Uterine Prolapse

Author: Raafat S Barsoom, MD, Staff Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center
Coauthor(s): Richard H Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Introduction

Background

Definition

Uterine prolapse (also called descensus or procidentia) means the uterus has descended from its normal position in the pelvis farther down into the vagina.

Normal uterus versus a prolapsed uterus.

Normal uterus versus a prolapsed uterus.



Ut
erine prolapse is one type of pelvic organ prolapse (POP), and it is the second most common after cystourethrocele (bladder and urethral prolapse). Other types of pelvic organ prolapse are enterocele (prolapse of the small bowel), rectocele (prolapse of the rectum or large bowel), and vaginal vault prolapse.

Uterine prolapse was first recorded on the Kahun papyri (ancient Egyptian text discussing mathematical and medical topics) in about 2000 BC. Its many fragments were discovered by Flinder Petrie in 1889. Hippocrates described numerous nonsurgical treatments for this condition. In 98 BC, Soranus of Rome first described the removal of the prolapsed uterus when it became black.1

Pathophysiology

Normally, the uterus is held in place by the muscles and ligaments that make up the pelvic floor. Uterine prolapse occurs when the pelvic floor muscles and ligaments stretch, become damaged and weakened, so they can no longer support the pelvic organs, allowing the uterus to fall into the vagina. Prolapse can be incomplete or, in more severe cases, complete when the uterus slips and drops outside of the vagina.
 
In 1996, a standardized terminology for the evaluation of pelvic organ prolapse (POP) was established by the International Continence Society, the American Urogynecologic Society, and the Society of Gynecologic Surgeons. That terminology replaced terms as cystocele, rectocele, enterocele, and urethrovesical junctions with precise descriptions relating to specific anatomic landmarks.
 
The first points are on the anterior vaginal wall and categorize anterior vaginal wall prolapse accordingly. Point (Aa) is a point located in the midline of the anterior wall 3 cm proximal to the urethral meatus and is roughly the location of the urethrovesical crease. Point (Ba) represents the most distal position of any part of the anterior vaginal wall. Point (C) represents either the most distal edge of the cervix or the leading edge of the vagina if a hysterectomy has been performed. Point (D) represents the location of the posterior fornix (pouch of Douglas) in a woman with a cervix. Point (Bp) is a point most distal of any part of the upper posterior vaginal wall, and point (Ap) is a point located in the midline of the posterior vaginal wall 3 cm proximal to the hymen.

To record measurements, these points should be expressed in centimeters above or below the hymen. It is important for the examining individual to express the position and other circumstances of the examination (eg, straining or not, patient flat on table or in examining chair).

Staging of Pelvic Floor Prolapse Using International Continence Society Terminology (POP Quantification)

  • Stage 0: No prolapse is demonstrated. Points Aa, Ap, Ba, and Bp are all at -3 cm and either point C or D is between total vaginal length -2 cm.
  • Stage I: Criteria for stage 0 are not met, but the most distal portion of the prolapse is >1 cm above the level of the hymen.
  • Stage II: The most distal portion of the prolapse is less or equal to 1 cm proximal or distal to the plane of the hymen.
  • Stage III: The most distal portion of the prolapse is >1 cm below the plane of the hymen but protrudes no further than 2 cm less than the total vaginal length in centimeters.
  • Stage IV: Essentially complete eversion of the total length of the lower genital tract.

Frequency

United States

Approximately half of all women older than 50 years complain of symptomatic prolapse.2
 
Studies have estimated that 50% of parous women have some degree of urogenital prolapse and, of these, 10-20% are symptomatic.3

International

Same as that in US Frequency.

Mortality/Morbidity

Significant morbidity can occur, usually secondary to alterations in bowel, bladder, or sexual function. No reliable data are available on mortality related directly to uterine prolapse.

Race

Studies show that white and Hispanic women have the highest rate of pelvic organ prolapse, followed by Asian and black women. Little information is available about the incidence of prolapse in women of other (or more specific) ethnic groups.

Sex

Uterine prolapse affects females only.

