Uterine Prolapse – Causes, Symptoms, Diagnosis, Treatment and Ongoing care
- Uterine prolapse occurs when the integrity of pelvic supporting structures is lost. This allows the uterus to descend into the vagina. In advanced cases, complete protrusion with inversion of the vagina occurs, known as procidentia.
- Before menopause, the degree and severity of prolapse are usually related to the number of pregnancies and the difficulty of childbirth. After menopause, atrophy and loss of tissue integrity can lead to further prolapse.
- System(s) affected: GI; Renal/Urologic; Reproductive
- Synonym(s): Uterine prolapse; Genital prolapse; Genital relaxation; Uterine descensus; Total or partial procidentia; Dropped uterus
This is largely a disease of aging, and incidence will be much higher as the median age of the population increases.
Prolapse in newborns has been reported, but it is rare and usually associated with congenital disorders and neuropathies.
- Annual incidence approximately 2%
- Predominant age: Perimenopausal and postmenopausal women
- Predominant sex: Female only
∼30–50% of women experience some degree of prolapse.
- Childbirth, particularly multiple parity
- Vaginal delivery, especially operative vaginal delivery
- Advancing age
- Caucasian or Hispanic (4–5-fold increased risk compared to African Americans)
- Tobacco use
- Occupations requiring heavy lifting
- Various connective tissue and neurogenic disorders
- Conditions resulting in increased intra-abdominal pressure (e.g., obesity, abdominal or pelvic tumors, pulmonary disease with chronic coughing, chronic constipation)
- Estrogen-deficient state
- Common among Caucasians
- Less common among Asians and African Americans, and particularly uncommon in South African Bantus and West Africans
- Kegel exercises increase the strength of the pelvic diaphragm muscles and may provide some pelvic support.
- Weight loss and proper management of conditions that increase abdominal pressure help to prevent prolapse.
- Tobacco cessation
- Postmenopausal estrogen replacement therapy
- Advancing age and vaginal childbirth are the most important factors.
- Incidence of prolapse increases with frequency and difficulty of vaginal deliveries (e.g., operative vaginal delivery); <2% of prolapse occurs in nulliparous women.
- Although this disorder in large part results from the distension and distortion of supporting tissues with vaginal childbirth, pregnancy, regardless of mode of delivery, may contribute to prolapse.
- Other less common causes of prolapse include connective tissue disorders with lax tissue (e.g., Marfan syndrome), neurogenic disorders (e.g., multiple sclerosis), cloacal agenesis, chronic constipation, pelvic tumors or ascites, and chronic coughing resulting from chronic lung disease.
- Patients who have undergone radical vulvectomy with loss of the external supporting structures have a higher rate of prolapse.
Commonly Associated Conditions
Cystocele, rectocele, enterocele, and vaginal vault prolapse are often associated with uterine prolapse.
- Patients are often asymptomatic. They may experience:
- Pelvic pressure and low back pain
- Bulging sensation in vagina or at introitus
- Difficulty with urination or defecation
- Symptoms often worsen following long periods of standing
- Vaginal bleeding (mucosal irritation)
- Inquiry should be made as to:
- The number of pregnancies, modes of deliveries, episiotomies, extent and repair of vaginal/perineal lacerations
- Previous pelvic surgery
- Congenital abnormalities
- Medical conditions that chronically increase intra-abdominal pressure (e.g., chronic obstructive pulmonary disease [COPD])
- Diagnosis is confirmed by pelvic exam. With coughing and straining, the cervix will prolapse toward introitus or beyond.
- Use only 1 blade of speculum during pelvic examination to better appreciate prolapse.
- The patient needs to be examined while standing as well as lying down to confirm diagnosis.
- Severity of symptoms and degree of prolapse are not strongly correlated.
- Can use 1 of many evaluation systems to describe extent of prolapse
- Baden-Walker system (1):
- Grade 0: Normal position
- Grade 1: Descent halfway to the hymen
- Grade 2: Descent to the hymen
- Grade 3: Descent halfway past the hymen
- Grade 4: Maximum possible descent
- Pelvic Organ Quantification (POP-Q) system also used, but is more complex and used primarily in research settings
Diagnostic Tests & Interpretation
- Evaluation of renal function (blood urea nitrogen [BUN] and creatinine) to rule out ureteral obstruction
- Urinalysis to rule out urinary tract infection (UTI)
- IV pyelogram to rule out ureteral obstruction in complete uterine prolapse (optional)
- Pelvic ultrasound or CT scan to rule out other pelvic pathology, if suspected (optional)
- If surgical correction is planned, urodynamic studies should be performed to evaluate for potential urinary incontinence masked by the prolapse (2)[B].
- If ulceration or bleeding is present, Pap smears and appropriate cervical and endometrial biopsies should be done to rule out concomitant malignancies.
Hyperkeratosis of the cervical and vaginal tissues occurs with prolapse beyond the introitus due to chronic irritation and drying. As the irritation becomes more pronounced, bleeding and ulceration occur.
- Other pelvic organ prolapse (e.g., cystocele, rectocele, enterocele)
- Pelvic mass, benign or malignant
- Vaginal estrogen therapy can increase blood supply to the vagina and supporting tissue, which may improve tissue strength; may also be beneficial for mild urinary incontinence.
- This is especially important in postmenopausal women using pessaries or undergoing reconstructive pelvic surgery (2)[B].
- Progestin therapy or monitoring of endometrial status in a woman with an intact uterus is not necessary with vaginal estrogen therapy.
