosis

Uterine prolapse is not a life-threatening condition in and of itself. Poor body image, low self-esteem, anxiety, depression, physical pain, bowel and bladder incontinence, and sexual limits can all result from it.

 

Complications

Complications of uterine prolapse include the following:

  • Ulcers: The vaginal lining may be dislodged and visible in severe cases of uterine prolapse. This can cause vaginal ulcers, which can get infected.
  • Incarceration: If the patient is a young woman who is pregnant, it is critical that the uterus be replaced before it enlarges and becomes stuck in the lower pelvis or vagina. Edema may cause imprisonment and potentially a lack of blood flow to the uterus if this occurs.
  • Prolapse of other pelvic organs: If the uterus prolapses, other pelvic organs, such as the bladder and rectum, may prolapse as well. A prolapsed bladder bulges into the front of the vagina, resulting in a cystocele, which can cause difficulties peeing and an increased risk of urinary tract infections. Weakness of the connective tissue underlying the rectum can result in a prolapsed rectum (rectocele), which can make bowel motions difficult.

 

Conclusion 

Patients with uterine prolapse may have their condition evaluated in a number of clinical settings. Patients frequently present to their gynecologist, as well as the emergency room, urgent care facilities, or their primary care physician's office, with symptoms of vaginal pain.

Once identified, it is critical to provide the patient with adequate uterine prolapse follow-up, since advancement can lead to long-term morbidity. As a result, a patient diagnosed with uterine prolapse should be referred to a gynecologist or family practice physician who has experience treating uterine prolapses.