Age

The risk of uterine prolapse increases with age as pelvic muscles weaken and the natural reduction in estrogen at menopause also causes muscles to become less elastic.

Clinical

History

Mild cases of uterine prolapse may have no obvious symptoms. If symptoms are present, they are less bothersome in the morning but worsen as the day goes on.

Patient may complain of one or more of the following:

  • A feeling of heaviness or pressure in the pelvis
  • Feeling as if sitting on a small ball or as if something is falling out of the vagina
  • Pain in the pelvis, abdomen, or lower back
  • Pain during intercourse
  • A protrusion of tissue from the vagina
  • Recurrent urinary tract infections (UTIs)
  • Unusual or excessive discharge from the vagina
  • Difficulty with urination, including involuntary loss of urine (incontinence ), or urinary frequency or urgency
  • Symptoms may be worsened by prolonged standing or walking; (this is due to the added pressure placed on the pelvic muscles by gravity.

Physical

An abdominal examination should be performed to exclude the presence of an abdominal or pelvic tumor that may be responsible for the prolapse. Pelvic examination to assess the degree of prolapse is usually performed with the woman either in the left lateral position using a Sims speculum or in a semirecumbent position in the examination chair. Physical findings may be enhanced by having the patient strain during the examination or by having her stand or walk prior to examination. In addition, digital examination in a standing position allows an accurate assessment of the degree of the prolapse.

  • Stages
    • Stage I - Descent of the uterus to any point in the vagina above the level of the hymen
    • Stage II - Descent to the level of the hymen
    • Stage III - Descent beyond the hymen
    • Stage IV - Total eversion or procidentia

Causes

  • Pregnancy and childbirth: Pregnancy is believed to be the main cause of pelvic organ prolapse. It can occur immediately after pregnancy or 30 years later. Many factors like the weight of the baby, the physical trauma of labor, and birth stresses can strain the pelvic muscles and ligaments. Some of the damaged muscles and ligaments will never fully regain their strength and elasticity. 
  • Large fibroids or tumors: Women who have large fibroids or pelvic tumors are at an increased risk of prolapse.
  • Ageing and menopause: The ageing process further weakens the pelvic muscles, and the natural reduction in estrogen at menopause also causes muscles to become less elastic. 
  • Obesity: Women who are severely overweight are at increased risk of prolapse. 
  • Chronic coughing, constipation, or straining: Chronic coughing, from smoking, asthma, or bronchitis, or the straining associated with constipation, increases the risk of prolapse because it may eventually weaken the pelvic support structures. 
  • Heavy lifting: Heavy lifting can also strain and damage pelvic muscles, and women in careers that involve regular manual labor or lifting, such as nursing, have an increased risk of prolapse. 
  • Genetic conditions: Women with a genetic collagen deficiency (Marfan syndrome or Ehlers-Danlos syndrome ) have an increased risk of prolapse even if they do not have any of the other risk factors.
  • Previous pelvic surgery: Pelvic surgery, for example bladder repair procedures, may damage nerves and tissues in the pelvic area increasing the risk of prolapse. 
  • Spinal cord injury and other muscular atrophy conditions: Spinal cord injury and conditions such as muscular dystrophy and multiple sclerosis increase the risk of prolapse. If the pelvic muscles are paralyzed or movement is restricted, the muscles weaken and cannot support the pelvic organs. 
  • Race: Women of Northern European descent have a higher incidence of uterine prolapse than do women of Asian and African descent.

Differential Diagnoses

Abortion, Complete
Ovarian Cysts
Abortion, Incomplete
Pregnancy, Ectopic
Abortion, Inevitable
Urinary Tract Infection, Female
Abortion, Missed
Vaginitis
Abortion, Threatened
 
Neoplasm
 

Workup

Laboratory Studies

  • From the perspective of an emergency physician, the workup of uterine prolapse consists of identifying the rare but serious complications related to uterine prolapse (infection, urinary obstruction, hemorrhage, strangulation).
  • Laboratory studies are unnecessary in uncomplicated cases.
  • When indicated, order CBC, basic metabolic panel, urinalysis, pregnancy testing, and cervical cultures to exclude other conditions in the differential diagnosis.
  • A Papanicolaou test (Pap smear cytology) or biopsy may be indicated in rare cases of suspected carcinoma, although this should be deferred to the primary care physician or gynecologist.