- Estrogen therapy should be used in the lowest possible dose for the shortest time.
- However, women may need long-term therapy due to the chronic nature of uterine prolapse.
- 3 forms of vaginal estrogen therapy:
- Vaginal cream (Premarin conjugated equine estrogen or estradiol cream): Insert via applicator each night × 14 days and then 2–3 times/week.
- Vaginal estradiol tablet: Insert via preloaded applicator each night × 14 days and then 2–3 times/week.
- Estradiol-containing vaginal ring: Insert into vagina and replace every 3 months.
- Breast- or estrogen-dependent carcinoma
- Undiagnosed vaginal bleeding
- Thromboembolic disorders
- Precautions: Any abnormal vaginal bleeding must be evaluated.
- Treatment depends on multiple variables, including the severity of prolapse, age, sexual activity, associated pelvic pathology, and desire for future fertility.
- Treatment of grade I or II prolapse is expectant unless patient is symptomatic.
- Conservative therapies include vaginal estrogen replacement, pessary use, and physical therapy (3)[C].
- Pessaries are indicated for women who are unfit for, or decline, surgery. Proper fitting and maintenance are required (4)[C].
- Pessaries also may be used in the preoperative evaluation of prolapse (4)[C].
- Surgery is indicated for women who fail conservative therapies and/or desire definitive treatment (2)[B].
Issues for Referral
Urogynecology evaluation for patients who may be surgical candidates
Physical therapy, including biofeedback, electrical stimulation, and pelvic muscle training (Kegels), may be an option for women with mild prolapse and/or those wishing conservative therapy (4)[C].
- Surgical candidates without additional pelvic pathology: Vaginal or abdominal hysterectomy ± enterocele, cystocele, rectocele, paravaginal repair, urethral suspension, and culdoplasty depending on coexisting pelvic organ prolapse (2)[B]
- Incontinence procedure often done at same time as prolapse repair although almost 1/3 of women relieved of stress urinary incontinence by prolapse surgery alone (5)[B]
- Vault suspension is typically necessary in conjunction with hysterectomy:
- Vaginal procedures include sacrospinous ligament fixation, uterosacral ligament fixation, and endopelvic fascial suspension.
- Sacral colpopexy can be performed via laparoscopic or open abdominal approach.
- The abdominal approach (sacral colpopexy) has decreased risk of recurrent apical prolapse and less postoperative dyspareunia and stress incontinence compared with the vaginal approach (sacrospinous ligament fixation). However, the abdominal approach is associated with longer operative time and recovery time (6)[A].
- Uterine suspension is an option for patients who desire to maintain reproductive function (2)[B].
- Older women who are not sexually active can be treated with colpocleisis or vaginal obliteration procedure.
- Inpatient when surgery is necessary
- Heavy lifting, sexual intercourse, and other activities that increase intra-abdominal pressure should be avoided for 6–12 weeks after surgical correction.
- Maintain ideal body weight.
- Expectant management is appropriate, with periodic follow-up exams.
- If a pessary is placed, it should be removed, cleaned, and replaced every 3–6 months (4)[C].
Avoid constipation by increasing dietary fiber and fluid intake.
- Kegel exercises when applicable
- American College of Obstetricians and Gynecologists (ACOG), 409 12th St., SW, Washington, DC 20024-2188; (800) 762-ACOG; http://www.acog.org
- It is expected that the incidence and severity of prolapse will increase as patients age.
- Although surgical correction is usually successful initially, reoperation rate is ∼29% (2)[B].
- Ureteral obstruction and renal failure
- Incarceration of bowel herniations
- Pessary use may not always be effective and may cause discomfort, ulcers, and infection.
1. Baden WF, et al. Fundamentals, symptoms and classification. In: Baden WF, et al., eds. Surgical Repair of Vaginal Defects. Philadelphia: Lippincott, 1992;14.
2. Thakar R, et al. Regular review: Management of genital prolapse. Br Med J. 2002;324:1258–62.
3. Fox WB. Physical therapy for pelvic floor dysfunction. Med Health R I. 2009;92:10–1.
4. Trowbridge ER, Fenner DE. Conservative management of pelvic organ prolapse. Clin Obstet Gynecol.2005;48:668–81.
5. Borstad E, Abdelnoor M, Staff AC, et al. Surgical strategies for women with pelvic organ prolapse and urinary stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct. 2010;21:179–86.
6. Maher C, Feiner B, Baessler K, et al. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2010;4:CD004014.
Farrell S, et al. The detection and management of vaginal atrophy. Int J Gynecol Obstet. 2005;88:222–8.
- 618.1 Uterine prolapse without mention of vaginal wall prolapse
- 618.2 Uterovaginal prolapse, incomplete
- 618.3 Uterovaginal prolapse, complete
- 618.4 Uterovaginal prolapse, unspecified
- 24976005 uterine prolapse (disorder)
- 198268002 uterovaginal prolapse, incomplete (disorder)
- 63871009 third degree uterine prolapse (disorder)
- 18973006 uterovaginal prolapse (disorder)
- Uterine prolapse occurs when the integrity of pelvic supporting structures is lost.
- Advancing age and vaginal childbirth (including the number of pregnancies and the difficulty of childbirth) are the most important factors that contribute to uterine prolapse.
- Conservative therapies include vaginal estrogen replacement, pessary use, and physical therapy.
- Surgery is indicated for women who fail conservative therapies and/or desire definitive treatment.