Uterine Prolapse

Definition | Aetiology | Risk Factors | Clinical Presentation | Staging | Investigations | Management | When to Refer | References

Definition

Uterine prolapse is a condition where the uterus descends from its normal position into the vaginal canal due to weakness or damage to the pelvic floor muscles and ligaments. It can vary in severity from mild descent to complete prolapse, where the uterus protrudes outside the vaginal opening.

Aetiology

Uterine prolapse is caused by weakening or damage to the pelvic floor muscles and ligaments that support the uterus. Factors contributing to this weakening include:

• Childbirth: Vaginal deliveries, particularly those involving large babies, multiple births, or instrumental deliveries (e.g., forceps), can stretch or damage the pelvic floor muscles.
• Menopause: Decreased oestrogen levels after menopause can lead to a loss of muscle tone and elasticity in the pelvic tissues.
• Chronic Increased Intra-Abdominal Pressure: Conditions such as chronic coughing, obesity, constipation, or heavy lifting can increase pressure on the pelvic floor, contributing to prolapse.
• Genetic Predisposition: A family history of pelvic organ prolapse may increase the risk due to inherited connective tissue weaknesses.
• Ageing: The natural ageing process leads to weakening of the pelvic floor muscles and ligaments, increasing the risk of prolapse.

Risk Factors

Several factors increase the likelihood of developing uterine prolapse:

• Parity: Having multiple pregnancies and vaginal deliveries increases the risk.
• Menopause: The decrease in oestrogen levels post-menopause contributes to the weakening of pelvic support structures.
• Obesity: Increased body weight adds extra pressure on the pelvic floor.
• Chronic Cough: Conditions like chronic obstructive pulmonary disease (COPD) that cause persistent coughing can increase intra-abdominal pressure.
• Heavy Lifting: Regularly lifting heavy objects can strain the pelvic floor muscles.
• Previous Pelvic Surgery: Surgeries like hysterectomy may disrupt the support structures of the pelvic organs.

Clinical Presentation

The symptoms of uterine prolapse can vary depending on the severity of the condition. Common symptoms include:

• Vaginal Bulge: A sensation of fullness, pressure, or a bulge in the vagina, which may worsen with standing or physical activity.
• Pelvic Discomfort: A feeling of heaviness or dragging in the pelvic area, often described as a pulling sensation.
• Lower Back Pain: Pain in the lower back, which may be related to the prolapse.
• Urinary Symptoms: Difficulty with urination, urinary incontinence, or incomplete bladder emptying. Some women may also experience urinary frequency or urgency.
• Bowel Symptoms: Constipation, difficulty with bowel movements, or a sensation of incomplete evacuation.
• Sexual Dysfunction: Discomfort or pain during sexual intercourse (dyspareunia), or a feeling of looseness in the vaginal area.
• Visible Protrusion: In severe cases, the uterus or vaginal walls may be visible outside the vaginal opening.

Staging

Uterine prolapse is classified into stages based on the degree of descent:

• Stage 1: The uterus descends into the upper part of the vagina but remains above the hymenal ring.
• Stage 2: The uterus descends to the level of the hymen or just inside the vaginal opening.
• Stage 3: The uterus protrudes outside the vaginal opening but is not fully externalised.
• Stage 4: Complete prolapse, where the entire uterus is outside the vaginal opening.

Investigations

The diagnosis of uterine prolapse is primarily clinical, but additional investigations may be required to assess severity and rule out other conditions:

• Pelvic Examination: A bimanual examination to assess the degree of prolapse and any associated pelvic organ prolapse (e.g., cystocele, rectocele).
• Urinalysis: To rule out urinary tract infections if urinary symptoms are present.
• Urodynamic Studies: May be performed if urinary incontinence or voiding dysfunction is present, to assess bladder function and identify the cause of symptoms.
• Pelvic Ultrasound: Occasionally used to assess the anatomy of the pelvic organs and rule out other pathology.
• Magnetic Resonance Imaging (MRI): May be utilised in complex cases to provide detailed imaging of the pelvic floor structures.

Management

The management of uterine prolapse depends on the severity of symptoms, the stage of prolapse, and the woman's preferences regarding fertility and sexual function:

Conservative Management

• Pelvic Floor Exercises: Also known as Kegel exercises, these strengthen the pelvic floor muscles and can improve symptoms in mild cases of prolapse.
• Pessaries: A vaginal pessary is a device inserted into the vagina to support the uterus and hold it in place. It is a non-surgical option for women who wish to avoid or delay surgery.
• Lifestyle Modifications: Weight loss, managing chronic cough, and avoiding heavy lifting can reduce symptoms and prevent further prolapse progression.
• Oestrogen Therapy: Local oestrogen therapy (e.g., vaginal cream or pessaries) can help improve vaginal tissue tone and reduce symptoms in postmenopausal women.

Surgical Management

• Vaginal Hysterectomy: Removal of the uterus through the vagina, often combined with pelvic floor repair, is a common surgical treatment for prolapse.
• Sacrospinous Ligament Fixation: A procedure to attach the vaginal vault to the sacrospinous ligament to provide support following hysterectomy.
• Sacrocolpopexy: A procedure that uses a mesh to support the vaginal vault or uterus by attaching it to the sacrum. It is often performed laparoscopically or via open surgery.
• Manchester Procedure: Shortens the cervix and re-suspends the uterus. This may be an option for women who wish to preserve the uterus.
• Colpocleisis: A procedure that closes the vaginal canal, used in elderly women who no longer desire sexual function.

When to Refer

Referral to a gynaecologist or urogynaecologist is warranted in the following situations:

• Severe symptoms that significantly impact quality of life and do not respond to conservative management.
• Consideration of surgical treatment, particularly in women with advanced prolapse (Stage 3 or 4).
• Recurrent prolapse following previous surgical treatment.
• Uncertainty in diagnosis or the presence of associated pelvic organ prolapse.

References

1. NHS (2024) Uterine Prolapse. Available at: https://www.nhs.uk/conditions/uterine-prolapse/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Uterine Prolapse: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng123 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Management of Uterine Prolapse. Available at: https://www.bmj.com/content/359/bmj.j4141 (Accessed: 26 August 2024).

Back to Top