Imaging Studies

  • A pelvic ultrasound examination may be useful to distinguish prolapse from other pathology when the history and physical examination suggest other processes in the differential diagnosis.
  • MRI has been used for staging of prolapse but generally is not indicated as an emergency test.

Treatment

Emergency Department Care

Emergency department care consists of the following:

  • Early diagnosis of uterine prolapse
  • Patient education - Risk factors, how to prevent and early detect prolapse
  • Early detection and treatment of complications
  • Consultations - Obstetrician/gynecologist (OB/GYN) for definitive management of prolapse
Conservative

Many studies were implemented to determine the effect of conservative management (pelvic exercise and lifestyle interventions) for women with prolapse in comparison with no treatment or other treatment options such as mechanical devices or surgery. Three trials of relevance were identified; the conclusion was that pelvic floor muscle training in an outpatient setting may reduce severity of prolapse in mild-to-moderate cases, but further evidence is still necessary.4    

Exercise

Special exercises, called Kegel exercises, can help strengthen the pelvic floor muscles. This may be the only treatment needed in mild cases of uterine prolapse. To perform Kegel exercises, ask the patient to tighten the pelvic muscles as if she is trying to hold back urine for few seconds and then release, to be repeated 10 times, up to 4 times a day.

Vaginal pessary

A pessary is a rubber or plastic doughnut-shaped device that fits around or under the cervix, helping to support the uterus and hold it in place. Pessaries are available in different varieties (Smith-Hodge, donut, cube, or inflatable). They require the replacement of the uterus and cervix to their original position in the pelvis before placement of these devices. Pessaries are available in varying sizes and should be properly fitted to the patient. The perineum must be capable of holding the pessary in place, or the pessary will frequently fall out.

Currently, no evidence is available from randomized controlled trials on pessary use to direct the selection of the device or to compare pessaries with surgery. A recent prospective trial found 75% of 203 women fitted with a pessary device successfully retained the device at 2 weeks. Failure to retain the pessary was significantly associated with increasing parity and past hysterectomy. Forty-eight percent of the women completed a questionnaire at 4 months. The pessary device reduced symptoms of prolapse, including general symptoms of a vaginal bulge. It also relieved urinary symptoms such as voiding problems in 40% of women, urinary urgency in 38%, and urge incontinence in 29%. No improvement was noted in stress urinary incontinence. Bowel symptoms improved as well.5

Proper care includes regular removal and cleaning, removal before sex, as well as use of vaginal estrogen cream for postmenopausal women with vaginal atrophy.    

Complications from vaginal pessaries are rare with proper use, but do include vaginal infections, bleeding, discomfort, vaginal erosion or ulceration, and impaction.

Estrogen replacement therapy (ERT)

Taking estrogen may help to limit further weakness of the muscles and other connective tissues that support the uterus. However, some drawbacks to taking estrogen include an increased risk of blood clots, gallbladder disease, and breast cancer.

Surgical

Vaginal hysterectomy with a vaginal vault suspension


The uterosacral and cardinal ligaments are preserved, so that they may be used in the support of the vaginal vault. The uterosacral ligaments should be sutured together so that the cul-de-sac is shortened or obliterated.
 
Abdominal hysterectomy

Under certain circumstances, like pelvic inflammatory disease or previous intra-abdominal operation for an inflammatory process, such as endometriosis, a vaginal hysterectomy is not advisable. Instead, an abdominal hysterectomy may be performed, followed by a vaginal anterior and posterior colporrhaphy, if needed. Under these circumstances, the cardinal and uterosacral ligaments should be treated as noted earlier.
 
