Uterine prolapse is falling or sliding of the uterus from its normal position in the pelvic cavity into the vaginal canal.
Pelvic relaxation; Pelvic floor hernia
Causes, incidence, and risk factors:
The uterus is held in position by connective tissue, muscle, and special ligaments in the pelvis. 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, as can chronic cough (such as a smoker's cough) and obesity. 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.
- A feeling as if "sitting on a small ball"
- Difficult or painful sexual intercourse
- Low backache
- Protrusion from the vaginal opening
- Sensation of heaviness or pulling in the pelvis
- Vaginal bleeding
Signs and tests:
A pelvic examination with the woman bearing down 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 show protrusion of the bladder and front wall of the vagina (cystocele ) or rectum and back wall of the vagina (rectocele) into the vaginal space. The ovaries 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 is not necessary unless the symptoms are bothersome. Uterine prolapse can be treated with a vaginal pessary or surgery.
A vaginal pessary is an object 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.
If the woman is obese, attaining and maintaining optimal weight is recommended. Heavy lifting or straining should be avoided.
Measures to treat and prevent chronic cough, such as smoking cessation, are also recommended.
Surgery should wait until symptoms are worse than the risks of having surgery. The surgical approach depends on:
- Degree of prolapse
- Desire for future pregnancies
- Other medical conditions
- Preservation of 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 sacral colpopexy. This procedure involves the use of surgical mesh material to support the uterus.
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.
Most women with mild uterine prolapse never have 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 for recurrent prolapse of the vaginal walls.
Ulceration and infection of the 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.
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.