Colpocleisis

In elderly women who are no longer sexually active, a simple procedure for reducing prolapse is a colpocleisis. The classic procedure was described by Le Fort and involves the removal of a strip of anterior and posterior vaginal wall, with closure of the margins of the anterior and posterior wall to each other. This procedure may be performed with or without the presence of a uterus and cervix; when it is completed, a small vaginal canal exists on either side of the septum. Prognosis for a colpocleisis procedure to reduce the prolapse and prevent recurrence is generally excellent. Case series report 91-100% success rates.

Sacrospinous fixation

A special circumstance involves the treatment of women who wish to maintain their fertility despite the fact that they have a total uterine prolapse. In the procedure, uterosacral ligaments bilaterally could be sutured to the sacrospinous ligaments, thereby reversing the prolapse.

Sacrohysteropexy

This procedure uses a strip of synthetic mesh to hold the uterus in place. The operation is performed abdominally, either through a 15-cm incision or laparoscopy. One end of the mesh is attached to the cervix and top of the vagina and the other to a bone (sacrum or sacral bone). Once in place, the mesh supports the uterus. Recent publications suggest that synthetic meshes are promising for vaginal prolapse repair. Long-term controlled studies will have to confirm the effectiveness and safety of new meshes and will have to include more functional data on sexuality and quality of life, before transvaginal meshes can be accepted as routine surgery.6

Robotic-assisted abdominal sacrocolpopexy/sacrouteropexy (RASC) is another approach, used for stages III and IV prolapse, was found to be safe and efficacious. Its anatomical outcomes compare favorably to the reported results for open or laparoscopic sacrocolpopexy.7

The American College of Obstetricians and Gynecologists has developed guidelines on the treatment and management of pelvic organ prolapse as well.8

Consultations

Consult an obstetrician or gynecologist for definitive management of symptomatic prolapse in adults and for long-term follow-up in all children.

Follow-up

Further Inpatient Care

  • Further inpatient care for patients with uterine prolapse is indicated only in cases complicated by severe ulceration, infection, or renal failure.

Further Outpatient Care

  • Arrange for follow-up care with an obstetrician or gynecologist in 1-2 weeks.

Deterrence/Prevention

  • A healthy diet, balanced in protein, fat, and carbohydrates, can help maintain a healthy body weight and prevent constipation.
  • Exercise should be performed on a regular basis.
  • Chronic straining, such as in chronic constipation, should be avoided.
  • Pelvic muscle exercise (Kegel exercises) should be performed.
  • Stopping smoking can reduce the risk of developing a chronic cough.
  • Correct lifting techniques should be used.

Complications

  • Ulcers: In severe cases of uterine prolapse, the vaginal lining may be displaced and exposed. This may lead to vaginal ulcers that could become infected.
  • Incarceration: If the patient is a young woman and pregnant, it is important to replace the uterus before it enlarges and becomes trapped in the lower pelvis or vagina. If this happens, edema may cause incarceration and even loss of blood supply to the uterus.
  • Prolapse of other pelvic organs: If uterine prolapse occurs, prolapse of other pelvic organs, including the bladder and rectum, is possible. A prolapsed bladder bulges into the front part of the vagina, causing a cystocele that can lead to difficulty in urinating and increased risk of urinary tract infections. Weakness of connective tissue overlying the rectum may result in a prolapsed rectum (rectocele ), which may lead to difficulty having bowel movements.

Prognosis

  • Objective data on the natural history of uterine prolapse are very limited.
  • Neonatal uterine prolapse is associated with an excellent long-term prognosis with conservative management.
  • Uterine prolapse in adults may be corrected with a variety of surgical procedures, the descriptions of which are beyond the scope of this article. Preservation of fertility is generally possible in younger patients.

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize rare complications
  • Failure to provide follow-up

References

  1. Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology, Second Edition . Informa HealthCare; 2006.

  2. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol . Aug 2000;183(2):277-85. [Medline] .

  3. Progetto Menopausa Italia Study Group. Risk factors for genital prolapse in non-hysterectomized women around menopause. Results from a large cross-sectional study in menopausal clinics in Italy. Eur J Obstet Gynecol Reprod Biol . Dec 2000;93(2):135-40. [Medline] .

  4. Hagen S, Stark D, Maher C, Adams EJ. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev . 2008.

  5. Katz VL, Lentz G, Lobo RA, Gershenson D. Comprehensive Gynecology . 5th ed. Mosby; 2007.

  6. De Ridder D. Should we use meshes in the management of vaginal prolapse?. Curr Opin Urol . Jul 2008;18(4):377-82. [Medline] .

  7. Daneshgari F, Kefer JC, Moore C, Kaouk J. Robotic abdominal sacrocolpopexy/sacrouteropexy repair of advanced female pelvic organ prolaspe (POP): utilizing POP-quantification-based staging and outcomes. BJU Int . Oct 2007;100(4):875-9. [Medline] .

  8. [Guideline] American College of Obstetricians and Gynecologists (ACOG). Pelvic organ prolapse. Washington (DC). Sep 2007;[Full Text] .

  9. DeLancey JO. Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol . Dec 1993;36(4):897-909. [Medline] .

  10. Hagen S, Stark D, Maher C, Adams E. Conservative management of pelvic organ prolapse in women. Cochrane Database Syst Rev . 2004;CD003882. [Medline] .

  11. Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol . Sep 1996;88(3):470-8. [Medline] .

  12. Haylen BT. The retroverted uterus: ignored to date but core to prolapse. Int Urogynecol J Pelvic Floor Dysfunct . Nov 2006;17(6):555-8. [Medline] .

  13. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women's Health Initiative: gravity and gravidity. Am J Obstet Gynecol . Jun 2002;186(6):1160-6. [Medline] .

  14. Loret de Mola JR, Carpenter SE. Management of genital prolapse in neonates and young women. Obstet Gynecol Surv . Apr 1996;51(4):253-60. [Medline] .

  15. Morley GW. Treatment of uterine and vaginal prolapse. Clin Obstet Gynecol . Dec 1996;39(4):959-69. [Medline] .

  16. Ozel B, White T, Urwitz-Lane R, Minaglia S. The impact of pelvic organ prolapse on sexual function in women with urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct . Jan 2006;17(1):14-7. [Medline] .

  17. Rinne KM, Kirkinen PP. What predisposes young women to genital prolapse?. Eur J Obstet Gynecol Reprod Biol . May 1999;84(1):23-5. [Medline] .

  18. Rush CB, Entman SS. Pelvic organ prolapse and stress urinary incontinence. Med Clin North Am . Nov 1995;79(6):1473-9. [Medline] .

  19. Sanai T, Yamashiro Y, Nakayama M, Uesugi N, Kubo N, Iguchi A. End-stage renal failure due to total uterine prolapse. Urology . Mar 2006;67(3):622.e5-7. [Medline] .

  20. Shaunik A. Pelvic organ myiasis. Obstet Gynecol . Feb 2006;107(2 Pt 2):501-3. [Medline] .

  21. Silva WA, Kleeman S, Segal J, Pauls R, Woods SE, Karram MM. Effects of a full bladder and patient positioning on pelvic organ prolapse assessment. Obstet Gynecol . Jul 2004;104(1):37-41. [Medline] .

  22. Soderberg MW, Falconer C, Bystrom B, Malmstrom A, Ekman G. Young women with genital prolapse have a low collagen concentration. Acta Obstet Gynecol Scand . Dec 2004;83(12):1193-8. [Medline] .

  23. Swift S, Woodman P, O'Boyle A, et al. Pelvic Organ Support Study (POSST): the distribution, clinical definition, and epidemiologic condition of pelvic organ support defects. Am J Obstet Gynecol . Mar 2005;192(3):795-806. [Medline] .

  24. Tan JS, Lukacz ES, Menefee SA, Powell CR, Nager CW. Predictive value of prolapse symptoms: a large database study. Int Urogynecol J Pelvic Floor Dysfunct . May-Jun 2005;16(3):203-9; discussion 209. [Medline] .

  25. Weber AM, Walters MD, Piedmonte MR. Sexual function and vaginal anatomy in women before and after surgery for pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol . Jun 2000;182(6):1610-5. [Medline] .

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Mon, 19 Jul 2010 @17:19

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